File #4File #4

Breast Cancer RehabilitationBreast Cancer Rehabilitation

Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer

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Breast Cancer RehabilitationBreast Cancer Rehabilitation

• The physical therapy profession is the ideal medical profession to deal with The physical therapy profession is the ideal medical profession to deal with all aspects of establishing and following a safe and realistic mobility and all aspects of establishing and following a safe and realistic mobility and strengthening plan of treatment for the breast cancer patient. This strengthening plan of treatment for the breast cancer patient. This professional has the ability to decipher all medical information presented by professional has the ability to decipher all medical information presented by the physician and diagnostic studies presented concerning the status of the the physician and diagnostic studies presented concerning the status of the breast cancer patient. breast cancer patient.

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Role of the physical therapist whenRole of the physical therapist when

treating breast cancer patientstreating breast cancer patients:: • Educate public of early detection• Educate the patient, family, physician and other health

care providers of the need for rehabilitation for the patient diagnosed with breast cancer.

• Follow a safe and functional rehabilitation program with realistic goals for each individual

• Help improve Quality of Life• Promote care to decrease side effects• Improve patient’s outlook on recovery

• Breast Cancer: FYI Resources suggests, “Consider at least one session with a physical therapist if you have any kind of breast cancer related surgery”.

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America Cancer Society, America Cancer Society, Surveillance Research, 2005 Surveillance Research, 2005 Estimated Breast Cancer In situ and Estimated Breast Cancer In situ and Invasive for Age GroupsInvasive for Age GroupsAGE In Situ InvasiveAGE In Situ Invasive

< 40 1,600 9,510< 40 1,600 9,510

40 and older 56,890 201,73040 and older 56,890 201,730

Under 50 13,760 45,780Under 50 13,760 45,780

50 and older 44,730 165,46050 and older 44,730 165,460

Under 65 37,040 123,070Under 65 37,040 123,070

65 and older 21,450 88,17065 and older 21,450 88,170

ALL AGES 58,490 211,240 ALL AGES 58,490 211,240

(American Cancer Society, 2005)

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THE REFERRAL FOR THE REFERRAL FOR PHYSICAL THERAPYPHYSICAL THERAPY

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Who is going to make the Who is going to make the therapy referral?therapy referral?• General PractitionerGeneral Practitioner• InternistInternist• SurgeonSurgeon• Plastic SurgeonPlastic Surgeon• OncologistOncologist• Radiation OncologistRadiation Oncologist• RadiologistRadiologist• PsychiatristPsychiatrist• PathologistPathologist

• NurseNurse• Social WorkerSocial Worker• PsychologistPsychologist• NutritionistNutritionist• ChaplainChaplain• Family MemberFamily Member• FriendFriend• PatientPatient• Physical TherapistPhysical Therapist

Many choices and potential referral sources.

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“Despite potential benefits, referrals of cancer patients for rehabilitation are often made needlessly late or not at all”. Physician Text: CANCER MEDICINE*************************************************

• Physical therapist may need to solicit Physical therapist may need to solicit the benefits of cancer rehabilitation the benefits of cancer rehabilitation to physicians, other cancer team to physicians, other cancer team members and patients.members and patients.

(Ragnarsson, 2003)

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Could breast cancer Could breast cancer rehabilitation rehabilitation be your Niche?be your Niche?

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Niche:Niche:

• A place, employment, status or activity for A place, employment, status or activity for which a person or thing is best fitted. which a person or thing is best fitted.

• A specialized marketA specialized market

(Webster’s Universal Encyclopedic Dictionary, 2002)

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What is your niche?What is your niche?• OncologyOncology• OrthopedicsOrthopedics• AthleticsAthletics• Temporomandibular Dysfunction'sTemporomandibular Dysfunction's• Urinary IncontinenceUrinary Incontinence• PediatricsPediatrics• Soft tissue workSoft tissue work• Relaxation ProgramsRelaxation Programs• AdministrationAdministration

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Determining your Determining your NicheNiche

Things to consider

Expertise Experience Interest

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Make your own nicheMake your own niche

• S SearchS Search

• U UnderstandU Understand

• C ConfidenceC Confidence

• C ChallengeC Challenge

• E ExcitementE Excitement

• S SupportS Support

• S SucceedS Succeed

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Health Care ReformHealth Care ReformICD-9-CM CodesICD-9-CM Codes

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HEALTH CARE HEALTH CARE

REFORMREFORM

Wellness reduces Illness

Wellness decreases expense

Key Issues ofKey Issues ofHealth Care ReformHealth Care Reform

Access to CareAccess to CareQuality of CareQuality of CarePreventionPreventionStandard Benefits PackageStandard Benefits PackageCost ContainmentCost ContainmentEducation and ResearchEducation and ResearchNational BoardsNational BoardsState AutonomyState AutonomyWorkers’ CompensationWorkers’ Compensation

(APTA, 1994)

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Helpful breast cancer ICD 9-CM codesHelpful breast cancer ICD 9-CM codes

• Fatigue – limiting ADL’s……………………….780.7 Fatigue – limiting ADL’s……………………….780.7

• Nausea – limiting ADL’s.……………………...787.0Nausea – limiting ADL’s.……………………...787.0

• Generalized pain limiting function…………780.9Generalized pain limiting function…………780.9

• Weakness limiting ADL’s……………………...780.7Weakness limiting ADL’s……………………...780.7

• Muscular wasting, disuse atrophy…………728.2Muscular wasting, disuse atrophy…………728.2

• Difficulty walking………………………………..719.7Difficulty walking………………………………..719.7

• Lymphedema…………………………………....457.1Lymphedema…………………………………....457.1

• Breast Pain……………………………..…………611.71Breast Pain……………………………..…………611.71

• Adhesive Capsulitis……………………..……..726.0Adhesive Capsulitis……………………..……..726.0(McCormack, 2002)

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For all of the expensive medical interventions, insurance companies should realize the benefit of physical therapy, to promote wellness and decrease sickness during and after treatment programs for breast cancer.

• Mammogram • Biopsy • Pathology • Lumpectomy • Radiation • Modified Radical Mastectomy • Reconstruction • Chemotherapy • Rehabilitation

Insurance reimbursement for program services is usually very good.All coding should be assigned to a patients’ functional diagnosis ratherthan the oncology diagnosis. The diagnosis should be based on whateverfunctional activities are limited and what is creating the limitation. (McCormack, 2002)

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Psychology and Support Psychology and Support IssuesIssues

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ARE YOU THE ARE YOU THE THERAPIST TO TREAT THERAPIST TO TREAT

THE PATIENT THE PATIENT DIAGNOSED WITH DIAGNOSED WITH BREAST CANCERBREAST CANCER

•The progress of your program will depend greatly upon your ability to motivate your patient.

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In each dish place the name of a family member that you could live without…….Pretty tough!

Just an idea of how cancer patients and families may think.

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Your patient is coping with:Your patient is coping with:

• Illness• Changes• Next holiday could be last• Medical environment and caregivers• Self Image• Relations coping with illness• Future• If in remission.....When will it return?

