S2L4: Cancer Rehabilitation Flashcards
Patients with CA live longer due to:
A. Late detection
B. A limited selection of treatment options
C. Better medical management
D. All of the above
C
Early detection
A broad selection of treatment options
2nd leading cause of death in the US and the Philippines
ca
ca is 2nd leading cause of death where (2)
US and the Philippines
Most common cancers include:
Breast,
lung,
colorectal,
liver, and
prostate
_ of every_Filipinos are afflicted with cancer
189, 100K
ca is the _ most common cause of _
13th, self-reported disability
TorF Throughout the years, detection and treatment
of cancer has already progressed; many survived
T
Patients diagnosed with cancer tend to live shorter now than before
TorF
F, LONGER
Rehabilitation goals are:
○ Restorative
○ Supportive
○ Preventive
○ Palliative
goals THAT are for chronic or life-limiting illnesses
Supportive and Palliative
rehab goal: aim to return patients to a previous level of function
restorative
rehab goal: attempt to prevent avoidable deterioration in function
related to disease or treatment process (e.g., weakening, LOM)
preventive
rehab goal: focus on maximizing functioning, independence
and participation in meaningful activities alongside disability
supportive
rehab goal: involve supporting people to adapt to and
come to terms with irreversible changes in function
and associated losses or to ‘habilitate’ to their new reality
palliative
rehab goal: (e.g., can’t walk causing further
frustration or tiredness; can give w/c)
palliative
rehab goal: Patient has good potential to regain
sufficient strength and balance to transfer independently
restorative
rehab goal: Patient is at risk of deconditioning and
further weakness arising from inactivity
preventive
rehab goal: Patient is unable to manage the stairs and
will not regain this level of function
palliative
rehab goal: Patient has insufficient balance to walk
to toilet independently but is safe with support of a walking aid
supportive
rehab goal: Give AD or balance exercises
to prevent or lessen the risk of falls
supportive
what percent of ALL cancers occur in people >/= 65 years old
60%
60% of ALL cancers occur in people_
> /= 65 years old
Cancer is not in our genes TorF
F
As we grow old, there is a higher chance to
activate these cancer cells TorF
T
Relative survival in 1950
35%
Relative survival in 1975-1977
51%
Relative survival in 1996-2002
66%
CA with high survival rates
breast prostate
A medically-based, exercise intervention for cancer survivors
PHYSICAL REHAB FOR CANCER
Exercises are composed of _ and _ training
resistance, aerobic
Trainers role is to:
○ Help navigate patient to exercise programs
○ Help learn how to use the equipment properly,
do different set-ups
○ Monitor their heart rate to ensure patients that
they are exercising at a safe range that will still improve cardiac health, more endurance and
higher fitness level
○ Ensure that patients will perform the exercise
properly
Cancer patients can be more functional prior to the
program TorF
F, less functional
They can be very apprehensive at first TorF
T
We can use _ to see if the
patient can perform moderately difficult exercises,
and monitor the amount of intensity they exhibit
Borg’s scale (RPE Scale)
scale used in classifying functional impairments or
perforamnce status in serious illness
KARNOFSKY SCALE
KARNOFSKY SCALE progressions
mild, mod , severe
mild progression scores:
80, 90, 100
mod progression scores:
50, 60, 70
severe progression scores:
0, 10, 20, 30, 40
Able to carry on normal activity and to
work; no special care
needed: what progression in the scale?
mild
Unable to care for self; requires equivalent
of institutional or hospital care; disease
may be progressing rapidly: what progression in the scale
severe
Unable to work; able to live at home and care
for most personal needs; varying amount of assistance needed:
what progression
Moderate
Normal; no complaints; no evidence of disease: what score
mild, 100
Normal activity with effort; some signs or symptoms of disease
mild, 80
Cares for self; unable to carry on normal activity or do active work
mod, 70
Able to carry on normal activity; minor signs or symptoms of disease
mild, 90
Requires considerable assistance and frequent medical care
mod, 50
Death
severe, 0
Severely disabled; hospital admission is
indicated; death not imminent
severe, 30
Moribund; fatal processes progressing rapidly
severe, 10
Requires occasional assistance; able to care for most
personal needs
mod, 60
disabled; requires special care and assistance
severe, 40
very sick; hospital admission necessary;
active supportive treatment necessary
severe, 20
karnofsky scale used by _ and _
doctors and nurses
To be more accurate, what scale is used?
