Oncology: Common Symptoms And Side Effects And Their PT Management Flashcards
What proportion of pts with cancer have pain at diagnosis? During active treatment? With advanced disease?
1/4 at diagnosis
1/3 during active treatment
3/4 with advanced disease
What are the various things that can contribute to cancer pain?
NS, endocrine, immune, systemic integration responses
Pressure, nerve infiltration, bone pain, and ischemic pain from the tumor
Surgery, chemo, radiation
Emotional response to diagnosis, emotional response to pain, though patterns surrounding pain
How does the NS contribute to cancer pain?
Peripheral and central sensitization
How does the endocrine system contribute to cancer pain?
The tumor changes hormonal regulation and hormones are released in response to pain
How does the immune system contribute to cancer pain?
Increased presence of inflammatory chemicals
What things are involved in PT management of cancer pain?
Education
Massage
Manual therapy
Movt
Mind-body care
Rarely electrophysical modalities
What is involved in education for cancer pain management?
Pain neuroscience education
Motivational interviewing
Goals and functional despite pain
Meds and medical treatment (timing meds with PT)
Massage is most helpful for what purpose in cancer pain management?
Stress reduction and relaxation as ms tension can feed into pain
T/f: there are many contradictions and precautions for manual therapy in treatment of cancer pain
True
What is the goal of manual therapy for management of cancer pain?
Improved kinesthetic sense and cortical mapping
NOT tissue change
T/f: skilled touch in manual therapy can be helpful for hypersensitivity and allodynia in cancer pain
True
What is involved in movement to manage cancer pain?
Graded motor imagery
Progressive loading
Aerobic activity
What is involved in mind body care for management of cancer pain?
Mindfulness integration
Breathing techniques
T/f: electrophysical modalities are generally contraindicated in cancer pts
True
Why are electrophysical modalities generally contraindicated for cancer pts?
Bc of concerns for tumor growth
How long should we avoid using electrophysical modalities in pts with a hx of cancer?
At least 5 years post remission
What are the 2 exceptions to the rule that electrophysical modalities are contraindicated in cancer pts?
Using low level laser for breast cancer associated lymphedema
Using modalities in palliative/hospice care where the benefits of pain control outweighs the risk for disease progression
What is cancer related fatigue?
Distressing, persistent sense of physical/emotional/cognitive fatigue not proportional to recent activity that significantly interferes with functioning
What is a sign of emotional fatigue?
Not talking to family and friends
What is a sign of cognitive fatigue?
Not being able to focus on a tv show or book
What is the prevalence of cancer related fatigue (CRF)?
> 90% of pts with cancer at some point during disease/treatment have CRF
What is the pathology behind CRF?
Unknown but multifactorial
What factors contribute to CRF?
Cancer directed therapies
Tumor growth
Unrelieved pain
Anemia
Meds
Deconditioning
Depression
Sleep disturbance
T/f: a screening of CRF should be included in the assessment of all pts with cancer
True
What is a highly recommended but expensive screening tool for CRF?
The European organization for research and treatment of cancer QOL Questionnaire-Core 30
What tool is the best practice recommended for CRF?
The one item fatigue scale that asks them to rate their fatigue on a scale of 0-10
What are the 3 highly recommended assessments for CRF?
Functional assessment of chronic illness therapy-fatigue
Piper fatigue scale-revised
Pt reported outcomes measurement into system-short form fatigue
According to the. 2012 Cochran review, what is the effect of exercise on fatigue?
Improved fatigue with exercise program
What level of aerobic exercise/resistance training should we do for pts with CRF?
Moderate
What borg level should exercise for pts with CRF be in?
11-15/20
2-3 on the modified Borg
What is the gold standard treatment for CRF?
Exercise therapy
What is the #1 cause of cancer related pain?
Cancers effects on bones
What is the effect of cancer on bones?
