Transcript File #4 - Health Professions Division

Oncology Rehabilitation: Web-based Learning for Physical Therapists
Who Provide Rehabilitation to Patients with Breast Cancer
File #4
Breast Cancer Rehabilitation
Breast Cancer Rehabilitation
• The physical therapy profession is the ideal medical profession
to deal with all aspects of establishing and following a safe and
realistic mobility and strengthening plan of treatment for the
breast cancer patient. This professional has the ability to
decipher all medical information presented by the physician and
diagnostic studies presented concerning the status of the
breast cancer patient.
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Role of the physical therapist when
treating breast cancer patients:
• Educate public of early detection
• Educate the patient, family, physician and other health
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care providers of the need for rehabilitation for the
patient diagnosed with breast cancer.
Follow a safe and functional rehabilitation program with
realistic goals for each individual
Help improve Quality of Life
Promote care to decrease side effects
Improve patient’s outlook on recovery
• Breast Cancer: FYI Resources suggests, “Consider at
least one session with a physical therapist if you have
any kind of breast cancer related surgery”.
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America Cancer Society, Surveillance
Research, 2005 Estimated Breast Cancer
In situ and Invasive for Age Groups
AGE
< 40
40 and older
Under 50
50 and older
Under 65
65 and older
In Situ
1,600
56,890
13,760
44,730
37,040
21,450
Invasive
9,510
201,730
45,780
165,460
123,070
88,170
ALL AGES
58,490
211,240
(American Cancer Society, 2005)
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THE REFERRAL FOR
PHYSICAL THERAPY
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Who is going to make the
therapy referral?
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General Practitioner
Internist
Surgeon
Plastic Surgeon
Oncologist
Radiation Oncologist
Radiologist
Psychiatrist
Pathologist
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Nurse
Social Worker
Psychologist
Nutritionist
Chaplain
Family Member
Friend
Patient
Physical Therapist
Many choices and potential referral sources.
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“Despite potential benefits,
referrals of cancer patients for
rehabilitation are often made
needlessly late or not at all”.
Physician Text: CANCER MEDICINE
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• Physical therapist may need to solicit the
benefits of cancer rehabilitation to
physicians, other cancer team members
and patients.
(Ragnarsson, 2003)
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Could breast cancer
rehabilitation
be your Niche?
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Niche:
• A place, employment, status or activity for which
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a person or thing is best fitted.
A specialized market
(Webster’s Universal Encyclopedic Dictionary, 2002)
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What is your niche?
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Oncology
Orthopedics
Athletics
Temporomandibular Dysfunction's
Urinary Incontinence
Pediatrics
Soft tissue work
Relaxation Programs
Administration
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Determining your Niche
Things to consider
Expertise
Experience
Interest
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Make your own niche
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S
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Search
Understand
Confidence
Challenge
Excitement
Support
Succeed
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Health Care Reform
ICD-9-CM Codes
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HEALTH CARE
REFORM
Wellness reduces Illness
Wellness decreases expense
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Key Issues of
Health Care Reform
Access to Care
Quality of Care
Prevention
Standard Benefits Package
Cost Containment
Education and Research
National Boards
State Autonomy
Workers’ Compensation
(APTA, 1994)
Helpful breast cancer ICD 9-CM codes
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Fatigue – limiting ADL’s……………………….780.7
Nausea – limiting ADL’s.……………………...787.0
Generalized pain limiting function…………780.9
Weakness limiting ADL’s……………………...780.7
Muscular wasting, disuse atrophy…………728.2
Difficulty walking………………………………..719.7
Lymphedema…………………………………....457.1
Breast Pain……………………………..…………611.71
Adhesive Capsulitis……………………..……..726.0
(McCormack, 2002)
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For all of the expensive medical interventions, insurance companies should
realize the benefit of physical therapy, to promote wellness and decrease
sickness during and after treatment programs for breast cancer.
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Mammogram
Biopsy
Pathology
Lumpectomy
Radiation
Modified Radical Mastectomy
Reconstruction
Chemotherapy
Rehabilitation
Insurance reimbursement for program services is usually very good.
All coding should be assigned to a patients’ functional diagnosis rather
than the oncology diagnosis. The diagnosis should be based on whatever
functional activities are limited and what is creating the limitation.
(McCormack, 2002)
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Psychology and Support Issues
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ARE YOU THE THERAPIST
TO TREAT THE PATIENT
DIAGNOSED WITH BREAST
CANCER
• The progress of your
program will depend greatly
upon your ability to motivate
your patient.
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In each dish place the name of a family member
that you could live without…….Pretty tough!
