July 8th Comprehensive Cancer Rehab

Chris Wilson PT, DPT, GCS

PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in PracticeJuly 2013

Types of Cancer

Types of cancers

Cancers are named by their origin:

• carcinomas• sarcomas

• lymphomas• leukemias

Sarcomas

Sarcomas are cancers that arise from cells of connective tissue, bone, muscle etc.

• osteosarcoma• myosarcoma• liposarcoma

• synovial sarcoma

Lymphomas

Lymphomas are cancers that arise from cells of the lymph nodes, lymph system and the body’s immune system

• Hodgkin's Disease• Non-Hodgkin's lymphoma

Leukemias

Leukemias are cancers that arise from cells of the bone marrow and blood stream.

• Acute lymphocytic leukemia• Chronic myelocytic leukemia

Carcinoma

• Most common type of cancer• Carcinomas arise from the cell linings of body

surfaces• Usually involve organs

Types of carcinoma

• lung• breast• colon

• prostate

Lung Cancer

• Second most commonly diagnosed cancer in men and women

• Leading cause of death in men and women

• Stage 1 – 4• Usually diagnosed in more

advanced stages• Difficult to screen for• Frequently metastasizes to

the brain

Lung Cancer Screening

Types of Lung Cancer

Prostate Cancer

Prostate Cancer

• Most commonly diagnosed cancer in men• Second leading cause of cancer deaths

Prostate Cancer Grading

• A pathologist looks for cell abnormalities and "grades" the tissue sample from 1 to 5.

• The sum of 2 Gleason grades is the Gleason score.

• These scores help determine the chances of the cancer spreading

• They range from 2, less aggressive, to 10, a very aggressive cancer.

• Gleason scores helps guide the type of treatment.

Colon Cancer

• Third most common cancer• Third leading cause of cancer deaths

• Very effective screening • Screening can lead to prevention

Prostate cancer surgery

Colon cancer surgery

Lung cancer surgery

Overview of “Historical” Physical Therapy for Cancer

• Patient complains of pain, dysfunction, disability• Doctor identifies a need for physical therapy• Patient is scheduled for physical therapy

services• Receives a bout of care and is commonly

discharged without follow up by P.T. • Very little to no communication between

therapists or physicians as a patient transitions from setting to setting

• Physical therapists often outside “routine” cancer management model

Philosophy of Rehab

PRISM

Prevention

Intervention

Sustained Wellness

“Empower patients to maintain their own health and commitment to healing, through an individualized exercise and wellness program” = PRISM

Prevention Phases

• Why Rehabilitation?– PT/OT treats impairment, such as mm weakness,

fatigue, restricted joint motion and poor cardiac respiratory fitness. Impartment could lead to disability and limitations.

– PT/OT aim to decrease or prevent disabilities and promotes safe activity, at home, work, or recreational activities

– PT/OT promotes participation and re-integration to society, by treating impartments and disabilities

Prevention and Wellness of the Oncology Patient

• Primary prevention – Prevention of a disease in a potentially susceptible population – impacting the active pathology stage

• Secondary prevention – Decreasing the duration and severity through intervention – impacting the impairment and functional limitation phase

• Tertiary prevention – Decreasing the degree of disability in those with irreversible disorders – impacts disability

Program Model

Rehabilitation Program Flow

Screening and Consultation• Patients scheduled for free consultation/screening

• Wilson Resource Cancer Center (Troy) Started June 2011– Breast – Breast cancer surveillance program pre/post surgery– GU– Lymphedema treatment when appropriate– All other cancer diagnoses

• Rose Cancer Center (Royal Oak) Started September 2012– Breast– GU– All other cancer diagnoses

• Grosse Pointe Started July 2012– All types

Exercise and Wellness

• Cancer Survivorship – Exercise & Wellness Program Similar to Cardiac Rehab- Phase III

• SOLA or community fitness• Home Exercise Program• Referrals as needed for other services

– Cancer Resource Centers– Local Support Groups – Org/Regional services– Integrative Medicine– American Cancer Society

Paradigm Shift of Healthcare Models

• Patient Centered Medical Home– Increased access, quality, decreased cost

• Accountable Care Organizations– Creating facility/physician based organization to

better coordinate management of disease– Shared profit and risk for savings and clinical and

patient outcomes• Managed Care Systems

– Focus on Use Management and Controlling Visits• Integrated Medical Records• Payment models shifting toward less visits

– copays or private pay

Oncology Rehabilitation7

• Comprehensive Oncology Rehabilitation– Began in 1922

• Program Success– Management Plan– Advanced certifications– Informed stakeholders

Management & Administrative Structure

• Comprehensive Oncology Rehab Team Members

• Professional Communications• Timing of Access to Patients• Protocol Guidelines• Advanced Training of Personnel• Professional resources, settings, equipment• Reimbursement, funding, costs to patients• Research

Advanced Education Requirements

• Oncology and Rehabilitation – Cancer Pathology & Staging– Cancer Treatments – Evolution of side effects– Timing of education & interventions– Prevention activities– Intensity of interventions- education, manual therapy

and exercise (flexibility, strengthening, aerobic)– Current Research– Rehab throughout the continuum of care