The normal balance of osteoblastic and osteoclastic activity is disrupted
Disturbed osteoblast/clast activity in cancer can be due to what things?
Primary bone tumor
Metastatic lesion (more likely)
Hormonal changes
Nutritional deficits
Environmental factors (chemo/radiation)
What cancer is known for causing boney lesions and significant amounts of pain from the lesions?
Multiple myeloma
What are the skeletal complications of cancer?
Osteoporosis/osteopenia
Bone lesions
Avascular necrosis
Osteoradionecrosis
Metastatic bone disease
Why are bone lesions a problem in cancer?
Bc the build up of cancer cells in bone marrow lead to bone destruction and increased risk for pathological fractures
Where is avascular necrosis likely to occur?
Head of the femur or anywhere near the radiation treatment
What are the clinical indications of metastatic bone disease?
Back pain not relieved by rest/laying down
Worse pain at night
Constant pain not relieved by position changes
Gradually worsening pain
Empty joint end feel
Pain with WB (cardinal sign of bone mets)
Noncapsular pattern of motion restriction
T/f: metastatic bone disease can lead to pathological fractures
True
Where are pathological fractures from metastatic bone disease most likely to occur?
In the hip and spine
What are the most common sites of bone metastasis?
Vertebrae
Pelvis
Femur
Ribs
Humerus
If the bone lesions in cancer are metastatic, is medical treatment usually curative or palliative?
Palliative
What are the palliative medical treatments for bone metastasis?
Radiation for decreased pain
Surgery for stabilization
Bracing
WB restrictions
Biphosphonates for increased bone quality)
Is surgery for bone metastasis usually prophylactic or for existing fractures?
Can be either
What is the goal of taking biphosphonates?
To increase bone quality
Treatment of skeletal complications depends on what factors?
Pain, prognosis, QOL expectations, desire to prolong physical functioning/mobility
What is involved in PT management of extremity bone metastasis?
WB precautions and exercise
In general, <25% cortical involvement of a bone lesion is okay for ______ _______ activities
Low impact
The focus of exercise with skeletal involvement should be on what?
Muscle strength and endurance
T/f: we should be including high impact activities with skeletal involvement
False, high impact activities should we avoided
T/f: we should avoid torsion in exercise with skeletal involvement
True
When there is >50% cortical involvement of cancer, what is typically the WB status?
TTWB or NWB
When there is 25-50% cortical involvement of cancer, what is typically the WB status?
PWB
When there is 0-25% cortical involvement of cancer, what is typically the WB status?
FWB
When there is >50% cortical involvement of cancer, what are the activity restrictions?
No resistance
No stretching
Avoid twisting
When there is 25-50% cortical involvement of cancer, what are the activity restrictions?
No stretching
Light aerobic
Avoid lifting/straining
When there is 0-25% cortical involvement of cancer, what are the activity restrictions?
None, monitor pain
T/f: spinal compression fracture is common with skeletal involvement in cancer
True
When would surgical stabilization of the spine be done with skeletal involvement in cancer?
When there is neuro compromise
What can be done to manage vertebral metastases?
Surgical stabilization
Kyphoplasty
Bracing
Spinal precautions
Exercise
What are the spinal precautions for vertebra metastases?
Limit flexion
No lifting >10lbs
No twisting
If thoracic-no protraction
In an exercise program for vertebral metastasis, what should be limited and what should be focused on?
Limit concentric abdominal strengthening
Focus on extensor strengthening
What is metastatic SC compression (MSCC)?
When the tumor puts pressure on the SC and causes ischemia that can lead to a SCI if not addressed immediately
T/f: MSCC is a medical ermergency
True!!!
What things can cause neuro compromise with vertebral metastasis?
Direct impingement of the tumor on the SC
Skeletal instability
Vascular compromise
What are the s/s of SC compression?
Pain that increases in supine
Pain with valsalva
Increased back pain
Sensory deficits
B/B dysfunction
Hyperreactive reflexes
What are the effects of cancer on connective tissues and joints?