Just an idea of how cancer patients and families may think. 20
Your patient is coping
with:
• Illness
• Changes
• Next holiday could be last
• Medical environment and caregivers
• Self Image
• Relations coping with illness
• Future
• If in remission.....When will it return?
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Common fears of cancer patients:
The 5 D’s
• Death
• Disfigurement
• Disability
• Dependence
• Disruption of Relationships
(Source unknown)
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Criteria for Depression
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Persistent low mood (4 weeks)
Inability to enjoy oneself
Repeated or early waking
Impaired concentration
Guilt, self blame or burden
Irritability and anger for no reason
Loss of interest
Agitation
Suicidal
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How patients and families may cope
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Laughter can keep you from feeling bad.
Notice those that might be worse off.
Fight with those around.
Important to have knowledge of illness.
Refuse to believe that it can happen.
Turn to others for support.
Stay busy to decrease time to worry.
Go over problems in mind.
Avoid illness as topic of conversation.
New faith in this experience.
(Snyder, 1992)
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SELF ESTEEM
• WIGS that guarantee
the hair will look so
much like the original
hair that the patient is
the only one to know it
is a wig.
• NATURAL:
• 1-800-272-2424
• HAT DESIGNS for
hair loss.........
1-215-247-8777
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CAREGIVERS
(Survey of 225 Families)
• 49%...Experienced prolonged depression
• 74%...Found unknown inner strength
• 69%...Frustrated
• 43%...Sad with experience
• 39%...Associated care with love
• 46%...Felt appreciated
• 30%...Felt taken for granted
• Caregiving and Cancer, should be
reviewed to promote this challenge at:
• http:/www.utmb.edu/insights/Outreach/Caregiving_and_Cancer ppt
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• American Cancer
Support Guide
• National Lymphedema
Network
1-800-541-3259
Society (ACS)
1-800-ACS-2345
• National Cancer
Institute (NCI)
1-800-4-CANCER
• Job Accommodation
• Equal Employment
1-800-526-7234
• National Coalition for
Cancer Survivorship
1-301-650-8868
Commission
1-800-872-3362
• State Dept. of
Vocational Rehab.
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AMERICANS WITH
DISABILITIES ACT
Legal Protection For Cancer
Patients Against
Employment Discrimination
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Dealing with Pain
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PAIN
Be prepared to deal with
patients reporting pain
and inform their
physicians of the
benefits of exercise.
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PAIN
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Agency for Health Care Policy and Research Guidelines for
Cancer Pain
• Promotes communication between the patient and the
health care provider dealing with pain.
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The American Cancer Society estimates that 70% to
90% of cancer patients will experience pain during
some phase of their disease or treatment.
(www.mskcc.org, 1999)
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PAIN
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Document location and description of pain.
Rate worse pain, using a 1-10 scale.
Time pain is increased and decreased.
What increases and decreases pain.
This documentation will allow you to
objectively assess changes in pain.
(Hassler, 1994)
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Why cancer pain?
• Biological mechanism
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Bone destruction
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Obstruction
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Infiltration or Compression
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Infiltration or Distention
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Inflammation, Infection and
necrosis of tissue.
(Otto, 2004)
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Pain Medications
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Soft tissue
Nonsteroidal Anti-inflammatory (NSAI)
Bone
NSAI
(Prednisolone)
Compression of nerves
(Dexamethasone)
Muscle spasm
(Diazepan or Baclofen)
Fungal tumor
Antibiotics
Cellulitis
Systemic
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Management of Cancer Pain
• Evaluation
• Physical and Neurological Exam
• Differential Diagnosis
• Pain history and pattern
• Present and past medication
• X-Rays, MRI, CT, EMG, lab results
• Nutrition history and interventions
• Functional evaluation
• Realistic Goals
• Plan management (Ca / pain / psych)
• Focus on patient and family
(Otto, 2004)
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Pain Management
A vicious cycle
• Which modalities are
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best suited for the
patient diagnosed
with cancer?
List Modalities
List considerations
List safety
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Pain
Fatigue
Anxiety
Depression
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Listed Physical Therapy Modalities
• Cutaneous Stimulation
• Heat
• Cold
• Massage, Pressure , and Vibration
• Exercise
• Repositioning
• Immobilization
• Counter stimulation
• Transcutaneous Electrical Nerve
Stimulation
• Acupuncture
(Pfalzer, 1992)
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Time Out Test
• As far as specialization, what is an advantage of being a physical
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ANSWERS
You can pick your individual field of interest; True; False; True; Death,
Disfigurement, disability, dependency and disruption of relationships; True;
Fatigue, anxiety and/or depression.
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therapist?
Wellness can decrease medical cost? T / F
A patient diagnosed with breast cancer, only thinks about their
diagnosis? T / F
As a physical therapist, you might note signs of depression? T / F
What are considered the 5 fears of a cancer patient?
