Complementary Care Current Issues

1
Complementary CareCurrent Issues
Trends in Oncology Rehabilitation

• Melissa S. Walker, MPT, CLT
• Hamilton Physical Therapy Services
• Hamilton, New Jersey

2
Objectives

• Discuss most prevalent side effects reported by
  patients with cancer
• Relate long term quality of life issues for
  cancer survivors
• Explore Physical Therapys role in Oncology
  Rehabilitation
• Understand benefits of exercise for cancer
  survivors

3
Objectives

• Discuss Trends in Oncology Rehabilitation
• Breast Cancer Rehabilitation
• Head Neck Rehabilitation
• Lymphedema Management
• Cancer Related Fatigue

4
Most Prevalent Side Effects During Cancer
Treatments
1

• Fatigue
• Nausea
• Restrictions
• Pain
• Weakness
• Stress
• Decreased QOL

5
Quality of Life Issues

• Perceptions of Upper Extremity Problems During
  Recovery from Breast Cancer Treatments.
• 24 women post op breast CA lt 18 months
• Return to normal took longer than women or MD
  expected
• Difficulties worsened simple everyday
  responsibilities
• Physical lead to psychological strain
• Driving, sleeping, employability, housework,
  yardwork

2
6
Quality of Life

• Association Between Exercise Quality of Life in
  Bladder Cancer Survivor a Population-based
  Study.
• 525 Bladder cancer survivors
• 22.3 active vs 61.7 sedentary
• Active group with increased QOL

3
7
Physical Therapys Role

• Regain mobility
• Improve strength
• Reduce pain
• Combat cancer related fatigue
• Minimize nausea

• Decrease stress anxiety
• Restore quality of life
• Monitor treat lymphedema
• Empowerment

8
Physical Therapy Tools

• Soft tissue and Joint mobilizations
• Stretching ROM exercises
• Strengthening exercises
• Lymphedema management
• Biofeedback
• Aerobic conditioning
• Patient education

9
Breast Cancer Rehab

• Long Term Treatment related to upper extremity
  morbidity and Quality of Life after Sentinel
  lymph node biopsy for Stage I II Breast CA.
• Assessed SLNB and ALND post-op 2yrs
• Pain
• Shoulder ROM
• Strength
• Arm Volume
• Perceived QOL Disability

4
10
Breast Cancer Rehab

• Changes in Shoulder Muscle Size and Activity
  Following Treatment for Breast Cancer.
• 74 women SPADI, EMG, MRI
• Upper trap greatest loss of activity
• Rhomboids
• Pectoralis major and minor size

5,6,7
11
Breast Cancer Rehab

• Conclusions
• Not in direct field of surgery or radiation
• Primary Muscle Shortening
• Secondary Loss of Muscle Activity

12
Breast Cancer Rehab

• Sequelae of Treatment
• Incisional tightness/pain
• Impaired sensation
• Postural asymmetry
• Psycho-social impact

13
Breast Cancer Rehab

• Continued
• Decreased function
• Loss of strength ROM
• Scar tissue/adhesions
• Axillary web syndrome
• Loss of normal joint mobility
• Core Stabilization

www.bccancer.bc.ca
14
Breast Cancer Rehab MRM

• Post Surgical Intervention
• Diaphragmatic breathing
• Soft tissue / scar tissue mobilization
• Joint mobilizations GH, AC, SC
• Patient education
• Phases of therapeutic exercises
• Beyond wall walking

8,9
15
Breast Cancer Rehab MRM

• Phases I Exercises post-op
• Shoulder shrugs
• Shoulder rolls
• Front bar lifts
• Side bar lifts
• Back bar lifts
• Active shoulder flexion
• Wall walking

10
16
Breast Cancer Rehab MRM

• Phase II (3-6 weeks)
• Rotator cuff elevation
• Side triceps extensions
• Shoulder extensions
• Shoulder abduction
• Sidelying horizontal arm lifts
• Sidelying shoulder ER
• Bilateral shoulder flexion

17
Breast Cancer Rehab MRM

• Phase III (6-10 weeks post-surgery)
• Continued bar lifts, ER, arm lifts
• Internal rotation towel stretching
• Forward ball stretch
• Shoulder rotation with ball
• Bridging
• Shoulder pullovers