Education of Stakeholders

• Physicians• Nurse Navigators• Patients• Caregivers• Social workers, nutritionists, chaplains, OT, SLP,

radiation therapists• Insurers• Universities & Residency Programs• Research

Advanced Education Opportunities

• APTA Oncology Section – Courses– Upcoming Certification Examinations

• Oakland University– Graduate Certificate in Oncology Rehabilitation– Annual Oncology Symposium

• Deb Doherty and Jackie Drouin

Documenting progress and justifying future care

• An important part of therapy is using functional tools to document and validate progression or regression of care

• We use established, evidence-based, researched outcome measures called functional tools to document the patient’s progress or current status

FUNCTIONAL OUTCOME MEASURES

• Berg Balance Training• 10 Meter Walk Test• Modified Borg Test • 5 Times Sit to Stand

Test• FACIT

– FACT – G– FACT – B – Etc…

• Functional Reach Test• Modified Reach Test• Cognitive Assessment• Bicep Test• Fear Avoidance

Behavioral Questionnaire

• SF-36

PT FUNCTIONAL OUTCOME MEASURES

BALANCE ASSESSMENTS

• Provide direction in terms of strength and areas of deficits or weakness

• Used a predictability tool• Provide risk factor information

PT FUNCTIONAL OUTCOME MEASURES

Berg Balance Assessment• Determine falls for older adults• Scored from 0-56

– High Fall Risk – 36 or lower– Medium Fall Risk – 37 - 45– Low Fall Risk – 45 or greater

• Helps with determining discharge disposition and predictive validity for future falls

10 Meter Walk Test

• Gait speed assessment– Gait speed is predictive of disability, fall risk, and

future need for ECF/Nursing Home– Therapist uses a stopwatch to quantify duration

for a patient to ambulate 10 meters.– The more slowly a person ambulates the higher

risk of falls, injury, and need for assistance at home

– Predictive of future morbidity and mortality

5 Times Sit to Stand

• Measures functional lower limb muscle strength

• Quantifying functional change of transitional movements

• Therapist asks pt to stand up and sit down 5 times as quickly as they can

• Time the patient how long to complete test

Rate of Perceived Exertion Scale

• Rating of how tired a person is on a 1-10

• Therapy grades the patient on this scale to determine intensity of treatment

FUNCTIONAL OUTCOME MEASURES

COGNITIVE• Orientation• Alertness/Attention

Span• Communication• Safety Awareness• Motivation

ASSESSMENT• Ability to follow

commands• Memory• Insight regarding

deficits

FUNCTIONAL OUTCOME MEASURES

COGNITIVE ASSESSMENT

Allen Leather Lacing Test• Screening test• Provides estimate of cognitive functioning,

information processing and ability to learn• Assists with goal setting, treatment planning

and determining discharge location

FUNCTIONAL OUTCOME MEASURES

FUNCTIONAL REACH TEST

• Completed in standing• Single-task dynamic test

that defines functional reach as “the maximal distance one can reach forward beyond arm’s length while maintaining a fixed base of support in a standing position”

FUNCTIONAL OUTCOME MEASURES

FUNCTIONAL REACH TEST

• Dynamic test that measures a person’s margin of stability during a functional task

• Predicts risk for falling in the next 6 months

FUNCTIONAL OUTCOME MEASURES

MODIFIED REACH TEST

• Adapted for patients that are unable to stand• Completed in sitting

FUNCTIONAL OUTCOME MEASURES

BICEP CURL• Test of upper body strength and endurance• 30 seconds of repeated biceps curls• Therapists count how many repetitions the

patient can perform in 30 seconds

Functional Assessment of Cancer Therapy - General

Nutrition and Physical Activity5

• American Cancer Society: • ~1/3 of the cancer deaths in US each year

due to – poor nutrition– physical inactivity– excess weight

• “Maintaining a healthy body weight, being physically active on a regular basis, and eating a healthy diet are as important as not using tobacco products in reducing cancer risk.”

Exercise and Wellness Program Overview

Exercise and Wellness Program Goal: Empower patients to maintain their own health and commitment to healing, through an individualized exercise and wellness program.

Exercise & Wellness Program

Acute Care Exercise Sessions

Community Education

Traditional Therapy (PT/OT)

PT Screening (NEW)

Supervised Exercise Sessions(NEW)

Research

Exercise and Wellness ProgramOverview

• Coordinate providers and services through continuum of care

– Hospital-Based Cancer Resource Center• Acute Care• Ambulatory Care

Patient Client Distribution

Exercise and Wellness ProgramHigh Level Process Flow

Physical Therapy Screening

(As Outpatient in WCRC or as Inpatient in Acute

Care Unit)

Supervised Exercise & Wellness Program

(Rehab & Dialysis Center 2nd Flr)

Traditional Therapy (Physical Therapy Troy)

Home Exercise(Patient’s Home)

Individual Wellness(Patient’s Personal Gym)

Ambulatory Patient Entry to Program- WCRC / ONNs- Support Groups- Radiation Onc- Inpatient Rounding- Multi-D Clinics- Physicians

Point of Entryto the Program

Follow Up CareScreening(A) (C)(B)

Acute Care Exercise Program

(Inpatient Unit)

Acute Care Patient Entry to Program- Inpatient Unit

HospitalDischarge

Programs for the Medically Compromised Patient in an

Inpatient Setting• Need therapists who are dedicated to oncology floor as their primary practice area• Establish a personal relationship and trust with physicians, nurses, patients, multidisciplinary team• Non-direct care time just as valued as direct treatment time

