week 4 Flashcards
1
Q
common problems in PT and cancer
but not just cancer
A
- cancer related fatigue - most common symptom
- pain
- spinal cord compression
- pathologic fracture/bone mets/lytic lesions
- lymphedema
- altered blood counts and immunity
- venus thromboembolism (VTE: DVT + PE)
2
Q
cancer related fatigue (CRF)
A
- distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning
- associated with multiple domains: cancer, cancer treatment (chemo/radiation), surgery
- does not improve with rest
- limits QOL
- affects ability to concentrate, calculate, or remember – similar to chemo brain
- “can’t get through the day”
3
Q
subjective and objective components of CRF
A
- physical performance: weakness or tiredness
- mood: depression, anxiety
- motivation: lack of initiative
- cognition: slowing of thought processes, distraction, or memory deficits
- social functions: reduced ability to sustain social relationships
4
Q
needs for improved CRF management
A
- CRF is a multifactorial,bio-behavioral phenomenon
- impacts: ADLs/functional capacity, mental/emotional well-being, social/behavioral, occupation, caregivers
- multidimensional
- CRF is under-reported, under-diagnosed, under-treated
- fatigue should be assessed at every patient interaction
5
Q
CRF education example
A
- you have a battery/money, and you want to have enough to last all day
- going up stairs on a good day takes 5%, but on a bad day, it takes 20%
6
Q
screening
for CRF
A
- screening tools are generally unidimensional, easy to administer, easy to interpret
- often dichotomous - yes/no
- may provide simplistic evaluation for severity, but should trigger a more in depth screen
- importance: triggers need for more “in depth” assessment and referral for care for typically unmet needs and additional medical consultation
- fatigue thermometer: pick 0-10 that describes fatigue you have had in the past week including today
- one item fatigue scale: rate fatigue on scale 0-10, 0: no fatigue, 1-3: mild fatigue, 4-6: moderate fatigue, 7-10: severe fatigue
7
Q
assessment of CRF
A
- assessment tools identify extent of a problem, including impact on function and health-related QOL
- generally multidimensional in nature
- comprehensive in scope
- importance: provides greater direction for treatment plan
- multiple well-validated measures: fatigue severity scale, fatigue impact scale, brief fatigue inventory and functional assessment of chronic illness threapy - fatigue (FACIT-F)
8
Q
eastern cooperative oncology group (ECOG)
performance scale - v important
A
- ECOG scale: details
- 0: normal activity
- 1: symptoms demonstrated but patient remains ambulatory, able to perform self care
- 2: ambulatory > 50% of the time, requires occasional assistance
- 3: ambulatory < 50% of the time, requires nursing care
- 4: bedridden
- 5: death
- cancer trials use this for cutoffs
9
Q
karnofsky performance status scale
performance scale
A
- able to carry on normal activity and work, no special care needed
- 100: normal, no complaints - no evidence of disease
- 90: able to carry on normal activity, minor signs or symptoms of disease
- 80: normal activity with effort, some signs or symptoms of disease
- unable to work, able to live at home and care for most personal needs, varying amount of assistance needed
- 70: cares for self, unable to carry on normal activity or to do active work
- 60: requires occasional assistance, but is able to care for most of his personal needs
- 50: requires considerable assistance and frequent medical care
- unable to care for self, institutional or hospital care, disease may be progressing rapidly
- 40: disabled, requires special care and assistance
- 30: severely disabled, hospital admissions is indicated although death not imminent
- 20: very sick, hospital admission necessary, active supportive treatment necessary
- 10: moribund, fatal processes progressing rapidly
- 0: dead
10
Q
physical therapy interventions
A
- exercise: aerobic and strength training
- complimentary and alternative therapies: acupuncture and yoga
- lymphedema mangament
- start easy: low and progress slow, but progress
11
Q
caution performing exercise with any of the following
A