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Common fears of cancer Common fears of cancer patients: patients: The 5 D’s The 5 D’s

• DeathDeath• DisfigurementDisfigurement• DisabilityDisability• DependenceDependence• Disruption of RelationshipsDisruption of Relationships

(Source unknown)

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Criteria for DepressionCriteria for Depression

• Persistent low mood (4 weeks)Persistent low mood (4 weeks)• Inability to enjoy oneselfInability to enjoy oneself• Repeated or early wakingRepeated or early waking• Impaired concentrationImpaired concentration• Guilt, self blame or burdenGuilt, self blame or burden• Irritability and anger for no reasonIrritability and anger for no reason• Loss of interestLoss of interest• AgitationAgitation• SuicidalSuicidal

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How patients and families may copeHow patients and families may cope

• Laughter can keep you from feeling bad.Laughter can keep you from feeling bad.• Notice those that might be worse off.Notice those that might be worse off.• Fight with those around.Fight with those around.• Important to have knowledge of illness.Important to have knowledge of illness.• Refuse to believe that it can happen.Refuse to believe that it can happen.• Turn to others for support.Turn to others for support.• Stay busy to decrease time to worry.Stay busy to decrease time to worry.• Go over problems in mind.Go over problems in mind.• Avoid illness as topic of conversation.Avoid illness as topic of conversation.• New faith in this experience.New faith in this experience.

(Snyder, 1992)

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SELF ESTEEMSELF ESTEEM

• WIGS that guarantee the hair will look so much like the original hair that the patient is the only one to know it is a wig.

• NATURAL: • 1-800-272-2424• HAT DESIGNS for hair loss......... 1-215-247-8777

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CAREGIVERS CAREGIVERS (Survey of 225 Families)(Survey of 225 Families)

• 49%...Experienced prolonged depression• 74%...Found unknown inner strength• 69%...Frustrated• 43%...Sad with experience• 39%...Associated care with love• 46%...Felt appreciated• 30%...Felt taken for granted • Caregiving and Cancer, should be reviewed to promote this challenge at:

• http:/www.utmb.edu/insights/Outreach/Caregiving_and_Cancer ppt

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Support GuideSupport Guide

• American Cancer Society (ACS) 1-800-ACS-2345

• National Cancer Institute (NCI) 1-800-4-CANCER

• Equal Employment Commission 1-800-872-3362

• State Dept. of Vocational Rehab.

• National Lymphedema Network 1-800-541-3259

• Job Accommodation 1-800-526-7234

• National Coalition for Cancer Survivorship 1-301-650-8868

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AMERICANS WITH AMERICANS WITH DISABILITIES ACTDISABILITIES ACT

Legal Protection For Cancer Patients Against

Employment Discrimination

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Dealing with PainDealing with Pain

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PAIN

Be prepared to deal with patients reporting pain and inform their physicians of the benefits of exercise.

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PAINPAIN

• Agency for Health Care Policy and Research Guidelines for Cancer Pain

• Promotes communication between the patient and the health care provider dealing with pain.

• The American Cancer Society estimates that 70% to 90% of cancer patients will experience pain during some phase of their disease or treatment.

(www.mskcc.org, 1999)

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PAINPAIN

• Document location and description of pain. Document location and description of pain.

• Rate worse pain, using a 1-10 scale. Rate worse pain, using a 1-10 scale.

• Time pain is increased and decreased.Time pain is increased and decreased.

• What increases and decreases pain.What increases and decreases pain.

• This documentation will allow you to This documentation will allow you to objectively assess changes in pain.objectively assess changes in pain.

(Hassler, 1994)

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• Biological mechanism• Bone destruction• Obstruction• Infiltration or Compression• Infiltration or Distention• Inflammation, Infection and necrosis of tissue.

Why cancer pain?

(Otto, 2004)

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Pain MedicationsPain Medications

• Soft tissue Nonsteroidal Anti-inflammatory (NSAI)Soft tissue Nonsteroidal Anti-inflammatory (NSAI)

• Bone NSAI (Prednisolone)Bone NSAI (Prednisolone)

• Compression of nerves (Dexamethasone)Compression of nerves (Dexamethasone)

• Muscle spasm (Diazepan or Baclofen)Muscle spasm (Diazepan or Baclofen)

• Fungal tumor AntibioticsFungal tumor Antibiotics

• Cellulitis SystemicCellulitis Systemic

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Management of Cancer PainManagement of Cancer Pain • Evaluation

• Physical and Neurological Exam• Differential Diagnosis• Pain history and pattern• Present and past medication• X-Rays, MRI, CT, EMG, lab results• Nutrition history and interventions• Functional evaluation

• Realistic Goals• Plan management (Ca / pain / psych)• Focus on patient and family

(Otto, 2004)

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Pain Management Pain Management A vicious cycle A vicious cycle• Which modalities Which modalities

are best suited for are best suited for the patient the patient diagnosed with diagnosed with cancer?cancer?

• List ModalitiesList Modalities

• List considerationsList considerations

• List safety List safety

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Pain Pain FatigueFatigue

Anxiety Anxiety DepressionDepression

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Listed Physical Therapy ModalitiesListed Physical Therapy Modalities

• Cutaneous Stimulation• Heat• Cold• Massage, Pressure , and Vibration• Exercise• Repositioning• Immobilization• Counter stimulation• Transcutaneous Electrical Nerve

Stimulation • Acupuncture

(Pfalzer, 1992)

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Time Out TestTime Out Test• As far as specialization, what is an advantage of being a As far as specialization, what is an advantage of being a

physical therapist?physical therapist?

• Wellness can decrease medical cost? T / FWellness can decrease medical cost? T / F

• A patient diagnosed with breast cancer, only thinks about A patient diagnosed with breast cancer, only thinks about their diagnosis? T / Ftheir diagnosis? T / F

• As a physical therapist, you might note signs of depression? As a physical therapist, you might note signs of depression? T / FT / F

• What are considered the 5 fears of a cancer patient?What are considered the 5 fears of a cancer patient?

• By supplying information concerning support organizations, By supplying information concerning support organizations, you can help decrease patient stress? T/Fyou can help decrease patient stress? T/F

• The pain cycle can lead to what other complications?The pain cycle can lead to what other complications?

ANSWERSYou can pick your individual field of interest; True; False; True; Death, Disfigurement, disability, dependency and disruption of relationships; True; Fatigue, anxiety and/or depression.

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LIVING A QUALITY LIFE LIVING A QUALITY LIFE THROUGH THROUGH REHABILITATIONREHABILITATION

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Mission StatementMission Statement

• Through emotional support, Through emotional support, education, rehabilitation, and exercise education, rehabilitation, and exercise we strive to empower the patient we strive to empower the patient diagnosed with cancer to maintain diagnosed with cancer to maintain and improve their quality of life.and improve their quality of life.

(Coleman Consulting, 1997)

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PhilosophyPhilosophy

• Physical rehabilitation should be Physical rehabilitation should be synonymous with cancer care. Loss of synonymous with cancer care. Loss of strength and function, as well as overall strength and function, as well as overall physical fitness must be restored in order to physical fitness must be restored in order to maintain quality of life. Our aim is to assist maintain quality of life. Our aim is to assist the patient diagnosed with cancer with the patient diagnosed with cancer with education, exercise and support throughout education, exercise and support throughout the treatment and recovery periods. the treatment and recovery periods. Promotion of wellness allows an individual Promotion of wellness allows an individual the opportunity to meet future health the opportunity to meet future health challenges.challenges.

(Coleman Consulting, 1997)

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Rehabilitation Rehabilitation OptionsOptions

• Prevention: Prevent functional loss in early Prevention: Prevent functional loss in early stages of diagnosis.stages of diagnosis.

• Restorative: Reach maximal function when Restorative: Reach maximal function when physical impairment or disability are physical impairment or disability are present.present.

• Supportive: Increase self care and mobility Supportive: Increase self care and mobility for the patient with progressive cancer and for the patient with progressive cancer and impairment. Teach energy saving methods.impairment. Teach energy saving methods.

• Palliative: Comfort and function for those Palliative: Comfort and function for those patients diagnosed with terminal conditions.patients diagnosed with terminal conditions.