Common reasons for admission to hospital

• Initial diagnosis and workup – Variable receptiveness to P.T. but “plant the seed”

• Chemotherapy treatments – “well visit”

• Related sequelae – ex. UTI, sepsis, confusion, dehydration, nausea, diarrhea,

vomiting, weakness, falls• Unrelated medical issue

– still placed on oncology floor • Decline in status or worsening of cancer

– re-evaluate patient needs or functional status

Exercise and Wellness Program

Physical Therapy Screening• Standing request from nurse manager and

oncology chief/champion for PT Screen• Essentially direct access for referral to PT

services – Order often a formality but obtained– Medical executive order reauthorized annually

• Avoids traditional model of a patient not often getting a PT treatment till day 3-4

• Direct communication between nurse and PT for any possible patient needs with immediate assessment and treatment

Rounding therapist gets patient list from unit clerk

Provide Occupational Therapy Screening for education/ADL training for benefit of caregiver

Patient Hospice

?

Stop

Initiate ScreenIs pt on PT

schedule?

Check Nurse Progress Notes for - ambulation in halls- exercising- safety

Safety concerns?

Stop

Recommend evaluation for physical therapyProvide an exercise prescription /

recommendation for therapy -home-gym-mentor exercise program-outpatient therapy

Stop

Contra-indications

to PT?

Stop

Yes

Yes

Yes

Yes

NoNo

NoNo Inpatient Rounding Process Flow

Exercise and Wellness Program

Physical Therapy Screening

Multidisciplinary Rounds• Attendees

– Oncologist– Staff nurse– Nurse manager– PT/OT– Pharmacist– Social Work– Nurse Navigator from

Cancer Center– Pastoral Care– Dietary– Care

management/discharge planner

• Roundtable – everyone must talk about

their insights on the case• Approximately 6 patients

discussed– 1 Hour total – Twice a week

• Patients chosen by Nurse Manager due to complexity, medical issues, social issues, length of stay concerns

Oncology Daily Huddles

• Brief meeting at 11:00 -11:22 AM on days when there are not Multi Disciplinary Rounds– All nurses, nurse manager, PT/OT, care manager, hospice

nurses, etc.– Other members of MultiD team welcome

• 1 minute per patient• Nurse clarifies any daily needs or concerns that

need to be addressed• PT outlines any issues with safety, compliance,

handoff, discharge needs

Bone Metastases and Tumors

• Breast, prostate, renal, thyroid, and lung carcinomas commonly metastasize to bone5

• Osteolytic bone mets more commonly cause long bone fx than osteoblastic8

• Bisphosphonates are commonly prescribed to inhibit osteoclast mediated bone-resorption8

• Orthopedic evaluation and radiographic studies • Prophylactic internal fixation favorable outcomes vs after

pathologic fx– If unable, radiotherapy and NWB may be prescribed

• Bone mets should prompt conversation with primary oncologist

Bone Metastases/Tumors and PT

• In any cases of cancer, PTs should be vigilant for bone metastases9

• Conservative management of WB and resistive forces/manual therapy until risk of fracture of bone mets established

• PTs can and should prompt for radiographs if concern for mets or unexplained pain

• Risk Factors for Imminent Fracture:9,10

– Pain• Especially with movement

– Anatomical site• translational forces• WB bones

– Size of metastasis• When 50% of cortex destroyed,

fx rate ~80%9

– Cortical lesions >2.5–3.0 cm– Unresponsive to radiation

Bone Metastases/Tumor Guidelines11

• >50% cortex involved – No exercises – touch down or non-weight bearing – use crutches, walker – active ROM exercise (no twisting)

• 25–50% cortex involved – No stretching– partial weight bearing– light aerobic activity– avoid lifting/straining activity  

• 0–25% cortex involved– Full weight bearing

• “Bone metastases in the shaft of the humerus of a bronchial carcinoma with cortical destruction in both planes.”

• Chestradiology.net

Destruction of the right vertebral arch and the transverse processes of L3 as well as a

large paravertebral soft tissue tumor.

• Diffuse skeletal metastases.

• Rib metastases on the right side.

• Left-sided pseudolesions at the costo-chondral transition, which are caused by microfractures in Osteoporosis.

Blood levels and exercise6

• Platelets and thrombocytopenia– Normal 140,000-400,000– 50-140k low intensity exs and

aerobic exs– 30-50k recommend AROM

and walking unless at high fall risk

– < 25k therapy and mobility contraindicated

• Neutropenia – increased infection risk– patient should wear mask

outside of room – PT/PTA should wear mask in

room• Hemoglobin

– ♀ normal – 12-16 mg/dl– ♂ normal – 14-17mg/dl– 8-10mg/dl – exs intolerance– <7-8 mg/dl – bedrest unless

very close monitoring

Brain Metastases11

• ~8%–10% occurrence of brain mets in adults with CA11

• Majority of brain mets from: – lung CA (40%–50%)– breast CA (15%–25%)– melanoma (5%–20%)

• Historical standard of care:– corticosteroids – whole brain radiation therapy

• Common symptoms of brain mets:– Headache– Seizures– Paralysis or focal weakness– Altered mental status– Ataxia

• PT can expect some recovery of function if radiation, chemo, steroids effective

“Brain metastases should be included in differential diagnosis of any cancer patient in whom new neurologic symptoms or

signs develop”