Australia-modified Karnofsky Performance Status (AKPS)
Totally bedfast and requiring extensive
nursing care by professionals and/or family
20
Normal; no complaints; no evidence of disease
100
Comatose or barely rousable
10
Cares for self; unable to carry on
normal activity or to do active work
70
Almost completely bedfast
30
Able to carry on normal activity; minor sign of symptoms of disease
90
Normal activity with effort; some signs or symptoms of disease
80
In bed more than 50% of the time
40
Able to care for most needs; but requires occasional assistance
60
Considerable assistance and frequent medical care required
50
Non ca patietn improve more than ca pts in terms
of functional gains from in pt rehab TorF
F. CA = Non CA patients
Improvement in regular pts can be expected
from those c cancer as well TorF
T
Functional improvements gained
from inpatient rehab is maintained _ after D/C
3 months
Once we see initial improvement, we cannot
expect to see improvement for at least 3 months after discharge
TorF
F, we CAN expect
what has no adverse effect on rehab outcomes?
Chemotherapy,
radiation therapy and
specific tumor type
Regardless if pt is under chemotherapy or not,
it is still ideal that they are doing exercises. TorF
T
Same improvement for all, normally an improve in_
inc VO2Max
VO2Max can be an indicator of lifespan TorF
T
CA has greater incidence of transfer back to acute
care from rehab TorF
T
Risk factors for transfers of ca pts:
Low albumin,
elevated creatinine,
use of feeding tube or indwelling catheter
Pts who are undergoing treatment have a
lower chance of returning to acute care TorF
F, HIGHER CHANCE
rehab priorities during initial dx:
Detect and manage acute morbidity from cancer treatments
Address worsening of premorbid physical impairments
rehab priorities during surveillance:
Physically recondition
Detect and address delayed cancer treatment toxicities
Promote reentry into vocational , social, and family roles
Pts are usually weak especially with _
progressive
cancer
Leading cause for those who had undergone
treatment is _
cardiotoxicity
Quality of life would greatly depend on their _
function
what Comes mainly after a comprehensive assessment
Addressing worsening of premorbid physical impairments
rehab priorities during recurrence:
Screen for cancer treatment toxicities, given the increased risk
Proactively manage early-stage impairments
○ Assess changes in function
○ Frequent re-eval especially if change
in function is observed
where is this in rehab priorities?
recurrence
rehab priorities during temporization:
● Control symptoms
● Prevent and proactively address disablement (caused by the disease itself)
rehab priorities during palliation:
● Preserve community integration
● Support and educate caregivers/family members
● Maintain functional autonomy as feasible
Quote from proponent of modern palliative care :
“Goal is to enable patients to live as actively as
possible”
Just because prognosis is poor, it doesn’t
mean that we would not try to help them TorF
T
is not a
contraindication to inpatient rehab if functional gains
are to be expected
Poor expected long term survival
Functional gains of patients who are in the advanced
stage of the disease should include _
family/caregiver training
highest 5 yr survival local
prostate
highest 5 yr survival regional
prostate
highest 5 yr survival distant
pharynx and oral cavity
lowest 5 yr survival local
pancreas
lowest 5 yr survival regional
pancreas
lowest 5 yr survival distant
pancreas
Common Sites of Metastatic spread for: lung and bronchus
Brain, bone, liver, mediastinal lymph nodes
Common Sites of Metastatic spread for: breast
Brain, lung, bone, liver
Common Sites of Metastatic spread for: prostate
Bone, pelvic lymph nodes
Common Sites of Metastatic spread for: colon and rectum
Liver, lung
Common Sites of Metastatic spread for: ovary
Peritoneum, pleura
Common Sites of Metastatic spread for: uterine cervix
Peritoneum, lung, retroperitoneal lymph nodes
Common Sites of Metastatic spread for: uterine corpus
Retroperitoneal lymph nodes, lung
Common Sites of Metastatic spread for: pharynx and oiral cavity
Lung, regional lymph nodes
Common Sites of Metastatic spread for: melanoma
Brain
Common Sites of Metastatic spread for: stomach
Liver, lung, peritoneum
Common Sites of Metastatic spread for: esophagus
Liver, lung
Common Sites of Metastatic spread for: pancreas
liver
Common Sites of Metastatic spread for: urinary bladder
Bone, intraperitoneal
Local means in
one organ
Regional means
spreads around one organ
Distal means
evident metastasis to other organs
When metastasis occurs, Five Year Survival rate
_ significantly.
decreases
have a high five-year survival
rate if cancer does not metastasize.