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General GoalsGeneral Goals

• Prevent DeconditioningPrevent Deconditioning• Maximal functional skillsMaximal functional skills• Emotional Support to patient and familyEmotional Support to patient and family• Education of patient of conditionEducation of patient of condition• Treatment and Home ProgramTreatment and Home Program• Assist in Pain and Symptom ControlAssist in Pain and Symptom Control• Assist in Health PromotionAssist in Health Promotion

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Specific GoalsSpecific Goals

• Increase Strength and EnduranceIncrease Strength and Endurance• Decrease nervousness, irritability & anxietyDecrease nervousness, irritability & anxiety• Increase attention span and concentrationIncrease attention span and concentration• Improve PostureImprove Posture• Maintain or Improve ROM & flexibilityMaintain or Improve ROM & flexibility• Promote independence (gait/transfer/ADLs)Promote independence (gait/transfer/ADLs)• Development of disease education, including Development of disease education, including

treatment program.treatment program.

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Evaluation ToolsEvaluation Tools

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Evaluation ScalesEvaluation Scales

• Functional Independence Measure Functional Independence Measure (FIM)(FIM)

• Karnofsky Performance Status Scale Karnofsky Performance Status Scale

• Zubrod Performance ScaleZubrod Performance Scale

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FIMFIM• 7 Complete Independence (Timely, Safely) NO ASSISTANCE7 Complete Independence (Timely, Safely) NO ASSISTANCE• 6 Modified Independence (Device) 6 Modified Independence (Device) • Modified Dependence Modified Dependence

HELPERHELPER• 5 Supervision 5 Supervision

• 4 Minimal Assist (Subject = 75%+) 4 Minimal Assist (Subject = 75%+) • 3 Moderate Assist (Subject = 50%+) 3 Moderate Assist (Subject = 50%+) • Complete Dependence Complete Dependence • 2 Maximal Assist (Subject = 25%+) 2 Maximal Assist (Subject = 25%+) • 1 Total Assist (Subject = 0%+) 1 Total Assist (Subject = 0%+) • ADMIT / DISCHARGE / FOLLOW-UPADMIT / DISCHARGE / FOLLOW-UP• Self Care / Sphincter Control / Mobility / Locomotion / Self Care / Sphincter Control / Mobility / Locomotion /

Communication / Social CognitionCommunication / Social Cognition

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KarnofskyKarnofsky Able to carry on normal activity, Able to carry on normal activity,

no special care needed.no special care needed.

Unable to work, able to live at Unable to work, able to live at home and care for most home and care for most personal needs, varying personal needs, varying amount of assistanceamount of assistance

Unable to care for self, Unable to care for self, requires institution or hospital requires institution or hospital care for disease that may be care for disease that may be rapidly progressingrapidly progressing

• 100 Normal, no complaints, No 100 Normal, no complaints, No evidence of diseaseevidence of disease

• 90 Able to carry on normal90 Able to carry on normal

activityactivity minor signs or minor signs or symptoms of diseasesymptoms of disease

• 80 Normal activity with effort, 80 Normal activity with effort, some signs or symptoms of some signs or symptoms of diseasedisease

• 70 Cares for self, unable to 70 Cares for self, unable to carry on normal activity or to do carry on normal activity or to do work.work.

• 60 Requires occasional 60 Requires occasional assistance of others, but able to assistance of others, but able to care for most needscare for most needs

• 50 Requires considerable 50 Requires considerable assistance from others, frequent assistance from others, frequent medical caremedical care

• 40 Disabled, requires special 40 Disabled, requires special carecare

• 30 Severely disabled, death not 30 Severely disabled, death not certaincertain

• 20 Very sick, hospital, need 20 Very sick, hospital, need supportsupport

• 10 Moribund10 Moribund• 0 Dead0 Dead

Specific:General:

(Abraham, 2005)

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Important information to obtain Important information to obtain when evaluating the cancer when evaluating the cancer patientpatient• Medical InformationMedical Information

– Primary diagnosis / Stage of disease / Surgery / Chemo / Primary diagnosis / Stage of disease / Surgery / Chemo / Radiation / Blood counts / PrognosisRadiation / Blood counts / Prognosis

• Physical ExamPhysical Exam– Mental status / Vital signs / Strength / ROM / Reflexes / Mental status / Vital signs / Strength / ROM / Reflexes /

PainPain

• Mobility StateMobility State– Bed mobility / Balance / Transfers / Ambulation / Bed mobility / Balance / Transfers / Ambulation /

Assistive devicesAssistive devices

• Psychological StatePsychological State Coping skillsCoping skills

• Social StateSocial State Family / Job / RecreationFamily / Job / Recreation

• Home EnvironmentHome Environment

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Lab values and guidelinesLab values and guidelines

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Rehabilitation Treatment PlanRehabilitation Treatment Plan

• Bone Marrow Transplant Complications:Bone Marrow Transplant Complications:– Decreased mobility and joint ROMDecreased mobility and joint ROM– Decreased enduranceDecreased endurance– Increases fatigueIncreases fatigue– Decreased strengthDecreased strength– Increased painIncreased pain– Decreased functionDecreased function– Decreased motivationDecreased motivation– Decreased pulmonary functionDecreased pulmonary function

(Koczur, 1996)

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Guidelines when establishing a treatment planGuidelines when establishing a treatment plan Platelet Counts: < 20.000 : Palliation and Support (P&S) No anti-gravity exercise No resistive exercise 25-50,000 : Support and Restoration (S&R)

sub-maximal isometrics isotonic exercise (light weights)

no prolonged stretching no low speed isokinetics > 50,000 :Restoration and Prevention (R&P)

Most programs acceptable Under 50,000 can increase the risk of bleeding

(Hicks, 1990)

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Continual GuidelinesContinual GuidelinesHematocrit (Hct.) / Hemoglobin (Hb.)Hematocrit (Hct.) / Hemoglobin (Hb.)< 25/10: Palliation & Support < 25/10: Palliation & Support range of motionrange of motion no aerobicsno aerobics no isotonicsno isotonics25-35/10-12: Support & Restoration25-35/10-12: Support & Restoration low impact and intensitylow impact and intensity aerobics (bike ergometer)aerobics (bike ergometer) IsometricsIsometrics modified isotonicsmodified isotonics 35/12: Restoration & Prevention 35/12: Restoration & Prevention most programs acceptable most programs acceptable

(Hicks, 1990)

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Additional GuidelinesAdditional GuidelinesPFT’s (Cardio-Pulmonary function PFT’s (Cardio-Pulmonary function

impairment):impairment): 50% capacity P&S50% capacity P&S No aerobicsNo aerobics 50 – 75%: S&R50 – 75%: S&R Low intensity aerobicsLow intensity aerobics >75% R&P>75% R&P Most programs acceptableMost programs acceptableMetastatic or bone tumorMetastatic or bone tumor > 50% cortex involved P&S> 50% cortex involved P&S No exerciseNo exercise Non-weightbearingNon-weightbearing 25-50%: S&R25-50%: S&R Partial weight bearingPartial weight bearing Range of motion (No stretching)Range of motion (No stretching) 0-25%: R&P0-25%: R&P Full weight bearingFull weight bearing (Hicks,

1990)

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Time to think ExerciseTime to think Exercise

The best way to ensure desired outcomes from exercise is to The best way to ensure desired outcomes from exercise is to recognize the needs, limitations and capabilities of each recognize the needs, limitations and capabilities of each individual. Remember your patients’ need for required individual. Remember your patients’ need for required cardiovascular, pulmonary or muscle strength or endurance cardiovascular, pulmonary or muscle strength or endurance training.training.