By supplying information concerning support organizations, you can
help decrease patient stress? T/F
The pain cycle can lead to what other complications?
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LIVING A QUALITY LIFE
THROUGH REHABILITATION
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Mission Statement
• Through emotional support, education,
rehabilitation, and exercise we strive to
empower the patient diagnosed with
cancer to maintain and improve their
quality of life.
(Coleman Consulting, 1997)
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Philosophy
• Physical rehabilitation should be synonymous
with cancer care. Loss of strength and
function, as well as overall physical fitness
must be restored in order to maintain quality
of life. Our aim is to assist the patient
diagnosed with cancer with education,
exercise and support throughout the
treatment and recovery periods. Promotion
of wellness allows an individual the
opportunity to meet future health challenges.
(Coleman Consulting, 1997)
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Rehabilitation Options
• Prevention: Prevent functional loss in early
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stages of diagnosis.
Restorative: Reach maximal function when
physical impairment or disability are present.
Supportive: Increase self care and mobility
for the patient with progressive cancer and
impairment. Teach energy saving methods.
Palliative: Comfort and function for those
patients diagnosed with terminal conditions.
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General Goals
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Prevent Deconditioning
Maximal functional skills
Emotional Support to patient and family
Education of patient of condition
Treatment and Home Program
Assist in Pain and Symptom Control
Assist in Health Promotion
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Specific Goals
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Increase Strength and Endurance
Decrease nervousness, irritability & anxiety
Increase attention span and concentration
Improve Posture
Maintain or Improve ROM & flexibility
Promote independence (gait/transfer/ADLs)
Development of disease education, including
treatment program.
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Evaluation Tools
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Evaluation Scales
• Functional Independence Measure (FIM)
• Karnofsky Performance Status Scale
• Zubrod Performance Scale
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FIM
• 7 Complete Independence (Timely, Safely)
• 6 Modified Independence (Device)
• Modified Dependence
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NO ASSISTANCE
HELPER
5 Supervision
4 Minimal Assist (Subject = 75%+)
3 Moderate Assist (Subject = 50%+)
Complete Dependence
2 Maximal Assist (Subject = 25%+)
1 Total Assist (Subject = 0%+)
ADMIT / DISCHARGE / FOLLOW-UP
Self Care / Sphincter Control / Mobility / Locomotion /
Communication / Social Cognition
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Karnofsky
General:
Specific:
• 100 Normal, no complaints, No
evidence of disease
Able to carry on normal activity, no
special care needed.
• 90 Able to carry on normal activity
minor signs or symptoms of
disease
• 80
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Unable to work, able to live at
home and care for most
personal needs, varying amount
of assistance
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Unable to care for self, requires
institution or hospital care for
disease that may be rapidly
progressing
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Normal activity with effort,
some signs or symptoms of disease
70 Cares for self, unable to carry
on normal activity or to do work.
60 Requires occasional assistance
of others, but able to care for most
needs
50 Requires considerable
assistance from others, frequent
medical care
40 Disabled, requires special care
30 Severely disabled, death not
certain
20 Very sick, hospital, need
support
10 Moribund
0 Dead
(Abraham, 2005)
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Important information to obtain
when evaluating the cancer patient
• Medical Information
– Primary diagnosis / Stage of disease / Surgery / Chemo /
Radiation / Blood counts / Prognosis
• Physical Exam
– Mental status / Vital signs / Strength / ROM / Reflexes / Pain
• Mobility State
– Bed mobility / Balance / Transfers / Ambulation / Assistive
devices
• Psychological State
Coping skills
• Social State
Family / Job / Recreation
• Home Environment
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Lab values and guidelines
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Rehabilitation Treatment Plan
• Bone Marrow Transplant Complications:
– Decreased mobility and joint ROM
– Decreased endurance
– Increases fatigue
– Decreased strength
– Increased pain
– Decreased function
– Decreased motivation
– Decreased pulmonary function
(Koczur, 1996)
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Guidelines when establishing a treatment plan
Platelet Counts:
< 20.000 : Palliation and Support (P&S)
No anti-gravity exercise
No resistive exercise
25-50,000 : Support and Restoration (S&R)
sub-maximal isometrics
isotonic exercise (light weights)
no prolonged stretching
no low speed isokinetics
> 50,000 :Restoration and Prevention (R&P)
Most programs acceptable
Under 50,000 can increase the risk of bleeding
(Hicks, 1990)
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Continual Guidelines
Hematocrit (Hct.) / Hemoglobin (Hb.)