Radiation fibrosis (main one)
Surgical scars
Posture
What is radiation fibrosis?
Scarring and fibrosis resulting from the cell damage and inflammation caused by radiation therapy (XRT)
T/f: the effects of radiation fibrosis can least for years
True
What are the effects of radiation fibrosis?
MSK fibrosis
Avascular tissues
What tissues are affected by MSK fibrosis from radiation fibrosis?
Skin, subcutaneous tissues, and fascia
Treatment of what cancers with XRT are especially prone to radiation fibrosis?
Breast cancer
Head and neck cancers
What is the result of avascular tissues from radiation fibrosis?
Brittle bones and decreased skin sensitivity from avascular nerves
T/f: radiation fibrosis in late stages can continue to progress for years/decades after XRT and tissues become rigid, fragile, and poorly vascularized as a result
True
What things do PTs need to consider when a pt is undergoing XRT?
VS
Cardiopulmonary exercise testing before exercise prescription
Look for signs of cardiopulmonary exercise intolerance
Use RPE
Aerobic exercise prescription can assist with their fatigue and anemia
Education of CRF is important
What is the benefit of aerobic training for pts undergoing radiation?
It can improve their anemia and fatigue
What things do PTs need to consider when treating a pt with radiation fibrosis?
Impaired circulation and sensation in the irradiated area
Deep tissue techniques are contraindicated in irradiated areas
We can perform soft tissue mobilization around the irradiated area
Once subacute inflammation phase is over, we can begin soft tissue mobilization
Gentle AROM with visualization of the skin can decrease injury risk
Use heat WITH CAUTION
Counsel regarding factors affecting wound healing
When can we begin soft tissue mobilization in a pt with radiation fibrosis?
Once there are no signs of active inflammation (redness, swelling, heat)
When giving a pt with radiation fibrosis AROM exercises in their HEP, what should we tell them to do?
Do them in from of a mirror so they can visualize their skin to avoid damage
What are the effects of cancer on muscles?
Sarcopenia
Cachexia
Immobility
Frailty
What is sarcopenia?
Loss of ms fibers
What is cachexia?
Loss of metabolically active tissues (loss of ms and fat)
What can immobility be caused by in cancer pts?
Frequent hospitalization, pain, or post-op
What is frailty?
A combo of sarcopenia, cachexia, and immobility
Is the following characteristic of frailty, cachexia, or sarcopenia?
Decreased ms mass
Decreased function
Sarcopenia
Is the following characteristic of frailty, cachexia, or sarcopenia?
Decreased function
Decreased strength
Decreased endurance
Baseline functioning is much closer to the threshold below which you lose function and mobility
Frailty
Is the following characteristic of frailty, cachexia, or sarcopenia?
5% weight loss in 6 months
Decreased strength
Fatigue
Anorexia
Loss of metabolically active tissues
Inflammation
Cachexia
What are the common measures for oncologists to use to determine cancer treatment based on the level of frailty of the pt?
ECOG performance status
Karnotsky performance scale
On the ECOG performance scale, what is a 0?
Fully active, no restrictions
On the ECOG performance scale, what is a 1?
Some restrictions, but can carry out work and is ambulatory
On the ECOG performance scale, what is a 2?
Ambulatory and can do all self care but not work functions
On the ECOG performance scale, what is a 3?
Limited self care, bed/chair >50% of waking hours
On the ECOG performance scale, what is a 4?
Completely disabled and totally confined to bed/chair
On the ECOG performance scale, what is a 5?
Death
What is a more useful measure of frailty in cancer pts for PTs?
The Fried phenotype scale
What are the categories of the Fried phenotype?
Weight loss, fatigue, decreased gait speed, weakness, low physical activity
What score on the Fried phenotype tells us that a pts is frail?
Greater than or equal to 3/5
What are the neurological effects of cancer?