By enhancing everyday performance activities, your patient will By enhancing everyday performance activities, your patient will improve mobility and independence; Improve and maintain improve mobility and independence; Improve and maintain posture and muscle balance; show an awareness of injury posture and muscle balance; show an awareness of injury prevention; and promote physical and mental relaxation.prevention; and promote physical and mental relaxation.

5757

(Slide donated with permission to show by: Ronald H. Schuster, MD

Board Certified Plastic Surgeon)

Start to establish an exercise program.

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EXERCISEEXERCISE• Capacity depends on:Capacity depends on:

– Physical ConditionPhysical Condition– Stage and Type of CancerStage and Type of Cancer– Treatment ProgramTreatment Program– Side EffectsSide Effects– General HealthGeneral Health

• A fitness program differs for a mastectomy A fitness program differs for a mastectomy patient compared to late stage lung Ca.patient compared to late stage lung Ca.

• Exercise brings about immediate or acute Exercise brings about immediate or acute physiological responses as well as long term physiological responses as well as long term or chronic responses.or chronic responses.

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General Oncology RehabilitationGeneral Oncology Rehabilitation• Function / Cardio-Endurance / Energy Conservation /

Pain Management / Strength - Balance / Education.• 1st Visit...Eval. / OOB 1 hr. / energy conservation /

Deep breathing.• 2nd Visit..OOB < 1 hr. 2-3 X/day / energy and safe

home techniques / Vital signs with ambulation 20-40' / Cool down.

• 3rd Visit..OOB 2-3 hrs. 2-3 X/day / Continue energy conservation / Ambulate as tol./ Home Program / Eval home.

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Benefits of Regular ExerciseBenefits of Regular Exercise• Weight loss and decreased body fatWeight loss and decreased body fat• Lower risk of cardiovascular disease and Lower risk of cardiovascular disease and

cancercancer• Lowers blood pressureLowers blood pressure• Decrease insulin use in diabeticsDecrease insulin use in diabetics• Prevents OsteoporosisPrevents Osteoporosis• Lowers serum cholesterolLowers serum cholesterol• Slows aging of heart and lungsSlows aging of heart and lungs• Reduces back painReduces back pain• Improves self-imageImproves self-image

(www.healthclubs.com, 2006)

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Benefits of Exercise with Benefits of Exercise with CancerCancer

• IncreaseIncrease– Accumulation of muscle proteinAccumulation of muscle protein– Joint mobilityJoint mobility– StrengthStrength

• DecreaseDecrease– EdemaEdema– PainPain– AnxietyAnxiety– DepressionDepression

• Enhance Immune FunctionEnhance Immune Function• Decrease Infection susceptibilityDecrease Infection susceptibility

(www.sportsmedicine.about.com, 2006

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General Breast Cancer General Breast Cancer DiagnosisDiagnosisExercise … You Decide?Exercise … You Decide?

• AerobicAerobic (Walk, Jog, Cycle or Swim) (Walk, Jog, Cycle or Swim)• Increase heart rateIncrease heart rate• Increase lung capacity for O2 intakeIncrease lung capacity for O2 intake• Increase O2 to musclesIncrease O2 to muscles• Increase metabolism to control weightIncrease metabolism to control weight• Decrease in blood cholesterolDecrease in blood cholesterol• Increase in bone strengthIncrease in bone strength• Increase in enduranceIncrease in endurance

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Decide?Decide?

• Anaerobic:Anaerobic: (Weight lifting or (Weight lifting or Sprinting)Sprinting)

• Short burst of intense activityShort burst of intense activity

• Develop musclesDevelop muscles

• Develop strengthDevelop strength

• Develop speedDevelop speed

• Develop powerDevelop power

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Walking:Walking:

• Excellent choice of ExerciseExcellent choice of Exercise

• Increase lung functionIncrease lung function

• Stimulates bone growth and strengthens Stimulates bone growth and strengthens leg and back musculatureleg and back musculature

• METS to LE or back may eliminate running METS to LE or back may eliminate running but walking may be approved (Less but walking may be approved (Less trauma)trauma)

• In pool gentle yet stimulates heart & lungsIn pool gentle yet stimulates heart & lungs

• Consult M.D. when dealing with metastasisConsult M.D. when dealing with metastasis

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SwimmingSwimming

• Good choice with pain of spine, hips or Good choice with pain of spine, hips or pelvis possibly due to metastasispelvis possibly due to metastasis

• Increase aerobic capacity if performed Increase aerobic capacity if performed far and fast enoughfar and fast enough

• Stretches muscles and lung capacityStretches muscles and lung capacity

• Strengthening against water Strengthening against water resistanceresistance

• Consult M.D. when dealing with METSConsult M.D. when dealing with METS

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Stretching & YogaStretching & Yoga

• Increased flexibility and decreased Increased flexibility and decreased muscle tensionmuscle tension

• Increased circulationIncreased circulation• Well stretched muscles require less Well stretched muscles require less

energy for movementenergy for movement• Important for shortened muscles from Important for shortened muscles from

rest (Slow stretch prevents muscle tear)rest (Slow stretch prevents muscle tear)• Yoga and deep breathing promote an Yoga and deep breathing promote an

emotional edge due to body awareness.emotional edge due to body awareness.

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Exercise Facts:Exercise Facts:

• Exercise builds muscle tissue, Exercise builds muscle tissue, strengthens the heart, increases lung strengthens the heart, increases lung capacity to take in oxygen and improves capacity to take in oxygen and improves circulation.circulation.

• Exercisers report increased energy and Exercisers report increased energy and stamina with decreased deconditioning.stamina with decreased deconditioning.

• Stretching, Yoga, Walking & Swimming Stretching, Yoga, Walking & Swimming stimulate muscles & circulation without stimulate muscles & circulation without stress.stress.

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Psychological BenefitsPsychological Benefits

• Increase feeling of well beingIncrease feeling of well being

• Give patient sense of controlGive patient sense of control

• Improve self-esteemImprove self-esteem

• Enhances CopingEnhances Coping

• Increased attention span & Increased attention span & concentrationconcentration

• Decrease AnxietyDecrease Anxiety

• Decrease DepressionDecrease Depression

• Increase Strength, Mobility & FitnessIncrease Strength, Mobility & Fitness(Gavin, 2006)

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Functional AssessmentFunctional Assessment

• Must obtain measurable benefits Must obtain measurable benefits (Outcomes)(Outcomes)

• Rehabilitation judged by functional Rehabilitation judged by functional ability that results from treatmentability that results from treatment

• Assess function by monitoring Assess function by monitoring changes in activity of self care, changes in activity of self care, mobility, and communication. mobility, and communication.

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Accurate documentation Accurate documentation promotes future progresspromotes future progress

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DocumentationDocumentation

• Focus on function• Use vital signs for an objective measure• Focus on short term goals REALISTIC GOALS• Describe teaching sessions• Document lab values (Very Important when treating

cancer patients)

Comisac, 1996

7272

Ideal rehab candidates are Ideal rehab candidates are those who are/were those who are/were previously in excellent previously in excellent health, strength and health, strength and fitness. fitness.

Everyone is different and Everyone is different and should be treated as an should be treated as an individual.individual.

7373

Questions to ask ?Questions to ask ?

• What can the patient do?What can the patient do?

• What do they need to do?What do they need to do?

• What do they want to do?What do they want to do?

