Unit 3_Oncology for Rehabilitation Flashcards
What kind of rehabilitation does cancer and cancer treatment focus on?
physical, mobility, functional and cognitive problems
What are the goals of oncology rehabilitation?
- Improve QoL
- Maintain independence
- Reduce side effects or cancer/treatments
- Maintain and gain physical/mental wellness throughout survivorship
What can be addressed during oncology rehabilitation?
- Pain, swelling, weakness, fatigue, ROM, balance
- Neuropathy, lymphedema, axillary cording
- Functional independence with ADLs/IADLs (including sexual health)
- Pre-Op/Tx baseline assessments
- Swallowing, chewing food
- Multitasking, memory, safety awareness, medication management
- Body Image and general coping
- DME / AD Recommendations
Etc.
What focuses on cancer treatment and then surveillance of cancer recurrence? It lacks attention to patient’s physical and functional well-being.
Medical Model
What cancer medication includes the patient is required to chew ice 30 min prior to chemo infusion, during infusion and 2 hours after completion?
Melphalan
What focuses on early identification and treatment as a means to prevent or mitigate physical impairments & functional limitations?
- Integrated with cancer treatment to create a more comprehensive approach to survivorship health care
- The goals of the model are:
- To promote surveillance for common physical impairments and functional limitations associated with cancer treatment
- To provide education to facilitate early identification of impairments
- To introduce rehabilitation and exercise intervention when physical impairments are identified
- To promote and support physical activity and exercise behaviors through the trajectory of disease treatment and survivorship
Prospective Surveillance Model
What cancer medication includes unable to work with patient during infusion?
Crosses blood brain barrier → can cause seizures / seizure like symptoms
Will have Pharmacokinetic (PK) studies drawn at specific times (coordinate with nurse)
Busulfan
What cancer medication includes PPE Considerations?
Seeps out of skin → Required to shower at least 4 times a day.
Encourage patient to wear hospital provided clothing
Thiotepa
What cancer medication includes PPE Considerations (Aerosol only)?
**NO specific precautions for Oral
- Aerosol: do NOT enter room when medication is running
- Patient must remain in room for duration of treatment then use PPE until cleared by MD
Ribavirin
What cancer medication can cause Hypotension if administered too quickly and poses a high risk for developing CIPN?
Etoposide
What cancer medication is commonly given before infusions? Patient may become sleepy or affect balance.
Benadryl
What cancer medication includes the risk of muscle atrophy (especially proximally) & avascular necrosis?
Corticosteroids
What disease includes ~5% of all cancer patients will develop?
Cancer attacks/ infiltrates the meninges & CSF of brain/ spinal cord.
Common with Leukemia, Breast, Lung or Myeloma dx.
Diagnosed with MRI and Lumbar Puncture.
No Cure: ~6mo - 12mo survival rate.
Symptoms:
Confusion & mood
Headache, Neck and/or Back Pain
Seizures
Neuropathy
Incontinence
Dysautonomia
Aphasia
Ataxia and/or Impaired coordination
Impaired vision
Leptomeningeal Disease (LMD)
What disease is the possible result of Sentinel Lymph Node Biopsy (SLNB) or Axillary Lymph Node Dissection (ALND)?
- Common procedures for Breast Cancer patients
- Appears days to months post-procedure
- ALND = MORE likely to develop AWS compared to SLNB
- 6-72% of women develop post-ALND
- Younger Patients > Older Patients
- African American Women > Caucasian Women
- See or feel web of thick, rope like structures called “cords”
- May not be visible or felt from provider but the patient will report “pain and tightness”
- Pathology: Trauma to the CT encases bundles of blood vessels, lymph vessels and nerves.
- Results in inflammation, scarring and hardening of tissue
↓ ROM and ↓ Function
↑ Pain
Axillary Web Syndrome (AWS)
What disease is treated via:
- Education
- PROM/ AAROM/ AROM: UE, Trunk
- Nerve Glides
- Manual Therapy (may hear popping): Myofascial release, soft tissue mobilizations, cord manipulation, joint mobilizations, scraping
- Moist Heat (**Avoid if patient has Lymphedema)
- Anti-Inflammatory medications (per MD)
Axillary Web Syndrome (AWS)
What disease includes:
- Neurotoxic Effects on Neurons
- ~30-40% of patients receiving chemo will develop CIPN
Important Note: CIPN is More frequent than Neoplastic Neuropathies - Typically begins within the first 2 months of starting chemo
High risk chemos:
Methotrexate (specifically when administered intrathecally)
Cisplatin
Etoposide - Risk Factors:
Obesity
Lymph node involvement
↑ Age
History of smoking and/or alcohol abuse
Chemo Induced Peripheral Neuropathy (CIPN)
What disease includes:
Symptoms: Sensory > Motor (S/S begin distally and are typically symmetrical)
- “Pins & Needles”
- Cramping
- Twitching
- Burning
- Numbness
- Impaired ability to sense temperature (hyper or hypo)
Functional Presentation:
- Difficulty with writing, dressing, opening packages, typing, etc. (Fine Motor)
- Frequent Falls (Foot drop, Tripping, Grossly Impaired Balance)
- Clumsy (dropping items)
- Burns on hands or scratches/ bruises on feet
Chemo Induced Peripheral Neuropathy (CIPN)
What are the stages of CIPN?