18
Breast Cancer Rehab TRAM Flap

• Rehabilitation considerations
• Decreased shoulder range of motion
• Abdominal/truncal weakness
• Pain related to denervation
• Low back pain
• Lymphedema
• Breast
• Abdomen

19
Breast Cancer Rehab TRAM
Contraindications
11
20
Breast Cancer Rehab TRAM

• 0-3 Weeks
• Manual lymphatic drainage prn
• 3-5 Weeks
• Scar mobilization
• Gentle myofascial release (MFR)
• Manual stretching of UE (drains out)

• 8 Weeks
• Scar friction massage
• MFR as tolerates lateral chest wall, abdomen

21
Breast Cancer Rehab TRAM

• 4 weeks post-op

22
Breast Cancer Rehab TRAM
6 weeks post-op
23
Breast Cancer Rehab TRAM
10 weeks post-op
24
Breast Cancer Rehab

• Chemotherapy Effects
• Psycho-social effects
• Cardiac damage
• Decreased aerobic capacity
• Weight gain/loss (sarcopenia)
• Premature menopause
• Nausea
• Joint pain

• Radiation Effects
• Radiation Induced Fibrosis
• Muscle Impairments
• Shoulder and Neck range of motion deficits
• Lymphedema
• Osteoporosis
• Organ fibrosis
• Radiation Recall

25
Head Neck Cancer Rehab Issues
12,13,14

• Radical Neck Dissection RND
• Most shoulder disability 60-100
• Modified Radical Neck Dissection MRND
• Weakness _at_ 6months 50
• Selective Neck Dissection SND
• Preserve SANS least dysfunction

26
Head Neck RehabSurgerical Procedures

• MRND
• excision of all lymph nodes routinely removed in
  RND with preservation of one or more nonlymphatic
  structures (SAN, IJV, SCM).

27
Head Neck Case Study

• A 21 y/o non smoking Caucasian male s/p modified
  radical neck dissection 2nd squamous carcinoma of
  the oral cavity/tongue.
• Goalie in the off season of junior league hockey
  when diagnosed

28
Head Neck Post-op Evaluation

• Manual Muscle Testing
• Shoulder, Facial and Cervical
• Posture
• Range of Motion
• Shoulder, Cervical and Jaw
• Scar Mobility and Sensation
• Lymphedema vs Post Surgical Edema
• Pain

29
Head Neck Rehab
15

• Soft tissue mobilization
• AROM AAROM for affected areas
• Strengthening scapular muscles
• Desensitization
• Postural Awareness
• Education regarding

30
Head Neck Recovery Wellness

• Patient decided he wanted to return to team for
  final practice
• Patient was cleared by physician

31
Head Neck Sports Specific Rehab

• Aerobic Conditioning
• More aggressive strength training in upper and
  lower extremities
• Balance and Coordination
• Flexibility
• Bosu Ball and Sports Specific Drills

32
What is Lymphedema
16

• Abnormal accumulation of lymphatic fluids in the
  interstitial tissue
• It is protein rich fluid (compared to a low
  protein edema)
• Occurs most often in the arms and/or legs and
  less often in other parts of the body

33
Causes Lymphedema

• Primary lymphedema- present at birth or onset
  after puberty. Born without enough lymph nodes,
  or lymphatic collectors
• Secondary Lymphedema- developed due to trauma,
  infection, surgery, tumors, and/ or radiation to
  the lymph node regions. Can be within days to
  several years later.

34
Subjective Complaints

• Full sensation in the limb
• Skin feeling tight
• Decreased flexibility in limb
• Difficulty fitting clothing
• Persistent edema of the limb

35
Characteristics

• Slow onset, progressive
• Pitting
• Starts distally
• Squaring of toes, positive Stemmer sign
• Buffalo hump
• Loss of ankle contour
• Asymmetry of limbs

36
Characteristics Cont.

• Rarely Painful
• Discomfort due to heaviness
• Skin changes
• Hyperkeratosis, papillomas, peau Dorange
• Ulcerations unusual

37
Stage I

• Stage I mild, pitting of the limb, size is
  normal after rest or early in the morning.