7474

Examples of specific breast Examples of specific breast cancer rehabilitation cancer rehabilitation programsprograms

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Pre-Surgical EvaluationPre-Surgical Evaluation• Ideal programIdeal program

• Education of expectationsEducation of expectations

• Introduction helps decrease anxiety & fear.Introduction helps decrease anxiety & fear.• Screen patient’s condition prior to medical Screen patient’s condition prior to medical

intervention intervention (Psychologically, Strength, Mobility & Girth) (Psychologically, Strength, Mobility & Girth) ..

• Ability to initiate safe and functional Ability to initiate safe and functional rehabilitation program.rehabilitation program.

• Avoid undue stress on involved extremity.Avoid undue stress on involved extremity.

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Post-Surgical EvaluationPost-Surgical Evaluation

• Completed as soon as possible.Completed as soon as possible.

• Teach proper elevation for comfort Teach proper elevation for comfort and edema control. and edema control.

• Control upper extremity flexion Control upper extremity flexion until drains are removed.until drains are removed.

• Teach support programTeach support program

• Compare to pre-evaluationCompare to pre-evaluation

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EXERCISE PROGRAMEXERCISE PROGRAM

• Components of Components of ExerciseExercise

• Exercise is Exercise is essential, but essential, but precautions must precautions must be takenbe taken

• Range of MotionRange of Motion

• StrengthStrength

• Endurance Endurance

• SafetySafety

• ContraindicationsContraindications

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Safe Exercise ProgramSafe Exercise Program• Common senseCommon sense• M.D. ClearanceM.D. Clearance• Limit before lab work / infection /feverLimit before lab work / infection /fever• If ill from treatment: Wait a dayIf ill from treatment: Wait a day• Start SlowlyStart Slowly• Avoid PainAvoid Pain• Caution with low blood countsCaution with low blood counts• Avoid infections including foot careAvoid infections including foot care• Return to M.D. with persistent complaintsReturn to M.D. with persistent complaints

(Coleman Consulting, 1997)

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Contraindications to Contraindications to ExerciseExercise• Unusual fatigueUnusual fatigue

• Unusual weaknessUnusual weakness

• Irregular pulseIrregular pulse

• Decreased heart Decreased heart rate with workrate with work

• Leg pain / crampsLeg pain / cramps

• Nausea, Vomiting or Nausea, Vomiting or DiarrheaDiarrhea

• DisorientationDisorientation

• Dizziness, Blurred Dizziness, Blurred vision or Faintnessvision or Faintness

• Pallor or CyanosisPallor or Cyanosis

• Dyspnea onsetDyspnea onset

• IV chemo last 24 IV chemo last 24 hrs.hrs.

• Platelets <20,000Platelets <20,000

• White Blood Count White Blood Count <1500<1500

(Arnall, 2005)

8080

POSTUREPOSTURE

• Shoulder depression and internal rotation with scapula protraction

• Serratus Anterior weakness...Winging due to overstretch of long thoracic nerve.

• Latissimus dorsi weakness overstretch of thoracodorsal nerve.

• Pectoralis major/minor weakness.Minor may have been removed; Medial pectoral nerve no longer innervates lateral border of pectoralis major.

8181

Strength TrainingStrength Training

• Weight training to build musculatureWeight training to build musculature

• Must control resistance and calories Must control resistance and calories with proper monitoringwith proper monitoring

• Machines safer than free weights to Machines safer than free weights to assure good posture and functional assure good posture and functional mobilitymobility

• Manual resistance exercise regime Manual resistance exercise regime may be utilized to promote strengthmay be utilized to promote strength

8282

EXERCISEEXERCISE• Even with advanced disease exercise can help Even with advanced disease exercise can help

decrease depression, tissue loss and fatiguedecrease depression, tissue loss and fatigue• Passive mobility program may be appropriatePassive mobility program may be appropriate• Exercise with pain meds more beneficialExercise with pain meds more beneficial• Guide towards individual challenges: Marathon / Guide towards individual challenges: Marathon /

Bike Ride or a Walk around the block. This will be Bike Ride or a Walk around the block. This will be established between the patient and the therapist. established between the patient and the therapist. Be Be R-E-A-L-I-R-E-A-L-I-S-T-I-CS-T-I-C

• Additional study results follow, which will help Additional study results follow, which will help benefit you to expand your knowledge of the benefit you to expand your knowledge of the benefits of rehabilitation for breast cancer benefits of rehabilitation for breast cancer survivors.survivors.

8383

The Coleman 10 Step The Coleman 10 Step ProgramProgram

• I IndividualismI Individualism• II Physical Therapy EvaluationII Physical Therapy Evaluation• III Ancillary ServicesIII Ancillary Services• IV Patient EducationIV Patient Education• V Rehabilitation ProgramV Rehabilitation Program• VI Progress StepVI Progress Step• VII Group Exercise ProgramVII Group Exercise Program• VIII Follow-UpVIII Follow-Up• IX Out Reach ProgramIX Out Reach Program• X Home MaintenanceX Home Maintenance

(Coleman Consulting, 1997)

8484

R E H A B I L I T A T I O NR E H A B I L I T A T I O N• Rehabilitation interventions should begin at bedside, getting patient OOB as soon as possible to work towards discharge.

• Intense rehab after discharge is determined by patients life expectancy (> 1 year) and medical capabilities to participate (including motivation and mental considerations).

• After discharge to home setting, it is important to assure that patient has proper equipment and supplies.

• All follow-up programs must be set (including proper referrals) at time of discharge.

8585

Follow a safe post-Follow a safe post-operative breast operative breast cancer programcancer program• Remember to:Remember to:

– Review diagnosisReview diagnosis– Medical interventionsMedical interventions– Safe techniqueSafe technique– ContraindicationsContraindications– MotivateMotivate

• Acknowledge:Acknowledge:– ResearchResearch– Other programsOther programs– Realistic goalsRealistic goals

8686

Rehabilitation examples to Rehabilitation examples to remember:remember:

• Protocols for individualProtocols for individual

• Protocols depending on medical Protocols depending on medical interventionintervention

8787

Breast CancerBreast Cancer

• Therapy begins 2-5 days post-op.• Deep breathing & relaxation are beneficial• Range of motion (gentle)• Movement with support as needed• Isometrics of involved elbow/ wrist/ hand• Once drains removed increase exercise (active

shoulder mobility)• Home exercise program to promote independent plan• Possible complications that need to be prevented

include: Inflammation, scar formation, obesity, thrombophlebitis, and poor arm position.

8888

BREAST CANCERBREAST CANCER

• GOALS: FUNCTIONAL

EMOTIONAL COSMETIC

• FUNCTIONAL: Shoulder Range of Motion; Neurological Changes; Postural Deficits; Skin Integrity; Possible Lymphedema; ADL's

8989

Post-Surgical Rehabilitation Post-Surgical Rehabilitation TRAMTRAM

• Immediate Post-operativeImmediate Post-operative– Distal hand exercise to assist shoulder Distal hand exercise to assist shoulder

stabilization.stabilization.– Incisional splinting techniques to Incisional splinting techniques to

increase comfort with movementincrease comfort with movement

• Day 2 or 3Day 2 or 3– Reach to opposite shoulder & kneeReach to opposite shoulder & knee– ADL’s with active range per individualADL’s with active range per individual

(Grant, 1994)

9090

Post-operativePost-operative

• Two to four weeks according to M.D.Two to four weeks according to M.D.– Active / Passive ROM to involved shoulder Active / Passive ROM to involved shoulder

including overhead stretchincluding overhead stretch– Gentle resistive exerciseGentle resistive exercise– Progressive cardiovascular fitness Progressive cardiovascular fitness

program performed within safe program performed within safe limitationslimitations

(Grant, 1994)

9191

Post-operativePost-operative

• Six weeks (depending on patient)Six weeks (depending on patient)– Aggressive stretching and strengthening of Aggressive stretching and strengthening of

shouldershoulder– Strengthening of trunk and abdominalsStrengthening of trunk and abdominals– Cardiovascular cross trainingCardiovascular cross training– Return to work activities (Assimilation)Return to work activities (Assimilation)– Arm edema maintenance / preventionArm edema maintenance / prevention– Scar tissue management (Decrease Scar tissue management (Decrease

adhesions)adhesions)– Fitness through other medical interventions.Fitness through other medical interventions.