Brain mets from adenocarcinoma of lung

Emotional and Psychological Issues

• Monitor oncology staff and therapists for emotional overload – watch for burnout

• Mourning process and encourage sharing with colleagues, Social Work, Pastoral Care, friends

• Family dynamics in times of stress• At times, near the end stage of life, PT often fixated

on as “the last hope” or when PT not tolerated, as the final catalyst to transition to hospice/palliative care

Lessons Learned during Implementation

• Attempted a group exercise session with inpatients with cancer– Limited participation, isolation issues, patients preferred

to exercise with PT alone during IP stay– May revisit when Oncology Unit expands beyond 22 beds

• Dedicate staff and time to huddles, rounds• Constant connection, communication and follow up

between IP and OP and SAR/Homecare• Able to obtain dedicated exercise room in Oncology

Unit renovation due to new programs implemented

Hospice and Palliative Care• APTA HoD RC 17-11 – Unanimous and introduced by

Michigan• The APTA endorses the inclusion of the following concepts in

hospice and palliative care:– Continuity of care and the active, compassionate role of PTs and

PTAs– Rights of all individuals to have appropriate and adequate access to

PT, regardless of medical prognosis or setting– An interdisciplinary approach, including timely and appropriate

PT/PTA involvement, especially during transitions of care or during a physical or medical change in status

– Education of PT/PTAs and students in the concepts related to treating an individual while in hospice and palliative care

– Appropriate and comparable coverage and payment for physical therapy services

• Task force to develop a plan to achieve these goals

PTs Role in Hospice and Palliative Care

• Common misunderstandings about PTs role in Hospice/Palliative Care

• “Aggressive PT” and “No PT” are not the only options• Focus to avoid interruption in rehabilitation care• Even more sensitive to patient wishes/comfort

• Shift focus to:– quality of life– anticipatory future disability

and equipment needs– “bucket list” assistance– Prevention of pressure

ulcers, contractures, immobility pain

– Family/caregiver education and support/consultation

Ambulatory Patient Receiving Outpatient

Cancer Care

Cancer Related Fatigue

Fatigue is considered one of the most common side effects of

cancer.

Fatigue

• A distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion

• Related to cancer or cancer treatment • Not proportional to recent activity • Interferes with usual functioning

- NCCN 2011

Cancer-related fatigue (CRF)

Causes of Fatigue

• Etiology unknown• Anemia (hemoglobin < 12g/dL)

• Pain• Emotional distress• Sleep disruption• Altered nutrition• Altered activity• Medical issues (thyroid, heart, infections)

Fatigue Facts

• Fatigue is the most common side effect of cancer treatment.

• Fatigue is the most distressing side effect• MDs and RNs tend not to focus on fatigue• Patients tend to under report their fatigue

- ACS 2011

Fatigue Facts

• Cancer Related Fatigue is not relieved by rest

• Reported in 70-100% of persons undergoing CA Rx

• 30 – 50% of patients report fatigue lasting months to years after concluding treatment.

Fatigue Facts

• CRF is grossly under-treated

Fatigue Facts

• CRF has a cognitive and physical aspects

Fatigue Facts

Encourage your patients to make their physicians and nurses aware of

their fatigue level!

Origin of Fatigue

• From cancer treatment

• From the cancer itself

What is expected? - Surgery

• Some mild fatigue relieved with rest lasting 2-3 weeks post op

What is expected? - Chemo

• “Roller coaster fatigue”• Mild to severe fatigue• Increases with dosage• Unpredictable• Should begin to ease 4 weeks after

conclusion, but may take 3-12 months to resolve.

What is expected? - Radiation

• Linear fatigue• Usually begins at about 4 weeks• Increases linearly as dose increases• May peak 1 week after last dose• Should begin to ease 4 weeks after

conclusion, but may take 3-12 months to resolve.

What is not ok

• Increased shortness of breath with minimal exertion

• Uncontrolled pain• Inability to control side effects from

treatments (such as nausea, vomiting, diarrhea, or loss of appetite)

• Uncontrollable anxiety or nervousness• Ongoing depression

Fatigue Rating Scale

0 = no fatigue

1-3= mild fatigue

4-6= moderate fatigue

7-10= severe fatigue

Treatment of Fatigue

“ Try to be as active as possible as you go through treatment. Some patients, especially those who have extensive disease, should be referred to a physical therapist or to an expert in physical medicine to help decide on a specific exercise program.”

-NCCN 2005

NCCN CRF recommendations

• Fatigue should be screened, assessed, and managed according to clinical practice guidelines.

• All patients should be screened for fatigue at their initial visit, at regular intervals during and following cancer treatment, and as clinically indicated.

• Fatigue should be recognized, evaluated, monitored, documented, and treated promptly for all age groups, at all stages of disease, prior to, during and following treatment.

• Patients and families should be informed that management of fatigue is an integral part of total health care.

• Health care professionals experienced in fatigue evaluation and management should be available for consultation in a timely manner.

• Implementation of guidelines for fatigue management is best accomplished by interdisciplinary teams who are able to tailor interventions to the needs of the individual patient.

• Cancer-related fatigue should be included in clinical health outcome studies.

• Rehabilitation should begin with the cancer diagnosis.

NCCN Guidelines

• Consider initiation of exercise program of both endurance and resistance exercise

• Consider referral to rehabilitation: physical therapy, occupational therapy

NCCN 2011

Cancer Related FatigueWhat to do?