< 25/10: Palliation & Support
range of motion
no aerobics
no isotonics
25-35/10-12: Support & Restoration
low impact and intensity
aerobics (bike ergometer)
Isometrics
modified isotonics
35/12: Restoration & Prevention
most programs acceptable
(Hicks, 1990)
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Additional Guidelines
PFT’s (Cardio-Pulmonary function impairment):
50% capacity P&S
No aerobics
50 – 75%: S&R
Low intensity aerobics
>75% R&P
Most programs acceptable
Metastatic or bone tumor
> 50% cortex involved P&S
No exercise
Non-weightbearing
25-50%: S&R
Partial weight bearing
Range of motion (No stretching)
0-25%: R&P
Full weight bearing
(Hicks, 1990) 55
Time to think Exercise
The best way to ensure desired outcomes from exercise is to
recognize the needs, limitations and capabilities of each
individual. Remember your patients’ need for required
cardiovascular, pulmonary or muscle strength or endurance
training.
By enhancing everyday performance activities, your patient will
improve mobility and independence; Improve and maintain
posture and muscle balance; show an awareness of injury
prevention; and promote physical and mental relaxation.
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Start to establish an exercise program.
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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EXERCISE
• Capacity depends on:
– Physical Condition
– Stage and Type of Cancer
– Treatment Program
– Side Effects
– General Health
• A fitness program differs for a mastectomy
patient compared to late stage lung Ca.
• Exercise brings about immediate or acute
physiological responses as well as long term or
chronic responses.
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General Oncology Rehabilitation
• Function / Cardio-Endurance / Energy Conservation /
Pain Management / Strength - Balance / Education.
• 1st Visit...Eval. / OOB 1 hr. / energy conservation /
Deep breathing.
• 2nd Visit..OOB < 1 hr. 2-3 X/day / energy and safe
home techniques / Vital signs with ambulation 20-40'
/ Cool down.
• 3rd Visit..OOB 2-3 hrs. 2-3 X/day / Continue energy
conservation / Ambulate as tol./ Home Program /
Eval home.
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Benefits of Regular Exercise
• Weight loss and decreased body fat
• Lower risk of cardiovascular disease and
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cancer
Lowers blood pressure
Decrease insulin use in diabetics
Prevents Osteoporosis
Lowers serum cholesterol
Slows aging of heart and lungs
Reduces back pain
Improves self-image
(www.healthclubs.com, 2006)
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Benefits of Exercise with Cancer
• Increase
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– Accumulation of muscle protein
– Joint mobility
– Strength
Decrease
– Edema
– Pain
– Anxiety
– Depression
Enhance Immune Function
Decrease Infection susceptibility
(www.sportsmedicine.about.com, 2006
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General Breast Cancer Diagnosis
Exercise … You Decide?
• Aerobic (Walk, Jog, Cycle or Swim)
• Increase heart rate
• Increase lung capacity for O2 intake
• Increase O2 to muscles
• Increase metabolism to control weight
• Decrease in blood cholesterol
• Increase in bone strength
• Increase in endurance
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Decide?
• Anaerobic: (Weight lifting or Sprinting)
• Short burst of intense activity
• Develop muscles
• Develop strength
• Develop speed
• Develop power
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Walking:
• Excellent choice of Exercise
• Increase lung function
• Stimulates bone growth and strengthens leg and
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back musculature
METS to LE or back may eliminate running but
walking may be approved (Less trauma)
In pool gentle yet stimulates heart & lungs
Consult M.D. when dealing with metastasis
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Swimming
• Good choice with pain of spine, hips or
pelvis possibly due to metastasis
• Increase aerobic capacity if performed far
and fast enough
• Stretches muscles and lung capacity
• Strengthening against water resistance
• Consult M.D. when dealing with METS
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Stretching & Yoga
• Increased flexibility and decreased muscle
tension
• Increased circulation
• Well stretched muscles require less energy
for movement
• Important for shortened muscles from rest
(Slow stretch prevents muscle tear)
• Yoga and deep breathing promote an
emotional edge due to body awareness.
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Exercise Facts:
• Exercise builds muscle tissue, strengthens
the heart, increases lung capacity to take
in oxygen and improves circulation.
• Exercisers report increased energy and
stamina with decreased deconditioning.
• Stretching, Yoga, Walking & Swimming
stimulate muscles & circulation without
stress.
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Psychological Benefits
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Increase feeling of well being
Give patient sense of control
Improve self-esteem
Enhances Coping
Increased attention span & concentration
Decrease Anxiety
Decrease Depression
Increase Strength, Mobility & Fitness
(Gavin, 2006)
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Functional Assessment
• Must obtain measurable benefits
(Outcomes)
• Rehabilitation judged by functional ability
that results from treatment
• Assess function by monitoring changes in
activity of self care, mobility, and
communication.