(Grant, 1994)

9292

Post-operativePost-operative

• Long Term ManagementLong Term Management– Maintain stretching and muscle tone, Maintain stretching and muscle tone,

especially in radiated areas.especially in radiated areas.– Posture management programPosture management program– Quality of Life fitness programQuality of Life fitness program– Awareness of any problemsAwareness of any problems

(Grant, 1994)

9393

Post-Operative TRAMPost-Operative TRAM

(Slide donated with permission to show by: Ronald H. Schuster, MD

Board Certified Plastic Surgeon)

9494

Free Flap techniqueFree Flap technique

(Slide donated with permission to show by: Ronald H. Schuster, MD

Board Certified Plastic Surgeon)

9595

EducationEducation

• We must educate the patient, family, We must educate the patient, family, community, physician and other community, physician and other health care providers of the benefits health care providers of the benefits of rehabilitation for the patient of rehabilitation for the patient diagnosed with cancer.diagnosed with cancer.

9696

Supply educational Supply educational materialsmaterials

9797

General breast cancer General breast cancer programs used in my facility to programs used in my facility to promote safe techniques with promote safe techniques with functional mobility and functional mobility and activities of daily living activities of daily living

9898

OUT-PATIENT ONCOLOGY REHABILITATION

• Patient care management

• Promote wellness• Cost effective protocols• Decrease risk of adverse

outcomes• Provide forgotten rehab

Program• Establish continual case

studies• Provide continual

education programs (Coleman Consulting, 1997)

9999

BREAST WELLNESS CENTERBREAST WELLNESS CENTER

Comprehensive care dealing with the total patient, not just the diagnosisComprehensive care dealing with the total patient, not just the diagnosis

• Treatment program discussed with pt.

• Sensation change• Shoulder mov't

guidelines• Lymphedema• Posture• Prosthesis• Lifting precautions• Fatigue• Exercise Guide

• UE Elevation• Deep Breathing• Elbow/Shoulder controlled

program• Capsular Exercise• Active Exercise• Functional Shoulder

(Designed by Coleman Consulting)

100100

Breast Center in Health ClubBreast Center in Health Club

(Public Relations Photo – Breast Wellness Center)

101101

Gradual mobilityGradual mobility

(Public Relations Photo – Breast Wellness Center)

102102

Control exerciseControl exercise

( Public Relations Photo – Breast Wellness Center)

103103

Posture and mobilityPosture and mobility

(Public Relations Photo – Breast Wellness Center)

Program Program DevelopmentDevelopment

As you gain expertise and As you gain expertise and physician confidence, you will physician confidence, you will

also note an increase in patient also note an increase in patient compliance.compliance.

105105

Tips for building an Oncology Rehabilitation Tips for building an Oncology Rehabilitation programprogram

• Increase visibility of rehabilitation into oncology treatment plans with early intervention to prevent functional decline and, increase the ability to restore a quality life.

• Increased involvement in clinical studies to include outcomes for the oncology patient.

• Organization of Rehab team to assure quality of care to promote functional outcomes.

• Progress treatment plans to map out vocational and psychological programs.

(Coleman Consulting, 1996)

106106

Research supporting physical therapy Research supporting physical therapy rehabilitationrehabilitation

• Promotion of a quality life for patients Promotion of a quality life for patients diagnosed with breast cancer diagnosed with breast cancer

107107

Research completed by Drum and group in Research completed by Drum and group in the the Medical Science of Sports and Exercise, Medical Science of Sports and Exercise, 20032003

• Case study of female diagnosed with breast cancer, age 29 Case study of female diagnosed with breast cancer, age 29 receiving a modified radical mastectomy and at age 57 same receiving a modified radical mastectomy and at age 57 same procedure to opposite breast. Chemotherapy and radiation followed procedure to opposite breast. Chemotherapy and radiation followed second surgery.second surgery.

• Following medical interventions presented, patient followed a six Following medical interventions presented, patient followed a six month exercise program at the University of Colorado.month exercise program at the University of Colorado.

• Increased muscle strength, cardiovascular function and attenuating Increased muscle strength, cardiovascular function and attenuating career related fatigue and depression.career related fatigue and depression.

• Suggest health professionals collaborate with rehabilitation to Suggest health professionals collaborate with rehabilitation to increase work capacity to progress a quality life for the patient increase work capacity to progress a quality life for the patient diagnosed with breast cancer.diagnosed with breast cancer.

(Drum, 2003)

108108

Study by Holmes in the Study by Holmes in the American American MedicalMedical Association JournalAssociation Journal in 2005 in 2005

• Study followed the health of 122,000 female Study followed the health of 122,000 female nurses, 2,167 were diagnosed with breast cancer.nurses, 2,167 were diagnosed with breast cancer.

• The physical activity of the subjects was The physical activity of the subjects was recorded. This activity was measured up to 16 recorded. This activity was measured up to 16 years, most subjects walked for exercise. years, most subjects walked for exercise.

• Breast cancer survivors that exercised 3-5 hours Breast cancer survivors that exercised 3-5 hours per week lived longer than those that had per week lived longer than those that had minimal activity. Also noted those who completed minimal activity. Also noted those who completed regular exercise were less likely to die from their regular exercise were less likely to die from their breast cancer.breast cancer.

• Patients will receive major benefits from modest Patients will receive major benefits from modest exercise.exercise.

(Holmes, 2005)

109109

Mastros’ study published in the Mastros’ study published in the American Medical Association website American Medical Association website 20042004• Study of 49 women with breast cancer, 28 Study of 49 women with breast cancer, 28

were assigned to a six month exercise were assigned to a six month exercise program.program.

• Blood testing was used to determine Blood testing was used to determine immune response.immune response.

• Revealed that breast cancer patients that Revealed that breast cancer patients that completed an assigned six month exercise completed an assigned six month exercise program had better immune response and program had better immune response and less inflammatory complications. less inflammatory complications.

• Appropriate exercise can help breast cancer Appropriate exercise can help breast cancer survivor’s strengthen their immune system survivor’s strengthen their immune system with exercise. with exercise.

(Mastro, 2004)

110110

Following numerous Following numerous searches in the medical searches in the medical library and database library and database search engines, no search engines, no remarkable negative remarkable negative changes with exercise changes with exercise following the diagnosis of following the diagnosis of breast cancer were noted. breast cancer were noted.

111111

Research by WinninghamResearch by Winningham• Exercise may enhance Quality of LifeExercise may enhance Quality of Life• Interval Aerobic Training (Rest & Exercise) Interval Aerobic Training (Rest & Exercise)

enhances cardiovascular efficiency, overall enhances cardiovascular efficiency, overall functional ability and reduces incidence rates of functional ability and reduces incidence rates of nausea from chemotherapy.nausea from chemotherapy.

• Heavy prolonged exertion associated with Heavy prolonged exertion associated with hormonal and biochemical changes can have a hormonal and biochemical changes can have a detrimental effect on the immune systemdetrimental effect on the immune system

(Winningham, 1989)

112112

Research by SegarResearch by Segar

• Regular aerobic cycling Regular aerobic cycling decreased depression and decreased depression and anxiety as well as increased self anxiety as well as increased self esteem.esteem.