Chemo indicated peripheral neuropathy (CIPN)
Ototoxicity
Chemo induced cognitive impairment (CICI)
What causes CIPN?
Direct damage to the axons from chemo drugs
CIPN is dose dependent, meaning that the _____ the dose of chemo the _____ nerve damage there is
Higher/lower, more/less
CIPN is cumulative meaning that the longer you receive chemo the _____ nerve damage there will be
More
Is there a lot of research to support use of cryotherapy during chemo to reduce CIPN?
No, most evidence is anecdotal
What is the prognosis with CIPN?
It often improves over time but may have persistent symptoms
What are the symptoms/presentation of someone with CIPN?
Symmetric glove and stocking pattern
Sensory>motor>autonomic
Pain
Paresthesias
Decreased sensation
Hypersensitivity
Balance disturbance
Weakness
OH
T/f: the presentation of CIPN is like that of any peripheral neuropathy
True
What would cause balance disturbances in CIPN?
Toe, foot, and ankle sensation loss
Where would we expect to see weakness with motor involvement in CIPN?
In the toes, feet, ankles and fingers, hands, wrists
When would we see OH in CIPN?
With autonomic nerve involvement
What chemo drug is notorious for causing OH in CIPN?
Vincristine
What is the only highly recommended measure of CIPN?
The functional assessment of cancer therapy/gynecologic oncology group neurotoxicity subscale (FACT/GOC Ntx) (v4)
What is the FACT/GOC Ntx subscale?
A short 10 question self report form on how much someone has been affected by CIPN
What are 2 recommended balance measures specific to cancer and chemo?
Fullerton advanced balance scale (FABS)
TUG
What is involved in PT management of CIPN?
Skin checks
Injury prevention
Orthotics with motor involvement
Gait training
AD need assessment
Specific sensory and balance exercises
OH consideration
Referral to OT for ADL assessment
What is a specific sensory exercise we can give pts with hypersensitivity in CIPN?
Sensitization program where we find a texture that they don’t find noxious and have them rub it on their skin for one minute at a time 3x/day and then add in more textures and temps that may be uncomfortable but not painful to rewire their nerves to tell the brain it is okay to feel these things and they are not painful
Is there evidence that generalized resistance training programs improve balance related to CIPN?
Nope, exercise needs to be specific
What exercises should we use for CIPN?
Specific strengthening exercises for the feet, ankles, knees, hips
Specific balance exercises like in the FABS
What is ototoxicity?
Damage to the nerves of the inner ear
What are the consequences of ototoxicity?
Auditory and vestibular impairments
Who is especially at risk for ototoxicity?
Those who receive radiation to the head/neck
What chemo drug puts pts at more risk for ototoxicity?
Platinum based drugs like Cisplatin
What surgery puts pts at risk for ototoxicity?
Surgical removal of an acoustic neuroma (a benign tumor on the auditory nerve)
What is the focus of treatment for ototoxicity?
Vestibular system assessment and intervention
What is chemo induced cognitive impairment (CICI) commonly referred to as?
Chemo brain
What are the consequences of CICI?
Memory lapses
Trouble concentrating
Trouble remembering details
Difficulty multitasking
Increased time needed for tasks
Word finding difficulties
What is the role of PT in CICI?
Doing a few simple exercises to get the most bang for your buck
Use of memory aids
What are some memory aids we can teach pts about for CICI?
Writing down info
Using a diary, checklist, or schedule
What are the CVP effects of cancer?
Accelerated CV aging
Increased VTE risk
Edema
Cardiotoxicity
Pulmonary toxicity
Deconditioning
What are the consequences of accelerated CV aging in cancer survivors?
Higher rates of MI and at a younger age
Higher rates of CAD
Higher rates of heart failure and at a younger age
What is the most common cause of death in cancer pts behind cancer itself?
Heart disease
What are the risk factors for accelerated CV aging in cancer pts?