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Accurate documentation
promotes future progress
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Documentation
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Focus on function
Use vital signs for an objective measure
Focus on short term goals
REALISTIC GOALS
Describe teaching sessions
Document lab values (Very Important when treating
cancer patients)
Comisac, 1996
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Ideal rehab candidates are
those who are/were previously
in excellent health, strength
and fitness.
Everyone is different and
should be treated as an
individual.
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Questions to ask ?
• What can the patient do?
• What do they need to do?
• What do they want to do?
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Examples of specific breast
cancer rehabilitation programs
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Pre-Surgical Evaluation
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Ideal program
Education of expectations
Introduction helps decrease anxiety & fear.
Screen patient’s condition prior to medical
intervention (Psychologically, Strength, Mobility & Girth) .
Ability to initiate safe and functional
rehabilitation program.
Avoid undue stress on involved extremity.
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Post-Surgical Evaluation
• Completed as soon as possible.
• Teach proper elevation for comfort and
edema control.
• Control upper extremity flexion until
drains are removed.
• Teach support program
• Compare to pre-evaluation
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EXERCISE PROGRAM
• Components of
Exercise
• Exercise is essential,
but precautions must
be taken
• Range of Motion
• Strength
• Endurance
• Safety
• Contraindications
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Safe Exercise Program
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Common sense
M.D. Clearance
Limit before lab work / infection /fever
If ill from treatment: Wait a day
Start Slowly
Avoid Pain
Caution with low blood counts
Avoid infections including foot care
Return to M.D. with persistent complaints
(Coleman Consulting, 1997)
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Contraindications to Exercise
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Unusual fatigue
Unusual weakness
Irregular pulse
Decreased heart rate
with work
Leg pain / cramps
Nausea, Vomiting or
Diarrhea
Disorientation
• Dizziness, Blurred
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vision or Faintness
Pallor or Cyanosis
Dyspnea onset
IV chemo last 24 hrs.
Platelets <20,000
White Blood Count
<1500
(Arnall, 2005)
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POSTURE
• Shoulder depression and internal rotation with
scapula protraction
• Serratus Anterior weakness...Winging due to
overstretch of long thoracic nerve.
• Latissimus dorsi weakness overstretch of
thoracodorsal nerve.
• Pectoralis major/minor weakness.Minor may have
been removed; Medial pectoral nerve no longer
innervates lateral border of pectoralis major.
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Strength Training
• Weight training to build musculature
• Must control resistance and calories with
proper monitoring
• Machines safer than free weights to assure
good posture and functional mobility
• Manual resistance exercise regime may be
utilized to promote strength
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EXERCISE
• Even with advanced disease exercise can
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help decrease depression, tissue loss and
fatigue
Passive mobility program may be
appropriate
Exercise with pain meds more beneficial
Guide towards individual challenges:
Marathon / Bike Ride or a Walk around the
block. This will be established between the
patient and the therapist.
Be R-E-A-L-I-S-T-I-C
Additional study results follow, which will
help benefit you to expand your knowledge
of the benefits of rehabilitation for breast
cancer survivors.
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The Coleman 10 Step Program
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VI
VII
VIII
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Individualism
Physical Therapy Evaluation
Ancillary Services
Patient Education
Rehabilitation Program
Progress Step
Group Exercise Program
Follow-Up
Out Reach Program
Home Maintenance
(Coleman Consulting, 1997)
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REHABILITATION
• Rehabilitation interventions should begin at
bedside, getting patient OOB as soon as
possible to work towards discharge.
• Intense rehab after discharge is determined
by patients life expectancy (> 1 year) and
medical capabilities to participate (including
motivation and mental considerations).
• After discharge to home setting, it is important
to assure that patient has proper equipment
and supplies.
• All follow-up programs must be set (including
proper referrals) at time of discharge.
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Follow a safe post-operative
breast cancer program
• Remember to:
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Review diagnosis
Medical interventions
Safe technique
Contraindications
Motivate
• Acknowledge:
– Research
– Other programs
– Realistic goals
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Rehabilitation examples to
remember:
• Protocols for individual
• Protocols depending on medical
intervention
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Breast Cancer
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Therapy begins 2-5 days post-op.
Deep breathing & relaxation are beneficial
Range of motion (gentle)
Movement with support as needed
Isometrics of involved elbow/ wrist/ hand
Once drains removed increase exercise (active
shoulder mobility)
• Home exercise program to promote independent plan
• Possible complications that need to be prevented
include: Inflammation, scar formation, obesity,
thrombophlebitis, and poor arm position.
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BREAST CANCER
• GOALS:
FUNCTIONAL
EMOTIONAL
COSMETIC
• FUNCTIONAL:
Shoulder Range of Motion; Neurological Changes;
Postural Deficits; Skin Integrity; Possible
Lymphedema; ADL's
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Post-Surgical Rehabilitation TRAM
• Immediate Post-operative
– Distal hand exercise to assist shoulder
stabilization.
