Oncology: Principles In Onco Rehab Pt. 3 Flashcards
PT Imps in terms of Oncology
- Type and Stage of Cx
- Gen health
- QOL
- Financial and social strains
- Preventative, Restoratitve, Supportive, Palliative
- SEs from tx
- Discharge planning from ALL settings
Blood Clots
2 that we are Concerned W/:
- DVT
- PE
Deep Vein Thrombosis
DVT
Explaiin
- Clot of cellular material bound to fibrin located in DEEP VEINS
-
Sx’s:
- edema
- erythema
- PAIN
Pulmonary Embolism
PE
Explain:
Blood clot which obstructs the Pulmonary aa/vein
-
Sx’s:
- dypnea
- LOW O2sats
- tachycardia (reflex tachy)
- chest pain***
DVT
PE
Tx’s
- AntiCOAGULANTS (blood unable to clot)
- IVC filter (Inf. Vena Cava)
- for LE origin ONLY
VASCULAR
DVTs
Incidence in Cx Pts
- TWICE AS LIKELY TO DEVELOP DVTs***
- FREQ. complication
- 2nd leading cause of death***
- 90% of pts expe an INC in clotting activity
- MORE COMMON:
- ovarian
- pancreatic
- lymphatic
- liver
- stomach
- colon cx’s
Vascular complications
DVTs
Causes of a Hypercoagulable State
- Immobility
- SOME tumors release subs that INC blood’s ability to clot
- Sx OR CHEMO can injure vessel walls—> triggers blood coagulation
- Cx therapy can DEC body’s ability to produce adequate coagulants
Vascular comps
DVTs
PT imps:
- Awareness of Tx***
- Monitor approp. blood values
- Monitor SPO2 and HR***
Blood Clot forming
Embolus traveling thru heart INTO lung vessels
see pics
Sx Resection GOALS:
WHAT ARE THEY TRYING TO ACHIEVE?
CLEAN MARGINS
- Trying to achieve clean margins
- to be sure ALL cx cells removed
-
Tumor can be resected completely BUT
- ALSO want to resect an area of clean tissue or non-cx tissue to see if ACTUALLY CLEAN
SEs from Sx
- Loss of Function
- disfigurement or deformities
- PAIN
- infection
- Risk of bleeding or hemorrhage
- Fatigue
- dev. of scar tissue
PT Implications Following Sx
- EARLY mobility and pulm hygiene
-
Respiratory Considerations:
- Chest PT + Airway clearance
- Chest wall excursion (lateral costal breathing)
-
Soft tissue restrictions:
- ROM restricts
- WB restricts
- Scar restriction (after healing)
-
Weakness:
- Nerve resections
- Nerve traction injuries
- **Psychosocial implications
Chemotherapy
Common SE’s
**remember Chemo attacks ANY rapidly dividing cells (think GI, Hair follicles)
- PAIN
- Fatigue
-
Bone marrow suppression
- Infection
-
Alopecia**
- remember hair follicles attacked–rapidly dividing
- Infertility
-
GI effects**
- remember hair follicles attacked–rapidly dividing
- nausea, vom, constipation, anorexia
- Peripheral neuropathy
- DECd bone density
- skin rashes
- Wt. gain OR loss
- Jt pain
- Sexual dysf
- Hemorrhage
Hematological Considerations:
Bone Marrow Suppression:
3 things come from this
- Anemia
- Thrombocytopenia
- Leukopenia/Neutropenia
Anemia
What is it?
LOW RBC Count
Anemia
Lab values: HgB
Norms: M vs F?
MALE==14-17 g/dL
FEMALE==12-16 g/dL
Anemia
S/S
(Anemic)
- FATIGUE
- irritability
- lightheadedness
- HA
- Loss of concentration
- pallor
- SOB
Anemia
PT Imps:
- Monitor VITALS!!!