Breast cancer patients
have a higher five-year survival rate than breast cancer patients.
Prostate cancer patients
Prostate cancer develops in _ patients
geriatric
This cancer has a very good prognosis, and patients
will more likely die due to aging than the complications
and effects of cancer.
Prostate cancer
Addresses musculoskeletal problems
(lymphedema, contracture, pain, mobility, ADLs, self-care)
OUTPATIENT REHABILITATION
one of the most prominent side effects from chemotherapy,
exercising can help increase your energy levels.
Cancer related fatigue
is more of a chronic disease these days than a death sentence.
Cancer
is really important for your patients whether it would be
building their endurance again or just in general conditioning
Exercise
PRECAUTIONS (9)
Hematologic profile
Metastatic bone disease
Compression of a hollow viscous vessel or spinal cord
Fluid accommodation in the pleura, pericardium, abdomen or retroperitoneum
CNS depression or coma
Hypo/hyperkalemia, hyponatremia or hypo/hypercalcemia
Orthostatic Hypotension
HR > 110 bpm
Fever >101 F / >38C
What we look for in hematologic profile is the:
hemoglobin
_ = decreased exercise capacity
Lower hemoglobin levels
Patients can be fatigued easily if they are _.
anemic
Pt are not allowed to carry _ _, also
_ activities due to the risk for
_ _ because of a _ in
the bone which makes it weaker.
heavy weights, high-intensity, pathologic fx, tumor
Pain medications may help the patient if they
are _, but pain may persist if they move.
immobile
Cancer cells metastasize and may impinge the _
spinal cord
Thoracic level impingement = _
possible paraplegic pt
Results to resistance to movement of cardiovascular
organs which leads to decreased exercise capacity
Fluid accommodation in the pleura, pericardium, abdomen or retroperitoneum
As a result of cancer treatment
electroylte imbalance
Hypo/hyperkalemia, hyponatremia or hypo/hypercalcemia may be
d/t:
kidney damage
If pt has been bed bound for awhile and
suddenly stands up expect __ since they are not
used to upright position
OH
Need clearance from MD before participating in
exercise
HR
Exercise is not performed in pts with _
since it can cause further increase in HR which
will put the pt a risk
high HR
PTs do not treat pts with _ since there is an
infectious process going on
fever
Most important if they are undergoing
chemotherapy, as it should not cause a _
fever
Stop the patient and consult with the doctor if pt has
fever
_ of patients experience pain
60%
_ severe pain
25-30%
CANCER-RELATED PAIN is _
(+) pain with other associated symptoms -
decreased functional status
First line of rx for cancer related pain:
Non-opioid analgesics
Opioids example
Morphine
There are some hesitations regarding pts
who use _ as it can be addictive
Morphine
morphines are
regulated
is still used to control immense pain, and
prevent pts from being bedridden (d/t pain) which
can lead to loss of function and decline in QOL
Morphine
Timeframe of cancer related pain:
acute,
crescendo,
chronic
Crescendo means
increasing pain
Pathophysiology of cancer related pain
somatic
visceral
neuropathic
Temporal cancer related pain
continuous,
intermittent,
breakthrough
even if they are on pain medications, severity of pain increases.
Breakthrough
If breakthrough happens, _ such
as drugs will be given
adjunct pain Mx
adjunct pain Mx regulated by _ or_
oncologist, palliative care MD
Nonpharmacologic pain management approaches
○ Cryotherapy
○ Biofeedback
○ Iontophoresis
○ TENS
○ Massage
○ Relaxation techniques
○ Meditation
○ Art/Music therapy
○ Counseling
○ Aromatherapy
There are different theories surrounding pain perception,
but there is only one _ aspect for it.
biological
Pain has a _ aspect, and as PTs, it is good to approach
pain Mx using this model.