(Segar, 1998)

113113

Research by PintoResearch by Pinto

• Surveyed 72 Stage I and II breast Surveyed 72 Stage I and II breast cancer patients. Those who cancer patients. Those who exercised reported less depression exercised reported less depression and enhanced Quality of Life and enhanced Quality of Life compared to the sedentary control compared to the sedentary control group.group.

(Pinto, 1998)

114114

Research by DurakResearch by Durak• Health Club StudyHealth Club Study• Breast cancer program : Aerobic exercise / Breast cancer program : Aerobic exercise /

PRE’s on machines 2x/wk for 20 weeksPRE’s on machines 2x/wk for 20 weeks• Results:Results:

– CA pts. Showed:CA pts. Showed:• 60% increase in upper body strength60% increase in upper body strength• 31% increase in lower body strength31% increase in lower body strength• 35% increase in aerobic machines 35% increase in aerobic machines – Progress ADL’s, Strength & EnduranceProgress ADL’s, Strength & Endurance– Decreased Pain and Decreased NauseaDecreased Pain and Decreased Nausea

(Durak, 1997)

115115

Research by BernsteinResearch by Bernstein

• Women who have been physically Women who have been physically fit for many years reduce their fit for many years reduce their incidence of breast cancer.incidence of breast cancer.

• 3.8 hours of exercise per week 3.8 hours of exercise per week reduces riskreduces risk

(Bernstein, 1995)

116116

.Additional research on the benefits of .Additional research on the benefits of exercise for the breast cancer patient is exercise for the breast cancer patient is becoming available.becoming available.

• Support of the benefits of exercise are to Support of the benefits of exercise are to increase functional capacity, decrease body increase functional capacity, decrease body fat, increase lean muscle mass, decrease fat, increase lean muscle mass, decrease nausea & fatigue, improve quality of life.nausea & fatigue, improve quality of life.

• American College of Sports Medicine American College of Sports Medicine guidelines for exercise following breast cancer: guidelines for exercise following breast cancer: Frequency: 3-7 days /week; Intensity: 40-80% Frequency: 3-7 days /week; Intensity: 40-80% aerobic capacity; Duration: 20-40 min. of aerobic capacity; Duration: 20-40 min. of aerobic activity. Suggest normal fitness aerobic activity. Suggest normal fitness assessment: heart rate, blood pressure, body assessment: heart rate, blood pressure, body composition, strength, flexibility, aerobic composition, strength, flexibility, aerobic capacity.capacity.

• ONLY BENEFITS REPORTED ONLY BENEFITS REPORTED (ACSM, 1997)

117117

• Harvard Medical asst. professor Michelle Harvard Medical asst. professor Michelle Holmes,MD, studied 3,000 women noting little Holmes,MD, studied 3,000 women noting little exercise increases chances of surviving breast exercise increases chances of surviving breast cancer. 3 MET (Metabolic equivalent task) hrs. per cancer. 3 MET (Metabolic equivalent task) hrs. per week of 2 to 2.9 miles per hour for 1 hour decreases week of 2 to 2.9 miles per hour for 1 hour decreases risk of dying from breast cancer by one half.risk of dying from breast cancer by one half.

• Anne McTiernan, MD, PhD, author of Anne McTiernan, MD, PhD, author of Breast Fitness: Breast Fitness: An Optimal Exercise and Health Plan for Reducing An Optimal Exercise and Health Plan for Reducing Your Risk of Breast CancerYour Risk of Breast Cancer, stated “Women don’t , stated “Women don’t have to become athletes, just get up and get have to become athletes, just get up and get moving”. moving”.

(www.cancer.org, 2005)

118118

• Breast Cancer FYI, suggests that a patient should Breast Cancer FYI, suggests that a patient should consider at least one session with a physical consider at least one session with a physical therapist if any surgical procedures, due to breast therapist if any surgical procedures, due to breast cancer, have been performedcancer, have been performed

. .

• In the Yale Exercise & Survivorship Study, it was In the Yale Exercise & Survivorship Study, it was revealed, despite the evidence suggesting that revealed, despite the evidence suggesting that regular physical activity can decrease breast regular physical activity can decrease breast cancer risks and improve prognosis, efforts to cancer risks and improve prognosis, efforts to encourage this program were not a routine part encourage this program were not a routine part of cancer treatments. of cancer treatments.

119119

Results of studies on exercise during breast Results of studies on exercise during breast CACA

Bremer et alBremer et al 109 breast CA 109 breast CA survivors survivors (post-op)(post-op)

Cross-sectionCross-section Self reported Self reported exerciseexercise

Psychology Psychology adjustmentadjustment

No difference No difference with or with or without without exerciseexercise

Courneya & Courneya & FriedenreichFriedenreich

167 breast CA 167 breast CA survivorssurvivors

RetrospectiveRetrospective Self reported Self reported exerciseexercise

Quality of LifeQuality of Life Moderate to Moderate to strenuous strenuous exercise = exercise = best quality best quality of lifeof life

CunninghamCunningham 66 breast CA 66 breast CA survivors with survivors with METSMETS

ProspectiveProspective Self reported Self reported exerciseexercise

SurvivalSurvival With regular With regular exercise lived exercise lived longerlonger

MacVicar and MacVicar and WinninghamWinningham

10 on chemo 10 on chemo 6 healthy 6 healthy controlscontrols

Test Pre/PostTest Pre/Post Supervised Supervised exerciseexercise

Exercise test Exercise test and moodand mood

Exercise lead Exercise lead to increase in to increase in function and function and mood with mood with bothboth

McBride et alMcBride et al 500 early 500 early stage breast stage breast CA pts. CA pts. Various tx.Various tx.

Cross-sectionCross-section Self reported Self reported stage of stage of change change measuremeasure

Psychology Psychology impactimpact

No difference No difference with or with or without without exerciseexercise

WinninghamWinningham 24 breast CA 24 breast CA pts. On pts. On chemochemo

Test Pre/PostTest Pre/Post Home Home programprogram

Body weight Body weight & & compositioncomposition

Exercise dec Exercise dec body fat, inc body fat, inc mass; mass; Opposite for Opposite for controlscontrols

Authors Samples Design Intervention Outcome Results

(Courneya, 2002)

120120

Physical Therapy ModalitiesPhysical Therapy Modalities

121121

Which modalities are Which modalities are safesafe in in treating the patient diagnosed treating the patient diagnosed with breast cancer?with breast cancer?

• Moist HeatMoist Heat

• ColdCold

• Deep HeatDeep Heat

• TractionTraction

• Electrical StimulationElectrical Stimulation

• TENSTENS

• Compression PumpsCompression Pumps

• Manual TherapyManual Therapy

(Pfalzer, 1992)

122122

Progressive Relaxation ExerciseProgressive Relaxation Exercise

• Close your eyes …… Deep BreathingClose your eyes …… Deep Breathing

• Image: Ocean, Mountains, etc. Image: Ocean, Mountains, etc. See it / Hear it / Feel itSee it / Hear it / Feel it

• Contract --- Relax Mildly with 5 countContract --- Relax Mildly with 5 count– Forehead / Face / Neck / Shoulders / Upper Arms / Forehead / Face / Neck / Shoulders / Upper Arms /

Forearms / Hands / Chest / Abs / Gluts / Upper Forearms / Hands / Chest / Abs / Gluts / Upper Legs / Calves / FeetLegs / Calves / Feet

• Deep Breathing .. Total Body contract/relaxDeep Breathing .. Total Body contract/relax

• Repeat total processRepeat total process

Always a safe technique.