- RR INC, HR INC, SaO2 DEC
- Monitor LAB VALUES/Tx
- Monitor FATIGUE LVLS
NOTE: Have to use RPE ***
Thrombocytopenia
what is it?
LOW Plt count
- NORM== 150,000-400,000 mm^3
Thrombocytopenia
LOW Plts
S/S
- Bruising
- Bleeding—if too low
- Petechiae
- sm. raised rash on skin
-
microtrauma to superficial blood vessels
- __INAD. Plts
Thrombocytopenia
LOW Plt count
PT Imps:
- Monitor LAB VALUES/Tx
- FALL PRECAUTIONS
- train balance but NOT high lvl
- Focus on Functional Mobility
- __NO risky activity
How can you remember Plts easily??
They are YELLOW
SEE PICS
Leukopenia/Neutropenia
What is this ?
LOW WBC Count
- NORM== 3.5k to 10.5k cells/mcL
Leukopenia/Neutropenia
LOW WBCs
S/S
- Freq INFECTIONS
- Fevers
- Throat/mouth sores bc DECd ability to fight infections
Leukopenia/Neutropenia
LOW WBCs
PT implications:
- Reverse/Protective Isolation—Neutropenic Precautions
- PROVIDER (PT) dons PPE to protect pt
- Creative tx interventions
Bone Marrow Suppression Guidelines
aka Blood Counts outside normal ranges:
WBCs
- <5k–NO EX permitted
- >5k–light ex, progressive to resistance
Bone Marrow Suppression Guidelines
aka Blood Counts outside normal ranges:
HgB:
- <7.5g/dL== NO EX permitted
- 7.5-10g/dL== Lt ex, focus on functional mobility
- >10g/dL == Resistive ex permitted
Bone Marrow Suppression Guidelines
aka Blood Counts outside normal ranges:
Plts:
- <20k– NO EX OR ADLs/walking
- 20-30k– Lt ex, AROM, walking
- 30-50k– MOD ex, aquatic, stationary bike
- 50-150k– Progressive resist ex’s, swimming, bike
- >150k– Unrestricted normal act.
Bone Marrow Suppression Guidelines
aka Blood Counts outside normal ranges:
INR
- >4.0– NO EX permitted
Radiation Therapy
Common SEs
And what can occurr from each.
- PAIN
- Fatigue
-
Bone marrow suppression
- INFECTION
- Local hair loss
- attacks rapidly dividing cells
- Delayed wound healing
- DECd bone mass/strength
- Skin changes
- fibrosis
- erythematous skin
- fragile skin
- myofascial adhesions
- GI changes–attacks rapidly dividing cells
- diarrhea
- vom
- PRO deficiency
- anorexia
- Wt loss
- AVN: loss of blood supply==necrosis
Radiation Therapy
Common SEs
Radiation Myelitis
- damage to small blood vessels in spinal column
- –> DECd blood flow
- –> necrosis
-
–> demyelination
- –> sensory dysf and weakness
Radiation Therapy
Site Specific SEs
Abdomen and Pelvis
- Nausea
- bladder discomfort/dysf
- Sexual dysf
Radiation Therapy
Site Specific SEs
Head and Neck
- Diff eating
- dental hygiene
- Dry mouth
Radiation Therapy
Site Specific SEs
Breast
- DECd shoulder ROM
- Soreness
- Lymphedema
Radiation Therapy
Site Specific SEs
Chest
- Swallowing diff
- SOB***
Radiation Therapy Considerations
- Burns/blisters
-
Radiation fibrosis/necrosis
- brain
- lungs
- trismus
PT Implications following Radiation Therapy
Radiation Induced Fibrosis
*stuck, tight adhesions
Specifically what/where?