- bone metastases (cancer spread to the bone)
- thrombocytopenia (low platelets)
- anemia (low RBCs)
- neutropenia: avoid environments where the risk of exposure to infectious diseases (public swimming pools, crowded gyms)
12
Q
cancer related pain
A
- 20-50% of patients with cancer report pain as a symptom
- prevalence increases with progression of cancer and may reach 90% in terminal patients
- prevalence of 26-54% in cancer survivors
- pain is often undertreated
13
Q
characteristics of cancer pain
A
causes of cancer patients can be classified as:
1. directly related to cancer - direct invasion or compression of structures by cancer
2. related to cancer therapy - due to surgery, chemo, radiation
3. related to effects of cancers - bed sores, debility
4. age-related, comorbidities - chronic back pain, OA (not all pain is the C word)
14
Q
breakthrough pain
A
acute exacerbation of pain of short duration on teh background of stable pain pattern
15
Q
bone lesions
A
2 types:
1. osteolytic lesions: cancer has cuased bone breakdown or thinning, destroy bone material (bone is weakened, thin)
2. osteoblastic lesions: cancer has caused overproduction of bone cells (rigid, inflexible)
16
Q
mirels scoring system for pathologic fracture risk
A
- rate each area on site, pain, lesion, size (1-3) - diameter
- clinical recommendations are based on total score
- < 7 radiation therapy and observation
- 8 use clinical judgement
- > 8 prophylactic surgical fixation
increased lesion = increased fracture risk
17
Q
pain characteristics and fracture
impending fracture
A
- pain with:
- WB
- groin
- hip scour
- hip external rotation and abduction
- deep inspirtaion
- bance around chest wall
- supine
- with valsalva
18
Q
spinal cord compression
A
- primary or secondary disease spreads to the vertebra and impinges on the spinal column
- etiologies
- vertebral collapse (85%)
- direct invasion
- prolonged compression can disrupt of vascular supply (infarction)
- general S&S
- back pain is most frequent symptom (95%) - pain increases or is unrelieved with supine
- motor > sensory changes - DTRs change, ask about changes in bowel and bladder
19
Q
post prostatectomy incontinence
A
- the incidence of urinary incontinence after radical prostatectomy varies
- incontinence immediately after catheter removal may approach an incidence of 90%
- after one year, incontinence (very common) varies from 5% (0-1 pads daily) to 30-40%
20
Q
most common blood testes
A
- complete blood count (CBC) with differential
- basic metabolic profile (BMP, somtimes called a chem 7)
21
Q
complete blood count (CBC)
A
- **red blood cells (RBC) **
- male 4.7-5.5 mil cells/mm^3
- female 4.1-4.9 mil cells/mm^3
- white blood cells (WBC)
- 4,500-11,000 cells/mm^3
- hemoglobin (Hb)
- male 14.4-16.6 gm/dL
- female 12.2-14.7 gm/dL
- hematocrit (Hct)
- male 43-49%
- female 38-44%
- platelets (Plt)
- 150,000-350,000 platelets per microliter (mcL)
22
Q
plasma
A
- liquid part of blood (55%)
- pale yellow made up of 91% water, 9% other
- colloid: liquid containing suspended substances that don’t settle out
- albumin: important in regulation of water movement between tissues and blood (osmosis)
- globulins (anti-bodies): immune system and transport molecules
- clotting factors/fibrinogen: responsible for formation of blood clots (hemostasis), from liver
23
Q
formed elements in blood
A
- red blood cells: RBC, erythrocytes
- white blood cells: WBC, leukocytes
- granulocytes: neutrophils, eosinophils, basophils
- agranulocytes: lymphocytes, monocytes
- thrombocytes: platelets
24
Q
erythrocytes
A
- structure: biconcave, anucleate
- components:
- hemoglobin
- lipids, ATP, carbonic anhydrase
- function:
- transport oxygen from lungs to tissues and carbon dioxide from tissues to lungs
- acid:base balance
25
hemoglobin
* norms: women (12.2-14.7 g/dl), men (14.4-16.6 g/dl)
* **mild anemia**: > 10-11.9 g/dl
* therapy as indicated, no distinct precautions
* **moderate anemia**: 8-9.9 g/dl
* anticipate decreased cardiopulmonary reserve/limited endurance
* monitor VS closely
* patient symptoms: exercise intolerance/DOE/tachycardia/pallor
* **severe anemia**: < 7-8 g/dl
* therapy may be contraindicated - check institution P&P