biopsychosocial
helps people control their brain and body’s response to stress
Biofeedback training
In clinics, biofeedback training is seen to help
conditions that are _ such as _ or POTS.
dysautonomia, postural
orthostatic tachycardia syndrome
_ is the most problematic situations for clinicians
Metastasis to the skeleton
3rd most common for systemic metastasis
Skeleton
80% of bone metastasis is attributed
to _ _ _ _ _
breast,
lung
prostate,
kidney,
thyroid cancers
Bony metastases types
osteolytic
osteoblastic
mixed
mas lumalaki/dense ang buto
Osteoblastic
nasisira ang buto
Osteolytic
Highest rate of osteoclastic activities
lymphoma,
multiple myeloma,
thyroid,
renal cell malignancies
Most insidious clinical presentation of bony
metastases
Pain
pain in ca is
Insidious,
unrelenting,
not associated with trauma or activity,
present or worse at rest
pain is common in the _ and _
thoracic spine
shaft of femur
what is associated wth pain?
Weight loss,
point of tenderness over the involved
bone scan for pain
Triple phase bone scan
Most sensitive in identifying bony metastasis
Triple phase bone scan
Patients with localized bone pain, equivocal
scan, or neurologic impairment
MRI
When the lesion is osteoclastic
PET Scan
Survival Rate (after metastasis)
21-33 months
Mx for bony metastatic disease?
Protection,
pain control,
energy conservation,
maintenance of function
mx for Protection and pain control
Bracing (prevent fx),
mobility aids (AD),
activity precautions
Exercise prescription should focus on:
○ Strength
○ Endurance
○ Function with limited loading or torsion of the
affected bone
This is the most frequent nuclear type-imaging study.
3-Phase Bone Imaging
It is used to evaluate vascular flow, blood pool
activity, and delayed bone uptake.
3-Phase Bone Imaging
3 phase bone scan type of imaging evaluates for _ or
bone infection vs. cellulitis or soft tissue infection
vs. stress fx vs infected joint.
osteomyelitis
Great challenge for PTs, as pts may not meet
high levels of exercise, or at least moderate physical activity
CANCER-RELATED FATIGUE
cancer related fatigue may be d/t
May be d/t cancer treatment
cancer related fatigue is _ when it persists, occurs during our
usual activities, and does not respond to _
pathological, rest
is central goal of rehabilitation for ca related fatigue
Assessment and Rx
Used of mild/moderate/severe based on a 0-10 likert
scale
CANCER-RELATED FATIGUE
mild in likert scale
1 to 3
moderate
4 to 6
severe
7 to 10
omt for cancer related fatigue?
FACIT Fatigue Scale
Measures how much a patient’s ADLs are
affected by their fatigue
FACIT Fatigue Scale
Higher score of facit means_
better QOL
Most common associated factors: for cancer related fatigue?
Pain
Emotional distress,
sleep disturbance,
anemia,
nutritional deficiencies,
deconditioning,
medical comorbidities
mx for cancer related fatigueL
Strengthening
endurance programs,
nutritional management,
sleep optimization
Reversible sources of cancer fatigue
Anemia
Insomnia or lack of restorative sleep
Cytokine release (e.g. tumor necrosis factor)
Hypothyroidism
Hypogonadism
Depression
Deconditioning
Steroid myopathy
Centrally acting medications
Altered oxidative capacity
Pain
Adrenal insufficiency
Cachexia
insomnia causes _
easy fatigability
Cytokine release d/t
chemical build up in the body
chemical build up in the body can be excreted by _ or
controlled by _
kidneys, medication
when cv endurance improves, what increases
VO2max increases
_ has been associated with increased risk of death for cancer
Obesity
OW and obesity account for _% cancer deaths in men
14 percent
OW and obesity account for _% of cancer deaths in women
20 percent
minimum hours of exercise per week
150 mins per week
recommended exercise for ca pts:
30 minutes of moderately vigorous exercise
on 5 or more days of the week
_ is the most favored type of aerobic exercise
Cycle ergometry
non-WB, easier
Cycle ergometry
Precautionary measure is taken with _ patients
thrombocytopenic
Unrestricted exercises can be pursued with _
> 30-50k
Aerobic exercise okay in patients with _
platelets >10-20k
Active therapy not advocated with platelet
count _
<10k
Patients undergoing chemotherapy can sustain
_
premature cardiac damage
heart changes for pts undergoing chemo:
Reduced exercise time,
reduced maximum O2 uptake,
abnormal ST and T wave changes,
exercise induced hypertension
“Reduced exercise time,
reduced maximum O2 uptake,
abnormal ST and T wave changes,
exercise induced hypertension”
these can also happen even _ chemotx. this is a _ effect
after, long term
Supervised _ and _ program
among _ cancer patients at _% _
weekly for _ weeks: improve strength and endurance
strengthening, aerobic, breast, 40-60%, twice, 21
parameters of aerobic that improves endurance:
Aerobic training 3x/week for 15 weeks improves
endurance
EXERCISE FOR PATIENTS UNDERGOING
MARROW TRANSPLANT
Supine or sitting exercises well tolerated
exercise for pts marrow transplant:
_ exercises with the head of the bed _
supine, elevated
Supine exercises with the head of the bed elevated to avoid
_
hypotension
exercise for pts marrow transplant:
_ exercises for brief periods to avoid _
Standing, gastroc-soleus tightness
more exercises for pts marrrow transplant:
ROM,
aerobic exercise (walking, cycle ergometry),
light resistive exercises,
deep breathing exercises
neurologic complication of ca:
METASTATIC BRAIN DISEASE
Most common catastrophic neurologic
impairment in the cancer population
METASTATIC BRAIN DISEASE
metastatic brain disease occur most frequently with
lung,
breast,
colorectal,
melanoma,
genitourinary
percentage of affectation on brain: metastatic brain disease
in the cerebrum__ and in the cerebellum __
85% in the cerebrum, 15% in the cerebellum
METASTATIC BRAIN DISEASE sx:
Progressive HA,
hemiparesis,
seizures,
mental status change
metastatic brain disease seen thru:
Magnetic resonance imaging
Leptomeningeal disease sx:
Back pain,
radiculopathies
cranial nerve dysfunction
mental status changes
SPINAL CORD INVOLVEMENT occurs in what percent of all
ca pts
5-14% of all CA patients
Most common sources of spinal cord involvement:
metastases from
prostate,
breast,
lung,
kidney,
multiple myeloma
Areas of predilection percent in thoracic
70%
Areas of predilection percent in lumbar
20%
Areas of predilection percent in cervical
10%
when there is sc involvment, what is the type of pain?
Progressive, insidious back pain
worse when lying down
S/Sx of sc involvement:
Point tenderness,
paresis,
sensory impairment,
upper neuron lesion findings
polyneuropathy is _ induced
Chemotherapy-induced
Disruption of axoplasmic microtubule transport,
axonal “dying back”, has direct effects to the DRG
POLYNEUROPATHY
polyneurotpathy is the _ of _ _ _, axonal _, has direct
effects to the _
disruption, axoplasmic microtubule transport, dying back, DRG
for polyneuropathy what type of nerves are more affected
Sensory nerves > motor nerves
polyneuropathy sx:
Dysesthesias,
sensory loss,
allodynia
RADIATION THERAPY SIDE EFFECTS acute:
● Fatigue
● Nausea
● Vomiting
● Anorexia
● Skin erythema
● Desquamation
● Mucositis
● Xerostomia
● Taste loss
● Proctitis
● Cystitis
● Decreased libido
● Sterility
● Amenorrhea
● Hematological
changes
Dryness of or inflamed mucosal membrane
Mucositis
Dryness of mouth
Xerostomia
RADIATION THERAPY SIDE EFFECTS delayed:
● Soft-tissue fibrosis
● Skin atrophy
● Auditory changes
● Pulmonary fibrosis
● GI stricture
● Thyroid dysfunction
● Brain necrosis
● Myelitis
● Plexopathy
● Lymphedema
● Secondary
malignancies
● Osteonecrosis
most common malignancies assoc c lymphedema:
Breast cancer
melanoma
gynecological malignancies
lymphoma
Since the cancer cells travel along the lymph, it may also
affect the flow of the _
lymphatic circulation
torf lymphedema has pain
f, painless
painless, gtradual, colorless swelling with heaviness and loss
of limb contour
LYMPHEDEMA
lymphedema: _ symptoms, preserve _, maintain function,
decrease the risk of _
reduce, cosmesis, recurring infection
lymphedema resolved thru:
Complexion decongestive
therapy (MLD)
phases of complexion decongestive therapy:
○ Decongestive phase
○ Maintenance phase
As PTs, we do (for lymphedema)
Skin care,
stretching,
soft tissue mobilization to proximal limbs
massage
bandaging
More commonly a side effect of treatment
CANCER-RELATED SEXUAL DYSFUNCTION
_and _ may interfere
with sexual attractiveness
Physical changes, depression
Chemotherapy has adverse
effects in
_ and _ production
spermatogenesis, testosterone
Because chemotherapy is not selective.