• Exercise 6 days a week• Lower your expectations for the day• Pace yourself use energy conservation principles• Pay attention to energy swings and schedule

tasks during the most energetic part of the day• Take mini breaks with or without a nap• Alternate high and low physical activities• Eat a healthy diet• Reduce stress and anxiety• Go to bed 20-30 minutes earlier than your usual

time to “unwind”

Treatment of CRF

• Treat contributing factors– Treatment of medical issues– Nutritional support– Distress management– Sleep support

What the research says

• The only evidence based treatment for cancer related fatigue is:

Exercise

What the research says

• Exercise is safe during chemo and radiation.• Exercise is helpful to exercise during radiation and

chemotherapy.• Exercise should be encouraged• Exercise is under-utilized• Exercise is safe with advanced disease.• Exercise is recommended with palliative care and

end of life

What the research says• Exercise is helpful in persons with cachexia

– Cancer cachexia describes a syndrome of progressive weight loss, anorexia, and persistent erosion of host body cell mass in response to a malignant growth.

– Although often associated with preterminal patients bearing disseminated disease, cachexia may be present in the early stages of tumor growth before any signs or symptoms of malignancy.

– A decline in food intake relative to energy expenditure (which may be increased, normal, or decreased) is the fundamental physiologic derangement leading to cancer-associated weight loss.

– In addition, abnormalities of host carbohydrate, protein, and fat metabolism lead to continued mobilization and ineffective repletion of host tissue, despite adequate nutritional support.

Two ways to Fight Fatigue

• Medications– To fight anemia and increase red blood cells– Consult your physician

• Exercise– Increases red blood cells – Increase endorphins– Improve overall conditioning– Consult a PT/OT

Sleeping vs. Napping

• “Normal” uninterrupted nighttime sleep is crucial.

– If “normal” sleep is being achieved and the patient is exercising, napping as needed is ok.

– If not, napping should be discouraged.– Medication for improved sleep is recommended if

needed.

Exercise Cautions

• Bone metastases• Thrombocytopenia• Anemia• Fever or active infection• Limitations secondary to metastases or

other disease

Resources

• www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/

• www.pfizerpro.com/.../docs/NCCNFatigueGuidelines.pdf

Exercise is one factor within your control that can make a difference

in your life.

Exercise Benefits

Benefits of Exercise

• Enhances immune system• Reduces stress, anxiety

and depression• Stimulates production of

endorphins• Improves heart and lung

function• Enhances muscle strength

and endurance• Increases flexibility• Improves sleep

• Eases some side effects of treatment

• Maintain steady weight• Lowers cholesterol levels• Strengthens bones• Control blood sugar• Improves leans body mass• Lessens fatigue• Reduces “Chemo Brain”• Decreases constipation• Improves quality of life

Exercise Precautions

• Avoid exercise if you:– Have any type of infection– Feel dizzy or unstable– Have a fever– Had Chemotherapy with 24 hours– Have low blood counts

Cardiovascular Conditioning

• A form of exercise important to all cancer patients but especially those on Chemotherapy drugs that have cardiotoxic side effects.

• Improves physical and mental functioning• Prevent recurrence and extend survival• Consult physician about any precautions • Learn to take and track your heart rate• 30 minutes 5 days a week

Heart Rate

• Maximum Heart Rate = (MHR) • MMR = 220 – your age• Target HR (lower limit) = 0.6 x MHR• Target HR (upper limit) = 0.8 x MHR

Strength Training

• A gradual, progressive strength training program may actually minimize the risk for lymphedema by helping dilate or widen remaining lymphatic channels

• Prevents deconditioning from cancer related treatments

• Start slowly but 6 days a week• Alternate arm, leg and core exercise doing each

group 2 times per week• Low to moderate load for 8-10 reps.

Benefits to Strength Training

• Muscles burn calories twice as efficiently as fat and therefore help to maintain or lose weight

• Improve posture• Build stronger bones• Increase lean body mass• Improve balance and coordination• Use less effort to perform work and home

activities

Flexibility and Stretching

• Muscles and fascia can tighten up after surgery, radiation and chemotherapy

• Tight muscles and fascia can cause significant musculoskeletal problems to joints

• Stretching improves joint motions, decreases pain and increases circulation

Rules for Stretching

• Needs to be done in all positions…sitting, standing, hands and knees, side lying and lying on belly and back

• Long term effects of stretching needs to be done daily for long term

• Should be completed after cardiovascular and before strengthening

• Consult PT/OT for optimal exercise for your condition

Resources

• cancer.org (American Cancer Society)

• nci.gov (National Cancer Institute)

• nccn.org (National Comprehensive Cancer network)

• breastcancer.org• seer.cancer.gov (National Cancer Institute)

Exercise Education

• Weight loss / management is a critical part of the long term treatment success for our patient.