123123

Modality ContraindicationsModality Contraindications

• ColdCold– Over dysvascular tissueOver dysvascular tissue– Transient increase in blood pressureTransient increase in blood pressure– Delay in wound healingDelay in wound healing– Nerve injuryNerve injury– Peripheral Vascular DiseasePeripheral Vascular Disease– During RadiationDuring Radiation– Possible MetastasisPossible Metastasis

(Pfalzer, 1992)

124124

ContraindicationsContraindications• Deep HeatDeep Heat

– Over dysvascular tissueOver dysvascular tissue– Over poor sensationOver poor sensation– Increase in bleedingIncrease in bleeding– Directly over tumorDirectly over tumor– Over acute injuryOver acute injury– Open woundsOpen wounds– Elevated temp.Elevated temp.– Metal implantsMetal implants– Pacemaker or other implanted devicePacemaker or other implanted device

(Pfalzer, 1992)

125125

ContraindicationsContraindications

• TractionTraction– Structural Changes possible pathologic Structural Changes possible pathologic

fx.fx.

• Compression PumpCompression Pump– Active disease .. Metastasis can occur Active disease .. Metastasis can occur

through pump activitythrough pump activity

• Manual TherapyManual Therapy

(Pfalzer, 1992)

126126

ContraindicationsContraindications

• Electrical StimulationElectrical Stimulation– Possibility of pathologic fracturesPossibility of pathologic fractures– Implanted deviceImplanted device– Cardiopulmonary InsufficiencyCardiopulmonary Insufficiency– Active phlebitisActive phlebitis

• TENSTENS– ImplantImplant– Directly over woundDirectly over wound

(Pfalzer, 1992)

127127

RREHABILITATIONEHABILITATION

• ““The recognition and acceptance that The recognition and acceptance that breast cancer is a treatable disease breast cancer is a treatable disease even when it is metastatic has helped even when it is metastatic has helped professionals and patients alike accept professionals and patients alike accept rehabilitation efforts.” rehabilitation efforts.” Stephen Gudas, Stephen Gudas, 19921992

You have the knowledge and responsibility to develop a plan of treatment for the patient diagnosed with cancer.

128128

ONCOLOGIC ONCOLOGIC EMERGENCIESEMERGENCIES

129129

Reference to theReference to the GUIDE TO GUIDE TO PHYSICAL THERAPY PHYSICAL THERAPY PRACTICE A.P.T.A.PRACTICE A.P.T.A.• ““Through the examination, the Through the examination, the

physical therapist identifies physical therapist identifies impairment, functional limitations, impairment, functional limitations, disabilities, or changes in physical disabilities, or changes in physical function and health status resulting function and health status resulting from injury, disease, or other from injury, disease, or other causes to establish the diagnosis causes to establish the diagnosis and the prognosis and to determine and the prognosis and to determine the intervention”.the intervention”. (www.apta.org, 2006)

130130

The Guide:The Guide:

• A goal and prognosis will help establish the plan A goal and prognosis will help establish the plan and frequency of visits for the cancer patient.and frequency of visits for the cancer patient.

• Interventions to produce a change in condition Interventions to produce a change in condition are established by the plan of care, anticipated are established by the plan of care, anticipated goals and desired outcomegoals and desired outcome..

• Reexamination needed to evaluate clinical Reexamination needed to evaluate clinical findings to promote care or observe failure of findings to promote care or observe failure of response. response.

• Some examples of ICD-9-CM Codes related to Some examples of ICD-9-CM Codes related to cancer:cancer:– 232 Carcinoma in situ 232 Carcinoma in situ – 239 Neoplasm's of unspecified nature239 Neoplasm's of unspecified nature

(www.apta.org, 2006)

131131

Physical Therapy EvaluationPhysical Therapy Evaluation• Range of MotionRange of Motion• Manual Muscle TestingManual Muscle Testing• Shoulder AssessmentShoulder Assessment• Sensation TestingSensation Testing• Girth MeasurementsGirth Measurements• Posture AnalysisPosture Analysis• Cardiovascular FitnessCardiovascular Fitness• Body Fat AnalysisBody Fat Analysis• Additional tools you may need for assessment:Additional tools you may need for assessment:

– Skinfold caliperSkinfold caliper– SpirometerSpirometer– Heart rate monitorHeart rate monitor– Hand grip dynamometerHand grip dynamometer

132132

Effective AssessmentEffective AssessmentGuidelines of Rocky Mountain Cancer Rehabilitation CenterGuidelines of Rocky Mountain Cancer Rehabilitation Center

• Each parameter relevant to patient Each parameter relevant to patient progressprogress

• Procedures valid and reliableProcedures valid and reliable

• Administrate with rigid controlAdministrate with rigid control

• Protect patient’s rightsProtect patient’s rights

• Regular interval testingRegular interval testing

• Review and explain to patientReview and explain to patient

133133

Organ Toxicity and Life Organ Toxicity and Life Threatening Complications.Threatening Complications.

• Problems seen:Problems seen:• Hematologic (Dealing with blood and Hematologic (Dealing with blood and

blood forming organs)blood forming organs)• ObstructionObstruction• Increased Pressure / Fluid AccumulationIncreased Pressure / Fluid Accumulation• Metabolic (Dealing with chemical Metabolic (Dealing with chemical

processes of living organisms) processes of living organisms) • Pathologic FracturesPathologic Fractures

(Kirchner, 1996)

134134

Oncology Emergency SignsOncology Emergency Signs

• InfectionInfection• FeverFever• EcchymosisEcchymosis• Bleeding (Possible gums)Bleeding (Possible gums)• HeadachesHeadaches• Chest PainChest Pain• DizzinessDizziness• FatigueFatigue• InsomniaInsomnia• SwellingSwelling• Local or Radicular PainLocal or Radicular Pain• Neurological DeficitsNeurological Deficits• SOBSOB• Abdominal Pain / CrampAbdominal Pain / Cramp• Nausea / VomitingNausea / Vomiting

• Constipation / DiarrheaConstipation / Diarrhea• Hypertension / HypotensionHypertension / Hypotension• TachycardiaTachycardia• Changes in UrineChanges in Urine• Loss of AppetiteLoss of Appetite• Blurred VisionBlurred Vision• Change in Mental StateChange in Mental State• SeizuresSeizures• Respiratory ChangesRespiratory Changes• Weight ChangesWeight Changes• DepressionDepression• FracturesFractures• ComaComa• DeathDeath

(Otto, 2004)

135135

Time Out TestTime Out Test• Oncology Emergencies only pertain to the elderly? T / FOncology Emergencies only pertain to the elderly? T / F• The main mission for treating cancer in rehabilitation?The main mission for treating cancer in rehabilitation?• Palliative therapy is really not needed? T / FPalliative therapy is really not needed? T / F• What helps you establish your plan of treatment?What helps you establish your plan of treatment?• When was the first epidemiologic study on breast cancer and When was the first epidemiologic study on breast cancer and

exercise published?exercise published?• Functional assessments must document what?Functional assessments must document what?• Although there have been many negative changes, due to Although there have been many negative changes, due to

rehabilitation, it is still prescribed? T / Frehabilitation, it is still prescribed? T / F• What medical information appears important when working with What medical information appears important when working with

patient’s diagnosed with cancer?patient’s diagnosed with cancer?• What are the advantages of pre-surgical evaluations? What are the advantages of pre-surgical evaluations?

ANSWERSFalse; Maintain and improve Quality of Life; False; Prognosis and Goals; 1985;Measurable benefits; False, No negative findings; Lab values;To many to list.