* blood transfusion probable Hb < 7 g/dl - more common "criital value"
* **< 5 g/dl**: increased risk of cardiac event
26
hematocrit
| Hct
* ratio or volume of red blood cells to total volume of blood
* male: 43-49%
* female: 38-44%
* Hct < 25% often cited as a critical value and correlates to Hb < 7-8 g/dL
27
anemia and PT
* S&S of anema (low H/H)
* symptoms: weakness, fatigue, dyspnea
* signs: tachycardia, pallor
* confounding factors: rapid or slow change in values
* medical history: chronic illness, heart disease, cancer or cancer treatment, surgery
28
transfusion reactions
* **febrile non-hemolytic reaction**: most common
* fever, chills, SOB --> benign, reactions are small
* **acute hemolytic reaction**: rapid destruction of donor erythrocytes by preformed recipient antibodies
* triad of fever, flank pain, red/brown urine (hemoglobinuria)
* decreases H&H
* **anaphylactic reaction**:
* shock, hypotension, angioedema, respiratory distress --> life threatening
* **transfusion-associated acute lunk injury (TRALI)**:
* pulmonary edema --> life threatening
29
thrombocytes
| platelets
* small fragments of megakaryocytes
* platelets contain granules that are secreted in response to "activation"
* important in preventing blood loss: platelet plugs, promoting formation and contraction of clots
30
thrombocytes
| platelets
* small fragments of megakaryocytes
* platelets contain granules that are secreted in response to "activation"
* important in preventing blood loss: platelet plugs, promoting formation and contraction of clots
31
platelets and therapy considerations
* **normal**: 150,000-350,000/mm^3
* **subnormal - thrombocytopenia**: < 150,000/mm^3
* 50,000-149,999: low intensity progressive resistive exercise (PRE) and aerobic exercise (none to minimal elevations/resistance)
* 30,000-50,000: typically not associated with spontaneous bleeding, AROM exercise, walking ad lib
* <10,000-20,000: risk of spontaneous bleeding, petechiae, ecchymosis, therapy may be contraindicated/minimla AROM
* **elevated - thrombocytosis**: > 350,000/mm^3
* no distinct recommendation, paradoxical increased risk of bleeding
32
venus thromboemoblism (VTE)
| pulmonary emoblism
* PE hospitalization rates increased substantially from 1999 to 2010, with a higher rate for black patients
* PE mortality increases with age
* overall mortality rates decreased but remains high
* PE hospitalization rates have increased
* increase in hospitalization and continued high mortality confirm significant burden of PE (especially for black and older adult patients)
33
who is at risk for VTE
* **virchow's triad **
* **hypercoagulable state**
* malignancy
* pregnancy and peri-partum pareiod
* oestrogen therapy
* truama or surgery of LE, hip, abdomen, or pelvis
* inflammatory bowel disease
* nephrotic syndrome
* sepsis
* thrombophilia
* **vascular wall injury**
* trauma or surgery
* venepuncture
* chemical irritation
* heart valve disease or replacement
* atherosclerosis
* indwelling catheters
* **circulatory stasis**
* atrial fibrillation
* left ventricular dysfunction
* immobility or paralysis
* venous insufficiency or varicose veins
* venous obstruction from tumor, obestiy, or pregnancy
34
venous thromboembolism
| VTE
* DVT and/or PE
* disease that includes both deep vein thrombosis and pulmonary embolism
* 3rd most common cardiovascular illness: acute coronary syndrome (ACS) and CVS, 2/3 associated with hospitalization
35
wells prediction rule for DVT and PE
36
pulmonary embolism
* **hallmark clinical features**
* tachypnea: 16 breaths per minute or greater
* tachycardia (> 100 bpm)
* sudden onset dyspnea
* chest pain (acute onset)
* **other features**
* hypotension - dizziness, lightheadedness
* desaturation - decreasing pulse oximetry
* couch
37
is there a correlation between exercise and DVT
no, patient should already be on anticoagulants anyway
38
if on coumadin, check
INR
39
if on heparin, check
PTT
40
major complications of DVT and PE
* DVT: venous stasis syndrome (post-thrombotic syndrome), venous ulcer
* PE: chronic thromboembolic disease/pulmonary hypertension, post PE syndrome
41
post thrombotic syndrome (PTS)
* develops 20-50% of patients within 1-2 years