• Being too thin and too heavy is unhealthy

– Open discussion– Describe why it is hard on the body– Make a realistic plan for the patient

Exercise Education

• Give the patient a visual understanding of why they need to build cardiopulmonary and muscular strength

– “You are an athlete in training”– “fill your pantry”– “Manage you battery”

Exercise Guidelines

• Make sure the mode is enjoyable• The mode needs to be doable / accessible• Make sure the patient is successful

immediately

Exercise Guidelines

• Start aerobic exercise on first visit• Take advantage of post – operative or in-

between treatment timeframes

Exercise Guidelines

• Should involve both aerobic and strength exercise

• “longer” exercise is better than “faster” exercise• Should incorporate UE, LE and Core• Any amount of exercise is helpful

Exercise Guidelines

• Minimalist program:• Walk 5 minutes, twice a day• Wall pushups• Sit to stand

Exercise Guidelines

• Goal is an average of 1 to 5 hours per week of combined aerobic and strength exercise

• Direct correlation with the number of lymph nodes removed and if you are to receive radiation.

Lymphedema Triggers

• -INFECTION • - RADIATION • - EXTREMES OF HEAT • - TIGHT CLOTHING/ BP CUFFS • - AIRPLANES FLIGHTS

• results in swelling or accumulation of fluid in one or more limb or extremity

• caused by the break down of the body's ability to remove and filter intercellular fluids

• condition effects both men and women• may be a side effect of treatment for cancer• surgical removal of lymph nodes,

mastectomy/lumpectomy , radiation, trauma and hereditary factors can cause lymphedema.

Lymphedema

a. Hypoplasia- one does not have enough lymph vessels or the vessels are too narrow to carry an adequate load of fluid

b. Hyperplasia - the vessels are too wide and the valves are unable to work properly preventing effective removal of fluid.

c. Aplasia - absence of single lymph vessels or capillaries

d. Fibrosis - nodes become hardened and malfunction

Primary Lymphedema

• lymph nodes or lymph vessels damaged or removed

• may be the result of surgical removal of nodes

• radiation therapy • traumatic damage to large

lymph vessels or nodes following an accident

• infections, bacteria or fungi

Secondary Lymphedema

• when a tumor/cancer is the cause of lymphedema

Malignant Lymphedema

• Onset might be slow or rapid• Progressive swelling • In many cases starts distally

– Squaring of toes – Stammer’s sign positive – Loss of anatomical contours

• Asymmetric swelling if bilateral• Cellulitis is very common • Discomfort, heaviness, achiness • Skin changes in later stages

Lymphedema –Usual signs and symptoms

Diagnosis of Lymphedema

Case history and clinical examination are very important to determine diagnosis

• Diagnostic investigations are not generally necessary

• Other tests to rule out other causes of edema– Heart, kidney, liver, thyroid,

• Diagnostic investigation to exclude malignancy, prepare for surgical treatment, determine vascular status

Differential Diagnosis

• Lipedema • Lipolymphedema • Post-thrombotic syndrome/DVT • Chronic Venous Insufficiency • Ruptured Baker's Cyst • Malignancy• Reflex Sympathetic Dystrophy• Congestive Heart Failure • Fluid Retention Syndromes• Immobility/dependency• Hepatic/renal disorders

Stages of Lymphedema

Latency Stage• No visible signs of lymphedema. • Lymph collectors are able to keep up. • This stage, if identified early, we may be able

to prevent enlargement of a limb

Stages of Lymphedema

Stage I Reversible Lymphedema – Accumulation of protein rich edema fluid.– Develops after physical exertion or at the end of

the day and disappears after a nights rest. • Clinical signs:

– Soft pitting edema – Texture is smooth

Stages of Lymphedema

Stage II Spontaneously Irreversible Lymphedema• Protein rich fluid with connective and scar tissue. • Clinical signs:

– Pitting is denser– Gooey consistency– Texture harder because there is more protein present

• (fibrosis starts).

• Can get skin conditions such as eczema and erysipelas, papillamatosis and lymph fistule.

Stages of Lymphedema

Stage III Lymphostatic Elephantiasis – Protein rich fluid– Connective and scar

tissue– Hardening of dermal

tissue and papillomas of the skin• (angiomas)

• Clinical signs: – Extreme swelling of the

limb– Extreme deepening of

skin folds– Papillomas– leg looks like a column

and arm looks like a log– Ulceration and

lacerations are common

• Risk reduction, education, precautions• Early diagnosis and treatment • Complex Decongestive therapy –CDT

– Manual lymph drainage – Compression bandaging – Exercise– Skin and nail care– Instruction in self care

• Compression pumps • Surgery

Management of Lymphedema

Lymphedema Mgt. (Complete Decongestive Therapy)

Manual Lymph Drainage• Purpose of this hands on technique is to facilitate

peristalsis of the lymphangion• Increase in peristalsis will help pump the fluid

through the lymph system at a faster rate– increase LTV

• Reroutes the lymph flow around the blocked areas into more centrally located healthy lymph vessels which drain into the venous system.

Lymphedema Mgt(CDT)

Manual Lymph Drainage• The proximal area is treated

first, clearing first the adjacent and unaffected lymphotomes, then the proximal sections of the affected lymphotomes

• The direction of pressure depends on the areas of edema, and the direction should always be towards a cleared lymphotome

Lymphedema Mgt. (CDT)

Manual Lymph Drainage• The technique and variations are repeated

rhythmically at least 10 times either in the same location using stationary circles or in an expanding circle

• useless to do any less because the interstitial mass of the tissue fluid needs some time before it responds

Lymphedema Mgt.(CDT)

Manual Lymph Drainage• The pressure phase of a half circle lasts

longer than the relaxation phase • As a rule there should be no reddening of the

skin(this relative) • The technique should not elicit pain

Lymphedema Mgt.(CDT)