– Incisional splinting techniques to increase
comfort with movement
• Day 2 or 3
– Reach to opposite shoulder & knee
– ADL’s with active range per individual
(Grant, 1994)
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Post-operative
• Two to four weeks according to M.D.
– Active / Passive ROM to involved shoulder
including overhead stretch
– Gentle resistive exercise
– Progressive cardiovascular fitness program
performed within safe limitations
(Grant, 1994)
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Post-operative
• Six weeks (depending on patient)
– Aggressive stretching and strengthening of
shoulder
– Strengthening of trunk and abdominals
– Cardiovascular cross training
– Return to work activities (Assimilation)
– Arm edema maintenance / prevention
– Scar tissue management (Decrease adhesions)
– Fitness through other medical interventions.
(Grant, 1994)
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Post-operative
• Long Term Management
– Maintain stretching and muscle tone,
especially in radiated areas.
– Posture management program
– Quality of Life fitness program
– Awareness of any problems
(Grant, 1994)
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Post-Operative TRAM
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Free Flap technique
(Slide donated with permission to show by: Ronald H. Schuster, MD
Board Certified Plastic Surgeon)
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Education
• We must educate the patient, family,
community, physician and other health
care providers of the benefits of
rehabilitation for the patient diagnosed
with cancer.
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Supply educational materials
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General breast cancer programs
used in my facility to promote safe
techniques with functional mobility
and activities of daily living
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OUT-PATIENT ONCOLOGY REHABILITATION
• Patient care
management
• Promote wellness
• Cost effective protocols
• Decrease risk of adverse
outcomes
• Provide forgotten rehab
Program
• Establish continual case
studies
• Provide continual
education programs
(Coleman Consulting, 1997)
98
BREAST WELLNESS CENTER
Comprehensive care dealing with the total patient, not just the diagnosis
• Treatment program
discussed with pt.
• Sensation change
• Shoulder mov't
guidelines
• Lymphedema
• Posture
• Prosthesis
• Lifting precautions
• Fatigue
• Exercise Guide
• UE Elevation
• Deep Breathing
• Elbow/Shoulder controlled
program
• Capsular Exercise
• Active Exercise
• Functional Shoulder
(Designed by Coleman Consulting)
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Breast Center in Health Club
(Public Relations Photo – Breast Wellness Center)
100
Gradual mobility
101
(Public Relations Photo – Breast Wellness Center)
Control exercise
102
( Public Relations Photo – Breast Wellness Center)
Posture and mobility
103
(Public Relations Photo – Breast Wellness Center)
Program Development
As you gain expertise and physician
confidence, you will also note an
increase in patient compliance.
Tips for building an Oncology Rehabilitation
program
• Increase visibility of rehabilitation into oncology treatment
plans with early intervention to prevent functional decline
and, increase the ability to restore a quality life.
• Increased involvement in clinical studies to include
outcomes for the oncology patient.
• Organization of Rehab team to assure quality of care to
promote functional outcomes.
• Progress treatment plans to map out vocational and
psychological programs.
(Coleman Consulting, 1996)
105
Research supporting physical therapy
rehabilitation
• Promotion of a quality life for patients
diagnosed with breast cancer
106
Research completed by Drum and group in the
Medical Science of Sports and Exercise, 2003
• Case study of female diagnosed with breast cancer, age 29
receiving a modified radical mastectomy and at age 57 same
procedure to opposite breast. Chemotherapy and radiation followed
second surgery.
• Following medical interventions presented, patient followed a six
month exercise program at the University of Colorado.
• Increased muscle strength, cardiovascular function and attenuating
career related fatigue and depression.
• Suggest health professionals collaborate with rehabilitation to
increase work capacity to progress a quality life for the patient
diagnosed with breast cancer.
(Drum, 2003)
107
Study by Holmes in the American Medical
Association Journal in 2005
• Study followed the health of 122,000 female nurses,
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2,167 were diagnosed with breast cancer.
The physical activity of the subjects was recorded. This
activity was measured up to 16 years, most subjects
walked for exercise.
Breast cancer survivors that exercised 3-5 hours per
week lived longer than those that had minimal activity.
Also noted those who completed regular exercise were
less likely to die from their breast cancer.
Patients will receive major benefits from modest
exercise.
(Holmes, 2005)
108
Mastros’ study published in the American
Medical Association website 2004
• Study of 49 women with breast cancer, 28 were
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assigned to a six month exercise program.
Blood testing was used to determine immune
response.