Stage I: Sporadic pain and numbness
- You may notice symptoms occasionally, but not constantly
- Often symptoms are easily overlooked during this stage.
Stage II: Persistent pain and numbness
- Pain and numbness are more constant and increasingly difficult to ignore
- Addressing symptoms by this stage is critical to preventing further nerve damage.
Stage III: Debilitating pain and numbness
- The pain and numbness in stage III are so severe that activity is greatly affected. Walking will become difficult, and you may be unable to balance
Stage IV: Complete numbness
- Walking is almost impossible due to severely damaged and deadened nerves
- The risk of amputations and complications is highest at this stage.
What disease are the following treatments for?
Medications:
Gabapentin
Lamotrigine (Lamictal)
Duloxetine (Cymbalta) = most effective
OT & PT:
Gross balance
Fine motor strengthening and coordination
Fall prevention & recovery
General strengthening
Bracing/ splinting: AFOs
Providing AD & DME
Manual therapy
Modalities like TENS
Activity modifications
Education & Safety awareness
Chemo Induced Peripheral Neuropathy (CIPN)
What disease is caused by:
Cancer & cancer treatment (medications and/or radiation, etc.)
Anemia
Poor duration or quality of sleep
Inactivity
Poor nutrition
Low mood
As compared to typical fatigue: more severe, lasts longer, and can limit ADLs / IADLs
A feeling of debilitating tiredness or total lack of energy that lasts for days, weeks, or months
Can NOT be fixed by only sleeping (in fact too much sleep may worsen CRF).
Top 3 Most Common Symptoms/Side Effects Cancer Patients Report:
Pain
Fatigue (but is the least likely to be treated by providers)
Nausea / Vomiting
Cancer Related Fatigue (CRF)
How can CRF be treated?
There is no “cure” but there are ways to “manage” CRF.
- Save Energy:
1. Plan and Organize Day: By planning the day, the patient can have a sense of control and prioritize what is important to them. The patient can have ownership in how they want to gain energy and how they want to spend their energy.
Create a routine and stick to it!
Alternate high/ low level activities when able
Consider which activities will drain energy
Schedule rest breaks
Modify tasks:
On a busy or hard day, maybe brush teeth while sitting at the edge of the bed rather than standing at the sink.
Pace Yourself: Use a moderate pace (avoid spurts of energy)
- Control Environment:
When able, avoid hot or very cold temperatures
Have assistive equipment if needed/ prescribed (shower chair, walker, wheelchair, etc.) - Maintain Good Sleep Hygiene: results in good quality/ quantity of sleep
- Regular Exercise: While it seems surprising, research shows that cancer patients (including pediatric patients) who exercise have:
Increased energy levels
Improved appetite
Better quality sleep
Improved ability to complete physical activities
Reported a higher quality of life
Reported improved outlook and sense of well-being
What is often diagnosed by Neuropsychologist on Oncology Team?
Not exclusive to patients with brain cancer
- Changes in thinking and cognitive function (mild to severe)
- Forgetfulness (Short Term Memory)
- Slower thinking
- Difficulty concentrating
- Periods of mental fogginess
Prognosis:
- Most patients will improve over time (months post-tx) but some never fully recover
Treatment: *Important to validate the patient’s concerns (provide early education)
- Stimulants
- “Brain Training” games: cross words, matching games, puzzles, etc.
- Cognitive Strategies: OT & Speech Therapy (routine, memory aids & environmental modifications)
- Exercise
- Manage depression & anxiety
- Improve sleep quality
Cancer Related Cognitive Impairment (CRCI)
What type of immunotherapy modifies T cells to recognize & attack cancer?
- Approved by FDA in 2017
- Several therapies approved by FDA
- All approved therapies use Autologous T cells (Cells from the patient)
- Some clinical trials use T cells from donors
- Modified T cells are multiplied (millions) and infused to patient
Commonly used to treat: Leukemias, Lymphomas, and Multiple Myeloma
Process:
1. T Cell collection → ~5 weeks for cell modification
2. Hospital Admission: Intensive chemotherapy (to weaken immune system to aid modified T cells)
- T cell infusion (~1 hour) and cost over $1,000,000 just for infusion without insurance
3. Remain in hospital for at least 3-4 weeks (with no complications or infections)
Side Effects: Range from mild to life threatening
- Fever, infection, vomiting, diarrhea
- Temporary but serious neurological effects: +Confusion, slurred speech and seizures
+Cytokine Release Syndrome (CRS)
CAR-T: Chimeric Antigen Receptor (CAR) T Cell Therapy
What is caused by a large, rapid release of cytokines into the blood from immune cells affected by immunotherapy?
- Occurs within the 1st week of getting CAR-T cells
- Usually resolves within 1-2 weeks
- Typically precedes ICANS
Shorter Duration - S/S:
Fever (First Objective Sign)
Hypotension
Hypoxia
Organ Failure - Tx: Tocilizumab
- Measure = CRS Grading System (grades 1-4)
CRS:
Cytokine Release Syndrome
or “Cytokine Storm”