Compression Bandaging • Reduces the ultrafiltration rate • Improves the efficiency of the muscle pump

and joint pumps • Prevents the reaccumulation of evacuated

lymph fluid• Breaks up fibrotic tissue(scar and connective

tissue)

Lymphedema Mgt.(CDT)

Patient Education• Patient/family instructed in • self MLD• self Bandaging, • skin care precautions • therapeutic exercises• goal of the program is for the patient/family to be in

control of their lymphedema management

Compression

• Increases interstitial pressure, reducing leakage of capillary and increase absorption of tissue fluid by venous and lymphatic vessels during ultrafiltration

• Compression from foam pieces decreases fibrotic tissue

Compression

• Decrease capacity of superficial veins and lymph vessels by decreasing the vessel lumen diameter, which decreases blood volume, improves flow rate and decreases reverse flow

• Contraindications: Arterial occlusive disease , cutaneous infections and dermatitis.

Compression Bandaging

High elasticity(long stretch)• Continuous compression with low resistance,

i.e.Stockings and ACE wrap• can be extended 100-200% • contain high elastic components • develop high restoring force and hence develop

high resting pressure• should only be worn with activity and not at rest.

Compression Bandaging

Low elasticity(short stretch) • Gives resistance and compression• will have 30-90% extension • restoring force is low as is their resting pressure• When muscles are active, low stretch bandages

form a support since they create a high working pressure

• can be worn at rest and with exercise

Contraindications to CDT

Absolute Contraindications • Untreated malignant tumors tending toward

metastases • Acute inflammations(bacterial or viral) • Thrombosis • Active TB • Allergic reaction

Contraindications of CDT

Relative Contraindications • Chronic inflammation • Functional disturbances of thyroid (if treated

okay to do treatment) • Bone marrow patients(must be cleared to be

in the community without a mask, watch for fatigue)

Contraindications to CDT

Relative Contraindications• Bronchial asthma (do not treat during an acute

episode) • Cardiac arrhythmia(check with physician) • Deep abdominal drainage is not performed

during menses, on pregnant patients or inflammatory disorders of the abdomen

Contraindications to CDT

Contraindications to Bandaging • Arterial diseases • Cardiac edema • Acute infections • Malignant lymphedema (can do for palliative

treatment) • Bandaging should never cause pain,

numbness/tingling, discoloration of digits. Remove immediately if happens.

Goals of CDT

• Utilize remaining lymph vessels and other lymphatic pathways

• Decongest swollen body parts(arm/trunk) • Eliminate fibrotic scar tissue • Avoid the reaccumulation of lymph fluid • Prevent/eliminate infections Maintain normal

or near normal size of limb • Functional return to ADL's

Materials for Compression

Skin Care

• Skin obtains nourishment from underlying blood supply

• Swelling increases the distance between skin and blood supply

• Increased risk for infection

Skin Care

• Daily “skin checks”• Caution when cutting nails• Use wooden cuticle tools• Avoid artificial nails

Skin Care – Lotion

• Important to keep skin hydrated• Decrease risk for skin breakdown and

infection• PH level of lotion approximately 7.0

which is natural PH of skin• Gentle lotion – low in alcohol

– Johnson & Johnson Baby Lotion– Curel– Eucerin

Extreme Hot or Cold

AVOID:• Hot packs or

ultrasound• Deep massage on

affected limb• Saunas• Hot tubs• Sunburns• Hot showers

Exercise and Wellness Program

Point of Entry to the Program

• Ambulatory Patient Entry– Cancer Center / Oncology Nurse Navigators– Local Support Groups– Radiation Oncology Department– Multi-Disciplinary Clinics– Physicians / Physician Offices– Inpatient Unit Rounding (Acute Care PT Referral)– Patient Self Referral

Exercise and Wellness Program

Physical Therapy Screening

Patient referral to Survivorship Exercise & Wellness Program- Outpatient referral

Physical Therapist receives auto referral

from oneChart

Patient continues attending exercise

sessions in RDC 2nd floor gym as appropriate

Does patient require one-on-one rehabilitation with physical therapy?

Yes

No

Patient referral to Survivorship Exercise & Wellness Program- 2 North IP Unit

Referral from:- WCRC / ONNs - Support Groups- Radiation Onc - Patient (Self)- Multi-D Clinics - Physician Office

Physical Therapist meets with patient in

inpatient room

Clerical Coordinator contacts and coordinates

appointment time with patient

PTA tracks patient sign in for 6 sessions (location of sign in to

be determined)

Patient signs in and exercises in RDC 2nd floor gym with PTA

oversight

Patient arrives and Clerical Coordinator

checks in patient and completes initial

registration process (1st Floor RDC)

Clerical Coordinator

creates self pay appointment (CA SURV visit type)

with OP HAR

Clerical Coordinator contacts patient,

discusses program and schedules for

first exercise session

Physical therapist completes

registration form and hands/faxes to

Clerical Coordination(248-964-4020)

Physical Therapist develops

individualized program for ongoing

fitness

Patient undergoes PT/OT

Physical Therapy dept obtains

physicians referral for therapy with

signature

Clerical Coordinator schedules patient for

PT/OT

Physical therapist prescibes specific therapy based on

screening

Physical therapist provides patient

education

Physical therapist performs a screening

in WCRC

WCRC Clerical rep receives referral for

Survivorship Exercise & Wellness

WCRC Clerical rep faxes referral form to

PT/OT Clerical Coordinator

(248-964-4020)