Revealed that breast cancer patients that
completed an assigned six month exercise
program had better immune response and less
inflammatory complications.
Appropriate exercise can help breast cancer
survivor’s strengthen their immune system with
exercise.
(Mastro, 2004)
109
Following numerous searches
in the medical library and
database search engines, no
remarkable negative changes
with exercise following the
diagnosis of breast cancer
were noted.
110
Research by Winningham
• Exercise may enhance Quality of Life
• Interval Aerobic Training (Rest & Exercise)
enhances cardiovascular efficiency, overall
functional ability and reduces incidence rates of
nausea from chemotherapy.
• Heavy prolonged exertion associated with
hormonal and biochemical changes can have a
detrimental effect on the immune system
(Winningham, 1989)
111
Research by Segar
• Regular aerobic cycling decreased
depression and anxiety as well as
increased self esteem.
(Segar, 1998)
112
Research by Pinto
• Surveyed 72 Stage I and II breast
cancer patients. Those who exercised
reported less depression and enhanced
Quality of Life compared to the
sedentary control group.
(Pinto, 1998)
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Research by Durak
• Health Club Study
• Breast cancer program : Aerobic exercise / PRE’s on
machines 2x/wk for 20 weeks
• Results:
– CA pts. Showed:
• 60% increase in upper body strength
• 31% increase in lower body strength
• 35% increase in aerobic machines
– Progress ADL’s, Strength & Endurance
– Decreased Pain and Decreased Nausea
(Durak, 1997)
114
Research by Bernstein
• Women who have been physically fit for
many years reduce their incidence of
breast cancer.
• 3.8 hours of exercise per week reduces
risk
(Bernstein, 1995)
115
.Additional research on the benefits of exercise for
the breast cancer patient is becoming available.
• Support of the benefits of exercise are to increase
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functional capacity, decrease body fat, increase lean
muscle mass, decrease nausea & fatigue, improve
quality of life.
American College of Sports Medicine guidelines for
exercise following breast cancer: Frequency: 3-7
days /week; Intensity: 40-80% aerobic capacity;
Duration: 20-40 min. of aerobic activity.
Suggest normal fitness assessment: heart rate, blood
pressure, body composition, strength, flexibility,
aerobic capacity.
ONLY BENEFITS REPORTED
(ACSM, 1997)
116
• Harvard Medical asst. professor Michelle Holmes,MD,
studied 3,000 women noting little exercise increases
chances of surviving breast cancer. 3 MET (Metabolic
equivalent task) hrs. per week of 2 to 2.9 miles per hour
for 1 hour decreases risk of dying from breast cancer by
one half.
• Anne McTiernan, MD, PhD, author of Breast Fitness: An
Optimal Exercise and Health Plan for Reducing Your Risk
of Breast Cancer, stated “Women don’t have to become
athletes, just get up and get moving”.
(www.cancer.org, 2005)
117
• Breast Cancer FYI, suggests that a patient should
consider at least one session with a physical therapist if
any surgical procedures, due to breast cancer, have been
performed
.
• In the Yale Exercise & Survivorship Study, it was
revealed, despite the evidence suggesting that regular
physical activity can decrease breast cancer risks and
improve prognosis, efforts to encourage this program
were not a routine part of cancer treatments.
118
Results of studies on exercise during breast CA
Authors
Samples
Design
Intervention
Outcome
Results
Bremer et al
109 breast CA
survivors
(post-op)
Cross-section
Self reported
exercise
Psychology
adjustment
No difference
with or without
exercise
Courneya &
Friedenreich
167 breast CA
survivors
Retrospective
Self reported
exercise
Quality of Life
Moderate to
strenuous
exercise = best
quality of life
Cunningham
66 breast CA
survivors with
METS
Prospective
Self reported
exercise
Survival
With regular
exercise lived
longer
MacVicar and
Winningham
10 on chemo 6
healthy controls
Test Pre/Post
Supervised
exercise
Exercise test
and mood
Exercise lead to
increase in
function and
mood with both
McBride et al
500 early stage
breast CA pts.
Various tx.
Cross-section
Self reported
stage of change
measure
Psychology
impact
No difference
with or without
exercise
Winningham
24 breast CA
pts. On chemo
Test Pre/Post
Home program
Body weight &
composition
Exercise dec
body fat, inc
mass; Opposite
for controls
(Courneya, 2002)
119
Physical Therapy Modalities
120
Which modalities are safe in treating
the patient diagnosed with breast
cancer?
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Moist Heat
Cold
Deep Heat
Traction
Electrical Stimulation
TENS
Compression Pumps
Manual Therapy
(Pfalzer, 1992)
121
Progressive Relaxation Exercise
• Close your eyes …… Deep Breathing
• Image: Ocean, Mountains, etc.