It affects both cancer cells and healthy cells TorF
T
Permanent _ is side effect for women
menopause
Diagnoses most likely to affect long term
employment include _ _ _
CNS tumors,
head and neck tumors,
advanced hematologic malignancies
long term employment is Highly dependent on the _
type of cancer
SPECIFIC TUMORS AND REHABILITATION NEEDS (7)
breast cancer
head and neck cancer
hematologic malignancies
lung ca
GI malignancies
brain tumors
sarcomas of bone and soft tissue
Most common malignancy in women
BREAST CANCER
what do u call the pain present in breast cancer after surgery?
Post-surgical pain syndrome (post-mastectomy
pain syndrome)
Phantom breast pain is also called
Post-surgical pain syndrome (post-mastectomy
pain syndrome)
Post-surgical pain syndrome in breast ca:
○ Phantom breast pain
○ incisional allodynia
○ neuroma formation
○ pectoralis muscle pain
○ Intercostal neuropathy
mx for breast cancer:
Cutaneous desensitization,
soft tissue mobilization,
stretching,
shoulder ROM,
thermal modalities with caution
If cold modalities works on the patient, we must opt
for the:
cold modalities instead of heating modalities
Breast cancer-related shoulder dysfunction is d/t:
operation
what perectn affected for breast ca related shoulder dyfucntion:
> 50% affected
most common long term morbidity
Breast cancer-related shoulder dysfunction
HEAD AND NECK CANCER type of cell
Squamous cell carcinoma
head and neck ca d/t
Alcohol and tobacco use
head and neck also causes _ dyfunction
swallowing
Swallowing dysfunction causes:
loss of oral intake,
weight loss,
fatigue,
decreased survival
Effects of radiation therapy
○ Mucositis
○ Xerostomia
HEMATOLOGIC MALIGNANCIES often produce
fatigue
why hematologic malignancies produce fatigue?
because red blood cells are affected
Most common pain in hema malignancies:
neuropathic pain
hematologic malignancies:
Hodgkin’s vs Non-Hodgkin’s lymphoma
Leukemia
LUNG CANCER produce _ and _
fatigue and deconditioning
LUNG CANCER type of lung tumor:
Apical lung tumor (Pancoast tumor)
lung ca MX:
Pulmonary hygiene and breathing exercises,
coughing exercise
pursed-lip breathing
diaphragmatic breathing
segmental breathing
to keep the cough productive for easier expulsion of sputum
coughing exercises
done if the patient complains of difficulty in breathing
pursed-lip breathing
to preserve lung function
segmental breathing
is the 4th most common cancer in the US
Colorectal cancer
2nd leading cause of cancer death
GI MALIGNANCIES
The only major malignancy equally affecting
males and females
GI MALIGNANCIES
_ is the only curative treatment for gi malignancies
Surgery
BRAIN TUMORS could be:
benign
malignant
are the most common primary malignancies of the bone
Osteosarcoma,
chondrosarcoma,
pediatric Ewing’s sarcoma,
malignant fibrous histiocytoma
Usually, if these are early detected, the patients are required to
undergo _
amputation
Patients with _ usually has a good prognosis if they
undergo amputation and treatment
Pediatric Ewing’s Sarcoma
Most common malignancy in men
PROSTATE CANCER
Has high chance of survival
PROSTATE CANCER
True or False: prostate cancer is treatable
t
are the most common causes of death in prostate cancer
Bone metastasis
complications of androgen deprivation
PROSTATE CANCER may experience _ or _
incontinence or impotence
OMTs
australian modified karnofsky performance scale
barthel ADL index
FACIT
zarit caregiver burden assessment instruments