-
Trismus
- unable to open mouth by 30cm or 3knuckles
- Limtd cervical ROM
- Head drop—-literally
- Limtd chest wall excursion
-
Osteoradionecrosis
- Jaw bone
- Neuralgia
- loss of nerve conduction
- loss of flexibility
Radiation Therapy
Common SEs
CNS Effects: 3
- Radiation Necrosis
- Encephalopathy
- Myelopathy
Radiation Therapy
Common SEs
CNS effects: Radiation Necrosis
Lg mass of dead tissue that forms @ SITE of irradiated tumor
Radiation Therapy
Common SEs
CNS Effects: Encephalopathy
FOCAL neuro sx’s assoc’d w/ white matter changes (DECd)
Radiation Therapy
Common SEs
CNS Effecs: Myelopathy
Functional or pathological disturbance of Spinal Cord
**can be transient (short term) or chronic
Breast Cx: Radiation SEs
LEFT= burn + fibrosis
RIGHT= radiation burn
Radiation SEs
Radiation desquamation + skin changes
see pics
Radiation Therapy SEs
Pulmonary fibrosis
- Possible after lung or breast radiation
- NO current tx’s
PT Implications
Radiation Therapy
PRECAUTIONS:
- Blood values/lab results
- Infection control
- PAIN
- fatigue
- WB status
Radiation Therapy: PT Implications
Interventions:
ROM
FALL PREVENTION, Assess for approp. AD
pt+fam edu
PT implications Following Radiation Therapy
- Nerve injury
- weakness
- pain
- parasthesias
- Lymphedema
- Fatigue
- Compromised skin integrity
- Psychosocial imps
Stem Cell Transplant usually combined w/….
HIGH DOSE CHEMO
SES from Stem Cell Transplant
-
GVHD
-
Graft vs. Host Dis.
- body REJECTS stem cells
-
Graft vs. Host Dis.
- Immunosuppression
- Isolation
- Delayed wound healing
- Nausea and vom
- Osteoporosis
- 2* malignancy
Graft vs. Host Disease
GVHD
-
Transplant Rejection:
- Donor cells (graft) recognize body’s cells (host) as foreign and implement immulogic attack
- skin, liver, gut
-
Tx:
- INCd immunosuppressive drugs
Graft vs. Host Disease
when is it ACUTE
w/in First 100 days
Graft vs. Host Disease
When is it Chronic?
>100 days
General NEUROLOGIC Considerations
3:
-
Cognition
* A&Ox4
-
Cognition
- 2. Hydrocephalus: INCd ICP
- 3. Neuropathy/Radiculopathy: chemo affects nerves
Gen Neurologic Considerations
PT Imps:
- Safety awareness
- Orientation
- Ability to follow commands
- MEMORY
Gen NEUROLOGIC Considerations
Hydrocephalus
*incd ICP
PT Imps:
- AVOID valsalve maneuvers
- NO excess bending or heavy lifting
- **HOB elevated to 30deg or HIGHER
-
MONITOR:
- HA’s
- Nausea
- Dizzy
- INCd BP
Gen. NEUROLOGIC Considerations
Neuropathy/Radiculopathy
PT Imps:
- Assess/Monitor:
- sensation to lt. touch
- Proprio.
- balance
- coord.
Gen. MSK Considerations
Name them
- Bone pain
- Know WB precautions
- Bony Mets
- Pain w/ WB, not responsive to PT, pain w/ Valsalve
- Sk mm wasting
- Osteoporosis
- Steroid Myopathy ****
- Bedrest/Decond.
Gen MSK Considerations
Bony Mets
PT Imps:
- WB status
- ROM restrictions
-
Spinal precautions**
-
No BLT
- Bending
- Lifting
- Twisting
- LOG ROLL
-
No BLT
Gen MSK Considerations
Steroid Myopathy**
PT Imps:
-
PROX MM weakness
- monitor strength
Gen MSK Considerations
Bedrest/Deconditioning
PT Imps:
- VITALS*** t/o Tx
- Monitor loss of bone density
W/ Goal Setting
What should we keep in mind?
-
Prognostic Indicators
- be Realistic
-
Communication
- b/w PT, pt, family
- goals may be diff!!!