38
Stage II

• Stage II moderate, tissue is spongy and non
  pitting, fibrotic tissue increases, not relieved
  with rest

39
Stage III

• Stage III Severe, hard fibrotic tissue,
  unresponsive to position, hyperkerotic deposits

40
Obstructive Malignant Lymphedema

• The tumor is obstructing lymph flow

41
Lymphedema Management

• Complete Decongestive Therapy
• Manual Lymphatic Drainage
• Compression Bandaging
• Therapeutic Exercises
• Education Self Care
• Pumps and Debulking Surgeries

17
42
Manual Lymph Drainage
18

• Increase lymph vessel activity
• Increases re-absorption of protein-rich fluid
• Reduces fibrosis

• Promotes relaxation
• Treats the whole affected quadrant
• Facilitates collateral drainage

43
Compression Bandaging

• Low stretch bandages NOT ACE WRAPS
• Build a pressure gradient to facilitate improved
  lymph flow
• Continues to aid in reduction of fluids
• Once stable transition to compression sleeve

44
Remedial Exercises

• Performed with compression bandaging
• Low exertion
• Increases muscle and joint pump

• Increased venous and lymphatic return
• Active ROM, stretching, and strengthening

45
Lymphedema Management

• Skin Care
• Patient Education

46
Lymphedema Management

• This is a stage III lymphedema patient after
  three months of CDT treatment.

After
Before
47
Cancer Related Fatigue
1

• CRF is abnormal or pathologic fatigue.
• It appears during normal activities, persists for
  longer periods, and does not improve with rest.
• It can become severe enough to force patients to
  reduce their activity level.
• Occurs in 75-90 of cancer survivors

48
Symptoms of CFR

• Feeling tired even though youve had a good
  nights sleep
• Feeling sleepy throughout the day
• Feeling sudden, extreme tiredness
• Feeling too weak to stand

• Finding it difficult to start routine activities
• Needing to rest during normal activities
• Difficulty concentrating
• Withdrawing from social interactions due to lack
  of energy

49
CRF Management

• Pharmacological Interventions
• Procrit, Antidepressants, Pain medications, Sleep
  aides
• Non-Pharmacological Interventions
• Exercise, Energy Conversation, Nutrition

50
CRF Management
19,20,21

• Exercise reduces daily fatigue in women with
  breast cancer receiving chemotherapy. Schwartz
• Randomized controlled trial of exercise training
  in postmenopausal breast cancer survivors
  cardiopulmonary and quality of life outcomes
  Courneya
• A randomized, controlled trial of aerobic
  exercise for treatment-related fatigue in men
  receiving radical external beam radiotherapy for
  localized prostate carcinoma. Windsor

51
Benefits of Exercise for Cancer Patients
22

• Immune System Function
• Mood
• Quality of Life
• Bowel Mobility
• Cardiopulmonary Endurance
• Lean Muscle Mass

52
Benefits of Exercise for Cancer Patients

• Adverse Weight Gain
• Nausea
• Heart Rate
• Blood Pressure
• Pain
• Edema
• Cancer Related Fatigue

53
CRF Management

• Guidelines for Adults
• Engage in at least moderate activity for 30
  minutes or more on 5 or more days of the week
• 45 minutes or more of moderate to vigorous
  activity on 5 or more days per week may further
  reduce the risk of breast and colon cancer.

54
CRF Management
How to get started when I am always so very
tired!?
55
Conclusions
THEN
Amputations, Reconstructions, Burns
NOW
Mastectomy, Breast Reconstructions, Radiation
Fibrosis
56
Its not the size of the dog in the fight, but
the size of the fight in the dog. -Archie
Griffin
57
Special Thanks

• Nancy J Roberge, PT, DPT, MEd
• Lucinda A Pfalzer, PT, PhD, FACSM
• Jacqueline S. Drouin, PT, PhD