30 minutes per patientTuesdays 8-11am and Wednesdays 1-4pm

Tuesdays and Thursdays 10am-2pm

Clerical Coordinator tracks patient

referrals in existing tracking spreadsheet

Physician referral received for PT/OT

Physical Therapist provides findings to

referring physician(s) via fax, requesting clearance

for exercise program

Clerical Coordinator collects payment for 6

sessions ($42) in Counterpoint, prints 2

receipt copies and gives 1 to patient (1st Floor RDC)

Clerical Coordinator escorts patient to 2nd floor RDC gym and meets PTA to give

paperwork

PTA completes clinical documentation regarding patient activities (RODC

and chart stored in locked file cabinet)

Personal/family guarantor account; Billing indicator automatically applied to visit type to avoid use of insurance

Physical Therapist provides findings to

referring physician(s) via fax, requesting

prescription for PT/OT

Clerical Coordinator has patient sign

consent and waiver (1st Floor RDC)

If non-responsive after 48 hours, call physician office

Clerical Coordinator deposits payment

collections and receipts in dropbox at end of day

Patient pays for additional 6 sessions on 1st Flr RDC when needed

Linen used from 1st floor and deposited in soiled utility room

Exercise and Wellness Program

Follow Up Care• Physical Therapist will provide patient and

physician with an evaluation, a specific exercise assessment and an exercise prescription

• Patient will follow one of four programs:– 1. Traditional Therapy (requires physician Rx)

– 2. Supervised Exercise & Wellness Program– 3. Home Exercise– 4. Individual Wellness

Exercise and Wellness Program

Follow Up Care (Continued)

Supervised Exercise & Wellness Program– Patients are able to implement their recommended

exercise program in a Beaumont facility with skilled supervision• Located at the Beaumont Medical Center, Sterling Heights –

Rehabilitation and Dialysis Center– Open exercise sessions

• Tuesdays and Thursdays from 10am to 7pm (2-4pm by request)

– Nominal fee for participation• Self pay at $7 per session

– Shared gym space with Cardiac Rehabilitation Phase 3 and Pulmonary Rehabilitation

“To be complete, a healing system must be able to cover the entire field of human experiences – physically, mentally and spiritually.”

~ Stanley Burroughs

Acknowledgements

• Reyna Colombo – Director Rehab Services, Beaumont Troy

• Jackie Drouin – Oakland University• Deb Doherty – Oakland University• Kris Thompson – Oakland University• Dr. John Maltese – Physical Medicine and

Rehabilitation – Beaumont Health System• Dr. Adil Akhtar – Beaumont Oncology Services• Dr. Eric Brown – Beaumont Oncology Services

Questions?

For Further Information• Beaumont Health System

– www.beaumont.edu • Healthcare Advisory Board

– www.advisoryboardcompany.com• Association of Community Cancer Centers

– www.accc-cancer.org • American Physical Therapy Association –

Oncology Section– www.oncologypt.org

• American College of Surgeons – Commission on Cancer– www.facs.org/cancer

References1. National Coalition of Cancer Survivorship. Defining Terms. Available at

http://www.canceradvocacy.org/resources/take-charge/defining-terms.html Accessed February 20, 2012.

2. Association of Community Cancer Centers. Cancer Program Guidelines. Rockville, MD: Association of Community Cancer Centers; 2009.

3. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered-Care. Chicago, IL. American College of Surgeons: 2012.

4. Healthcare Advisory Board. Cancer survivorship. Available at http://www.advisory.com/Research/Oncology-Roundtable. Accessed February 20, 2012.

5. American Cancer Society. Cancer Facts and Figures 2012. Available at http://www.cancer.org/Research/CancerFactsFigures/index. Accessed January 12, 2012.

6. Malone DJ, Bishop Lindsay KL. Physical Therapy in Acute Care: A Clinician’s Guide. Thorofare, NJ. Slack Inc. 2006.

7. Stubblefield MD. Cancer Rehabilitation. Seminars in Oncology. 2011; 38: 386-393.

8. Michaelson MD, Smith MR. Bisphosphonates for Treatment and Prevention of Bone Metastases. J Clin Oncol 2005; 23: 8219-8224.

References9. Mirels H. Metastatic disease in long bones: A proposed scoring system for

diagnosing impending pathologic fractures. Clin Orthop. 1989; 249: 256-264.10. Coleman RE. Management of Bone Metastases. The Oncologist. 2000; 5:463-

470.11. DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles & Practice of

Oncology. 7th ed. Philadelphia, PA. Lippincott Williams and Wilkins. 2005. 12. Barnholtz-Sloan JS, Sloan AE, Davis FG et al. Incidence proportions of brain

metastases in patients diagnosed (1973 to 2001) in the Metropolitan Detroit Cancer Surveillance System. J Clin Oncol 2004;22:2865–2872.

13. Stout NL, Pfalzer LA, Springer B, et al. Breast cancer–related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care. Phys Ther. 2012;92: 152-163.

14. Drouin JS, Wilson E, Battle E, Seidell JW et al. Changes in Energy Expenditure, Physical Activity and Hemoglobin Measures Associated with Fatigue Reports During Radiation Treatment for Breast Cancer: A Descriptive and Correlation Study. Rehabilitation Oncology. 2011: 29: 3-8.

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