-
Caregiver Training
- If pt returns home–may need assist
-
When is PT Approp?
-
if achieved max lvl of benefit
- communication!!!
-
if achieved max lvl of benefit
Discharge Planning
-
Various Settings:
- acute, subacute, SNF, assist living, hospice,
- HOME–may req other services
-
Considerations:
- prognosis
- Pt/family desires
- futher tx
- Immunocompromised state
- PT’s input is extremely vital to discharge process***
Cancer Pain
- acute vs chronic
- several etiologies
- described as Intractable
Cancer Pain
Acute
- BRIEF duration
- Cause usually known
Cx Pain
Chronic
- Extends beyond 3mos
- Cause may be UNknown
Etiologies Cx Pain
Cx Pain Syndrome
- Diff types of pain
- Diff etiologies
- Diff tx methods
-
Can be from:
- sx pain
- hardware
- painful neuropathy from hardware
- DIFF REASONS!!!
MOST COMMON FORM OF Cx PAIN….
BONE PAIN
Cx Pain
Bone Pain
MOST COMMON
- Can be primary or 2* dis
Cx Pain
Visceral Pain
*organs
- Organs in thoracic and abdominal areas (sx in abdomen)
- Gnawing, Crampy, Constant, Aching, DEEP
Cx Pain
Neuropathic Pain
- FROM:
-
peripheral OR central sensory nerve trauma
- causes abnormal firing
-
peripheral OR central sensory nerve trauma
- CHARACTERIZED:
- Burning
- Shooting
- Tingling
Cx Pain
From Cx Tx
- Sx
- RT
- chemo
**ALL CAN EXACERBATE PAIN
Cx Pain
Pain UNRELATED to Cx
NOTE: Cond’s other than Cx cause pain
Cx pain
Factors affecting response to pain
Anxiety
Personal life experience
Culture/Religion
Mgmt of Cx Pain
FIRST STEP?
Determine Source
Attempt to Remove It
- Sx
- Radiation
- Chemo
**BUT remember these can all CAUSE PAIN as well***
Meds and Routes of Admin
- Oral
- Buccal/transmucosal
- Rectal
- Transdermal
- Subcutaneous
- IV
- Direct CNS admin
- Pt-Controlled Analgesia
- PCA pump—-LET THEM CARRY THIS DURING Tx
Delivery of Pain meds and Coordinating w/ PT and scheduling
- Scheduling
-
Breakthru Pain
- X avail all the time, Y if X not enough
- Coord w/ Pt and other HC providers
Other Methods Pain mgmt
Behavioral intervents
Modalities
-
Modalities
- Cutaneous Stim (STM’s)
- heat, cold
- TENS
Cx PAIN
PT Role
- ROM, gen therex
- mobs
- Positioning
- ADs
- Bracing
- Modals
PT Imps:
Cx Pain
Considerations
Assessment of Pain (1-10)
Pre-medication of pt (for comfort during tx)
SEs of meds***
Cx FATIGUE
*Overwhelming fatigue**
“Distressing, persistent, subjective, sense of physical, emotional and/or cognitive tiredness or exhaustion related to cx or its Tx that is not proportional to recent activity and interferes w/ usual functioning”
*present in those indiv’s w/ advanced cx
Cx Fatigue
ACUTE
-
Expected occurrence after energy is expended
- when you SHOULD feel tired, you do…but it is still overwhelmingly tired
- SHORT duration
- Usually alleviated by REST
Cx Fatigue
CHRONIC
- Abnorm or Excessive
- Can involve ENTIRE BODY
- NOT alleviated by rest
- Can be overwhelming
**Fatigue that takes over you
Pathophys of Cx Fatigue
Contributing factors?
Cx itself
Progress. of dis.