* severe PTS results in vvenous stasis ulcer: 1/4 to 1/3 of PTS
* common symptoms: pain, heaviness, cramps, itching, tingling, aggravated by standing/walking
* physical exam: edema, hyperpigmentation, telangiectasis, varicosities
* risk factors: proximal DVT (above knee), recurrent DVT, prolonged symptoms (> 1 month post event), obesity, inadequate and/or delayed anticoagulation
42
functions of lymphatic system
* functions: tissue drainage, fat transport, immune responses
* movement of lymph: lymphatic vessel contraction (like peristalsis), skeletal muscle contraction compression to lymph vessels
43
lymphedema
* accumulation of protein rich fluid: most often in the extremities (in area of treatment)
* injury/blockages to the lymphatic vessels, nodes, etc
* surgery, radiation, tumor
* acute or chronic
* treatments: surgery, complete decongestive therapy, pressure garments, pneumatic pressure pumps
| diagnosis based on history: CA, symptoms
44
what is lymphedema
abnormal circulation of protein rich fluid in the interstitium and often accompanied by reactive fibrosis and skin change
45
no edema vs lymphedema
* edema: excess fluid in the body tissues which is a result of abnormal leakage of fluid across capillaries from the plasma to interstitial spaces
* classified into: generalized (whole body), local (only in 1 part of body)
| no complete digestive therapy (CDT) for HF
46
stages of lymphedema
* stage 0: latent, sub-clinical
* stage 1: spontaneously reversible, present during the day but goes away overnight and/or with elevation, typically soft, no skin changes --> pitting starts between stage 1 and 2
* stage 2: spontaneously irreversible, does not fully reduce overnight or with elevation, skin becomes hard, brawny, hyperkeratosis --> need intervention but still modifiable, + Stemmers sign of digits, swelling of dorsum of hand/foot
* stage 3: lymphostatic elephantiasis --> change in limb morphology, more advanced skin changes, still manageable
stage 2 and 3 require intervention (lymphatic massage) to clear interstitial proteins -- increased risk of cellulitis. diuretics aren't helpful
47
stemmer sign
* pinch and lift skinfold at base of the second toe or middle finger
* A: if you can pinch and lift the skin, negative
* B: if you cannot life the skin, positive
* C: a negative test doesn't always rule out lymphedema
48
patient reports with lymphedema
* tightness or heaviness in limb
* achy
* pins and needles
* pain of congestion
* not unbearable pain - would imply something more sinister
49
common ways to reduce risk of developing/worsening lymphedema
* skin care
* activity and lifestyle: gradual increases in intensity/duration, monitor size/shape/texture
* avoiding limb constriction: BP cuff
* compression garments (if apprpriate): especially with exercise (weight training) and air travel, garments should be well fitting
* avoiding extremes of temperature: hot tub, sauna
50
UE lymphedema and XRT
51
how is lymphedema treated
* most common treatment for lymphedema is complete decongestive therapy (CDT)
* manual lymphatic drainage (MLD)
* bandaging
* compression garments
* exercise
* self care
52
complete decongestive therapy
* **phase 1**: decongestion
* meticulous skin drainage
* manual lymph drainage
* gradient compression bandaging
* remedial exercises
* compression garment
* **phase 2**: maintenance
* meticulous skin care
* day: compression garment
* night: gradient compression bandaging
* self-manual lymph drainage
* remdial exercises
* follow-up assessment
53
lymph nodes
* 600-700 lymph nodes in body
* major groupings: abdomen/intesintes, inguinal, axillary, supraclavicular
* 2-30 mm in length
* functions: filter and concentrate lymph through immune system
54
when to refer/consult certified lymphedema therapist (CLT)
* if patient has lymphedema diagnosis or you suspect lymphedema
* if patient is at risk of developing lymphedema -- post-axillary lymph node dissection
* if swelling is interfering with function
* if patient is experiencing uncontrolled pain due to swelling
* if patient needs compression stockings or sleeve
* if patient has non-healing wounds due to swelling
* help coordinating outpatient referrals