58
References

• 1. Winningham M. Fatigue and the Cancer
  Experience the State of Knowledge. ONF. 21(1)
  23-36 1994.
• 2. Collins, Nash, Newman. Perceptions of upper
  extremity problems during recovery from breast
  cancer treatment. Support Care Can. 2004 12 (2)
  106-113.
• 3. Karvinen KH, Courney KS, North S, Venner P.
  Association between exercise and quality of life
  in bladder cancer survivors a population-based
  study. Cancer Epidemiol Bio Prev. 2007 16 (5)
  984-990.
• 4. Reitman et al. Long-term treatment related to
  upper extremity morbidity and quality of life
  after sentinel lymph node biopsy for Stage I and
  II breast cancer. Eur J Surg Onc. March 2006.
• 5. Shamley DR, et al. Changes in shoulder muscle
  size and activity following treatment for breast
  cancer. Breast Cancer Res Treat. Jan 13, 2007.

59
References-continued

• 6. Shamley Dr, Barker K, Simonite V, Beardshaw
  A. Delayed verse immediate exercise following
  surgery for breast cancer a systemic review.
  Breast Cancer Res Treat.2005 90263-271.
• 7. Kakuda JT, Stuntz M, Trivedi V, Klein SR,
  Vargas HI. Objective assessment of axillary
  morbidity in breast cancer treatment. Am Surg.
  1999 65 995-998.
• 8. Kirshbaum MN. A review of the benefits of
  whole body exercise during and after treatment
  for breast cancer. J Clin Nurs. 2007 16 (1)
  104-121.
• 9. Kilbreath S, Refshauge K, Beith J, Lee M.
  Resistance and Strengthening shoulder exercises
  early following axillary surgery for breast
  cancer. Rehab Onc. 2006 24 (2) 9-13.
• 10. Clinton S, Kinler E, Pariser G, Nuss D.
  Physical Therapy Management of a Manual Laborer
  Following a Modified Radical Neck Dissection.
  Rehab Onc. 2007 25(2) 3-11.

60
References-Continued

• 11. Laverick S, Lowe D, Brown JS, Vaughn ED,
  Rogers SN. The impact of neck dissection on
  health-related quality of life. Arch Otolaryngol
  Head Neck Surg. 2004 130 149-154.
• 12. Sobel S, Jensen C, Sawyer W, Costiloe P,
  Thong N. Objective comparison of physical
  dysfunction after neck dissections. Am J Surg.
  1985 150 503-509.
• 13. McNeely Ml, Parliament M, Courneya KS, et
  al. A pilot study of a randomized controlled
  trial to evaluation the effects of progressive
  resistance exercise training on shoulder
  dysfunction caused by spinal accessory
  neurapraxia/neurectomy in head and neck cancer
  survivors. Head Neck. 200426518-530.
• 14. Kelly, DG. A primer on Lymphedema.
  Prentice Hall Upper Saddle River 2002.
• 15. Weissleder, H Schechhardt. Lymphedema
  Diagnosis and Therapy. Third Ed. Viavital
  Erlag. 2001.
• 16. Badger C, Preston N, SeerK, et al, Physical
  Therpies for reducing and controlling lymphedema
  of the limbs. Cochrane Database of Systematic
  Reviews 2004, Issue 4.

61
References-Continued

• 17. McNeely ML, Magee DJ, et al. The addition
  of manual lymphatic drainage to compression
  therapy for breast cancer related lymphedema.
  Breast CA Res Treat. 2004 86 95-106.
• 18. Schwartz A, Mori M, Gao R, NailL, King M.
  Exercise reduces daily fatigue in women with
  breast cancer receiving chemotherapy. Med Sci
  Sports Ex. 2001 33(5) 718-723.
• 19. Burnham T, Wilcox A. Effects of exercise on
  physiological and psychological variables in
  cancer survivors. Med Sci Sports Ex. 2002
  34(12) 1863-1867.
• 20. Courneya K, Mackey J, Gell G, Jones L, Field
  C, Fairey A. Randomized controlled trial of
  exercise training in postmenopausal breast cancer
  survivors cardiopulmonary and quality of life
  outcomes. Journal Clin Onc. 2003 21(9)
  1660-1668.
• 21. Windsor P, Nicol K, Potter J. A randomized,
  controll trial of aerobic exercise for
  treatment-related fatigue in men receiving
  radical external beam radiotherpy for localized
  prostate carcinoma. Cancer. 2004 101 550-557.