Pathophys of Cx Pain
Physical Factors that influence
- sleep/rest patterns
- nutrition
- GI probs
- bone marrow suppression
- mult meds
- overall phys condition***
- tx
- infection
- Meds SEs
Pathophys of Cx Fatigue
Psychosocial Factors that influence
- Depress/isolation
- anxiety
- appearance
- lack of control
- relationship changes
- sexual dysf
- finances
Measuring Fatigue
Clinical S/S
- DEC strength
- INC dyspnea
- rate, depth
- Tachycardia
- Diff concentrating
- DEC ability to perform ADLs
- DEC nutritional intake
- Change in sleep/rest cycles
PT Imps Cx Fatigue
Considerations:
- Help det possible causes of fatigue
- refer out
- RD
- sleep docs
- Measure VITALS!!!
PT IMPS
Cx Fatigue
PT Role
- Daily energy log
- EXERCISE—-#1 WAY TO TX FATIGUE!!!
- energy conservation
- ADs
Physiotherapy Program Reduces Fatigue In Pts w/ Adv Cx Receiving Palliative Care: RCT
Psyzora A, Budzynski J, et al.
See Study below
Lymphedema
What is it?
Disruption in lymphatic system which results in a chronic accumulation of lymphatic fluid
*PRO-rich lymphatic fluid
Lymphedema
Risk factors
- Lymph node dissection
- Radiation to lymph nodes
- Tumor impeding lymph flow
Common areas for Lymphedema
- Breast, arm, trunk following ALND (Axillary Lymph Node Dissection)
- Head and Neck following RND (Radical Neck Dissection)
- LEs and Genitals following PLND (Pelvic Lymph Node Dissection)
Lymphedema Prevention + Education
- Maint healthy wt.
-
PREVENT any trauma to affected area
- cuts, scrapes, burns
- AVOID BP in Affected Extremity
- AVOID IVs, injections, needles in affected extremity
- Proper nail and skin care
- AVOID cutting cuticles
- Avoid tight fitting jewelry, clothes, bags
Complete Decongestive Therapy
For Lymphedema
Components of this?
- Manual Lymphatic drainage—-must be trained
- Compression–bandaging
- Self-care
* exercise
* skin care
- Self-care
- Compression Garments
* TEDS
- Compression Garments
Axillary Web Syndrome
*Think Palpable Cord******
- Visible web of axillary skin which overlies a palpable cord of tissue including blood vessels, nerves, lymphatics
- MAY extend to medial ipsilat arm, antecubital space, base of thumb
- Pain w/ shoulder FLEX and ABD
Effects of a PT Program Combined w/ MLD on Shoulder Function, QOL, Lymphedema Incidence, and Pain In Breast Cx Pts w/ Axillary Web Syndrome Following Axillary Dissection
see study below
Superior Vena Cava (SVC) Syndrome
what is it and what will you see?
- Invasion of tumor (typ lung tumor) INTO SVC causing edema of neck and face
- Thoracic vein distention
- Tachypnea (>20breaths/min)
- Cyanosis (blue)
- Edema of UEs
- paralyzed vocal cords
SVC Syndrome
Tx
EBRT (Ext Beam Radiation Therapy) and Chemo (less common option)
Steroids for edema
Head and Neck Cx
Trismus
- Impaired mouth ROM
- Impaired jaw mobility
- INCd PAIN
Head and Neck Cx
Sx can cause
immobility and pain
scar tissue
Head and Neck Cx
Radiation can cause:
Fibrosis of jaw mm’s, skin, fascia
Trismus
Tx’s
- Myofascial Release
- Intra & Extraoral massage
- Jt mobilization
- Therex
- Splinting (see pics)
- Dynasplint
- LLPS—Low Load Prolonged Stretch
Pediatric Considerations
-
Long term SEs (for survivors as children)
- Cardiac or Pulm toxicity
-
QOL
- developmental OR educational delay
- MSK considerations and growth
- fertility
- Long term survival and Gen health follow-ups!!!
Outpatient Oncology Services
To manage the MSK, NMSK, integumentary and CP rehab needs of pts resulting from the tx of cx. This includes acute or chronic sequela of cx tx such as sx, RT, chemo.