•
See it / Hear it / Feel it
Contract --- Relax
Mildly with 5 count
– Forehead / Face / Neck / Shoulders / Upper Arms /
Forearms / Hands / Chest / Abs / Gluts / Upper Legs /
Calves / Feet
• Deep Breathing .. Total Body contract/relax
• Repeat total process
A
l
122
Modality Contraindications
• Cold
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Over dysvascular tissue
Transient increase in blood pressure
Delay in wound healing
Nerve injury
Peripheral Vascular Disease
During Radiation
Possible Metastasis
(Pfalzer, 1992)
123
Contraindications
• Deep Heat
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Over dysvascular tissue
Over poor sensation
Increase in bleeding
Directly over tumor
Over acute injury
Open wounds
Elevated temp.
Metal implants
Pacemaker or other implanted device
(Pfalzer, 1992)
124
Contraindications
• Traction
– Structural Changes possible pathologic fx.
• Compression Pump
– Active disease .. Metastasis can occur through
pump activity
• Manual Therapy
(Pfalzer, 1992)
125
Contraindications
• Electrical Stimulation
– Possibility of pathologic fractures
– Implanted device
– Cardiopulmonary Insufficiency
– Active phlebitis
• TENS
– Implant
– Directly over wound
(Pfalzer, 1992)
126
REHABILITATION
• “The recognition and acceptance that
breast cancer is a treatable disease
even when it is metastatic has helped
professionals and patients alike accept
rehabilitation efforts.”
Stephen Gudas, 1992
You have the knowledge and responsibility to develop a plan
of treatment for the patient diagnosed with cancer.
127
ONCOLOGIC
EMERGENCIES
128
GUIDE TO
PHYSICAL THERAPY PRACTICE
A.P.T.A.
• “Through the examination, the physical
Reference to the
therapist identifies impairment,
functional limitations, disabilities, or
changes in physical function and health
status resulting from injury, disease, or
other causes to establish the diagnosis
and the prognosis and to determine the
intervention”.
(www.apta.org, 2006)
129
The Guide:
• A goal and prognosis will help establish the plan and
frequency of visits for the cancer patient.
• Interventions to produce a change in condition are
established by the plan of care, anticipated goals and
desired outcome.
• Reexamination needed to evaluate clinical findings to
promote care or observe failure of response.
• Some examples of ICD-9-CM Codes related to
cancer:
– 232
– 239
Carcinoma in situ
Neoplasm's of unspecified nature
(www.apta.org, 2006)
130
Physical Therapy Evaluation
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Range of Motion
Manual Muscle Testing
Shoulder Assessment
Sensation Testing
Girth Measurements
Posture Analysis
Cardiovascular Fitness
Body Fat Analysis
• Additional tools you may need for assessment:
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Skinfold caliper
Spirometer
Heart rate monitor
Hand grip dynamometer
131
Effective Assessment
Guidelines of Rocky Mountain Cancer Rehabilitation Center
• Each parameter relevant to patient
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•
progress
Procedures valid and reliable
Administrate with rigid control
Protect patient’s rights
Regular interval testing
Review and explain to patient
132
Organ Toxicity and Life Threatening
Complications.
• Problems seen:
• Hematologic (Dealing with blood and
blood forming organs)
• Obstruction
• Increased Pressure / Fluid Accumulation
• Metabolic (Dealing with chemical processes
of living organisms)
• Pathologic Fractures
(Kirchner, 1996)
133
Oncology Emergency Signs
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Infection
Fever
Ecchymosis
Bleeding (Possible gums)
Headaches
Chest Pain
Dizziness
Fatigue
Insomnia
Swelling
Local or Radicular Pain
Neurological Deficits
SOB
Abdominal Pain / Cramp
Nausea / Vomiting
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Constipation / Diarrhea
Hypertension / Hypotension
Tachycardia
Changes in Urine
Loss of Appetite
Blurred Vision
Change in Mental State
Seizures
Respiratory Changes
Weight Changes
Depression
Fractures
Coma
Death
(Otto, 2004)
134
Time Out Test
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Oncology Emergencies only pertain to the elderly? T / F
The main mission for treating cancer in rehabilitation?
Palliative therapy is really not needed? T / F
What helps you establish your plan of treatment?
When was the first epidemiologic study on breast cancer and
exercise published?
Functional assessments must document what?
Although there have been many negative changes, due to
rehabilitation, it is still prescribed? T / F
What medical information appears important when working with
patient’s diagnosed with cancer?
What are the advantages of pre-surgical evaluations?
ANSWERS
False; Maintain and improve Quality of Life; False; Prognosis and Goals; 1985;
Measurable benefits; False, No negative findings; Lab values;To many to list.
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135