Pre-existing CAD
Sedentary life
Smoking
Female
Post menopausal
HTN
Hyperlipidemia
High dose chemo
Chest XRT
Why does chest XRT put pts at risk for accelerated CV aging?
Bc it speeds up atherosclerosis in the coronary arteries
What chemo drug puts pts at increased risk of CV disease?
Anthracycline
T/f: any person with cancer is at increased risk for VTE, even with thrombocytopenia
True
Why are UE DVTs common in cancer pts?
Bc cancer pts have increased DVT risk and they often have PICC lines which alone increases DVT risk
What things can cause edema?
Venous stasis
Malnutrition
Lymphedema
Heart failure
Kidney failure
Liver failure
Why does malnutrition cause dependent edema?
Bc it lowers oncotic pressure from decreased proteins causing an increase in filtration across them membrane and making it harder for fluid to leave
What diseases can result from cardiotoxicity as a result of cancer?
Cardiomyopathy, myocarditis, pericarditis, acute coronary syndrome
What disease can result from pulmonary toxicity as a result of cancer?
Pneumonitis
What things in cancer cause anemia?
Blood loss (esp with GI cancer)
Increased RBC destruction by cancer cells and immune responses
Decreased RBC production from bone marrow suppression and nutrient deficiency
Why may a cancer pts be deficient in iron, B12, or folate causing anemia?
Bc they have decreased nutrient absorption or they have no appetite to take in the nutrients
What things in cancer cause thrombocytopenia?
Bone marrow suppression from chemo/XRT
Bones marrow infiltration
What things in cancer can cause neuropenia?
Bone marrow suppression from chemo/XRT
Bones marrow infiltration
What are the GI effects of cancer?
Nausea and vomiting
Malnutrition
What is a very common GI effects esp with chemo?
Nausea and vomiting
What are some things that may contribute to nausea and vomiting with cancer pts?
Direct effects of cancer
Direct effects of chemo in GI tract cells
Neurotransmitter induced nausea
Surgery, opiates, XRT, and chemo
Why are GI cells so easily affected by cancer treatment?
Bc of their rapid cell turnover rate, they get effected very early on
What are PT considerations for the GI effects of cancer?
Timing of treatment
Coordination of PT with antiemetics
Watching nutritional level
Looking for signs of electrolyte imbalance (hypovolemia, hypo/hypernatremia, hypo/hyoerkalemia)
What things contribute to malnutrition in cancer?
Increased resting energy expenditure
Reduced intake
Reduced absorption
What things can cause reduced intake of calories in cancer pts?
Anorexia
Onodynia (oral pain)
Dysphagia
Early satiety secondary to an space occupying lesion
Fatigue
Nausea/vomiting
Xerostoma (dry mouth)
Depression
Constipation
What are the symptoms of malnutrition in cancer pts?
Ms wasting
Poor wound healing
Low bone mineral density
Cold intolerance
Irritability
Reduced appetite
Poor concentration
If severe protein deficiency LE edema and ascites
What does severe protein deficiency in cancer pts cause?
LE edema and ascites
What are the immune effects of cancer?
Infection and sepsis
What is sepsis?
Organ failure from massive infection
T/f: sepsis is a high risk with active cancer and cancer treatment
True
What measure do we use to determine if a pt is in sepsis?
The SIRS criteria and qSOFA
Using the SIRS criteria, what indications for sepsis are we looking for?
Increased or decreased temperature
HR>90
RR>22
WBC <4k/>12k/>10% immature
What SIRS criteria score indicates sepsis?
Greater than or equal to 2
Using the qSOFA, what indications are we looking for that signal sepsis?
SBP<100
RR>22
Altered mentation
What are the TIME signs we should pay attention to for sepsis?
Watch for increased or decreased TEMPERATURE
Watch for s/s of INFECTION
Watch for MENTAL decline
Watch for signs of EXTREME illness