PT Dx’s oncology pts in Outpatient setting
see list below:
Outpatient: Tx Interventions Cx Pts
see list below
Assesment of PT Strategies for Recovery of Urinary Incontinence after Prostatectomy
see study below
Outpatient Modalities for Cx pts
Indications (when to use):
- MAY reduce pain and spasm
- NOT proven effective for tx of deep cx pain or bone pain
Outpatient cx pts: Modalities
ABSOLUTE Contraindications
DO NOT USE WHEN:
- DIRECTLY over tumor
- Bleeding or hemorrhage
- long term corticosteroid or chemo
-
Damaged OR regenerating nerves
- RT or chemo induced
- they cannot give you response to modality!!!
- Implants in Tx area
Recognizing Red Flags
Examples
- Recognizing skin cx’s
- PTs VERY close to pts—we see all over body–ex. back where pt may not see
- Palpation of abnorm tissue
- Pain
- Neurologic changes
Red Flags
PAIN related…
- Insidious onset (just crept up)
- Worse @ night, interferes w/ sleep—-this is HUGE Red Flag**
- Unable to reproduce w/ positioning
Recognizing Red Flags
Neurologic Changes
- Mm weakness
- Numb/tingling
- Loss of B&B control
- Burning or shooting pain
Skin Cx’s
2 Types:
- Melanoma–
* occurs in DEEPEST part of epidermis
- Melanoma–
- Basal Cell Carcinoma–
* occurs in epidermis
- Basal Cell Carcinoma–
Skin Cx
Melanom
DEEPEST part of epidermis
- Pigmented blackish or brownish color
- IRREGULAR, ill-defined borders
- Spreads QUICKLY to skin and other parts of body
Skin Cx
Basal Cell Carcinoma
*in epidermis
- PEARLY ROUND appearance OR darkly pigmented
Skin Cx’s
ABCDE
-
A: Asymmetry
- one half of mole or birthmark NOT match other half
-
B: Border
- edges irreg, ragged, notched, blurred
-
C: Color
- color NOT same all over–brown, black, sometimes patches of pink, red, white, blue
-
D: Diameter
- spot LARGER than 6mm across (1/4in–size of pencil eraser)
- NOTE: melanomas CAN BE smaller than this
-
E: Evolving
- mole is changing in size, shape, color
CARDINAL SIGNS for Cx OCCURRENCE
- Unusual, non-reducible fatigue
- fever
- Unexplained wt loss
- weakness
- PAIN
- skin changes
- Night sweats
Oncology considerations for PT intervents
Considerations of Cx Hx
- explanation of current rehab Dx
- *Common PRIMARY cx’s to develop Bony Mets
- Breast
- Prostate
- Lung
- Kidney
*Common PRIMARY cx’s to develop Bony Mets
Breast
Prostate
Lung
Kidney
Oncology considerations for PT Intervention
Dev of Mets
- Altered mental status
- Altered balance
- Unresolved pain
- Bone pain—-common loc. for mets
- Nerve pain
- SUDDEN onset of weakness
- SC compression
- SOB
PT Imps
Bony Mets
PRECAUTIONS
- PAIN
- MMT
- WB status
- Cautions of Patho fx’s ***
PT Imps
Bony Mets
INTERVENTIONS
- Therex
-
Orthotics
- support/prevent Fx’s
- ADs
- pt edu/safety
CNS Mets Disease
Cx that has spread to brain
*NOTE: usually NOT the other way around***
PRESENTATION?
- HA’s
- Mm weakness
- Sensation changes
- Impaired balance/coord
- Behavioral changes
CNS Mets Disease
INTERVENTIONS
- Orthotics, ADs
- Therex
- NMSK re-ed
- safety assess/fam training
Cx Pts Multidisciplinary TEAM
COMMUNICATION IS KEY***
SEE LIST OF TEAM Mbrs
