Cancer rehabilitation

1. CANCER REHABILITATION
Presented by
Beemamol Hussain
40th BSc Nursing
Government College of Nursing Kozhikode

2. INTRODUCTION
 Cancer is a group of diseases characterized by uncontrolled growth and spread of
abnormal cells, which can result in death.
 Cancer is caused by both external factors (eg, chemicals, radiation, viruses) and
internal factors (eg, hormones, immune conditions, inherited mutations).
 Today, cancer is treated with surgery, radiation, chemotherapy, hormones, and/or
immunotherapy.

3. INTRODUCTION
 All tissue types have neoplastic potential and can become cancerous
 Tissues distinguished by rapid cell turnover (gastrointestinal mucosa), hormone
sensitivity (breast and prostate), and regular exposure to environmental mutagens
(lung and skin) have higher rates of malignant transformation
 Any tissue can develop cancer, means that cancer rehabilitation must address all
body parts and systems

4. REHABILITATION MEDICINE
 Physical medicine and rehabilitation, also known as rehabilitation medicine or
physiatry, is the medical specialty concerned with restoring and/or maintaining the
highest possible level of function, independence, and quality of life.
 The field of cancer rehabilitation focus on the evaluation and treatment of
functional and pain disorders in cancer patients and survivors.

5. DISEASE CONSIDERATIONS
Staging
 The specifics of cancer staging vary by disease site
 Stage I is early, locally contained disease, whereas stage IV is advanced disease
characterized by distant metastases
 Staging provides critical information for appropriate design of rehabilitation
interventions, and for gauging each patient’s risk of recurrence or progression

6. PLANNING
 In planning a long-term rehabilitation approach, it is important to anticipate
 where cancer is likely to spread
 how it will respond to treatment
 what cumulative toxicities might be associated with ongoing therapies
 how long patients will live

7. eg:
 Lung, breast, colon, and melanoma commonly spread to brain.
 Prostate, breast, and lung cancer commonly produce bone metastases
 Musculoskeletal pain in cancer populations can be due to primary or secondary
consequences of bony disease and should trigger an appropriate evaluation

8. Constitutional Symptoms
 Many symptoms are common in cancer, particularly among patients with stage IV
disease.
 Failure to adequately address symptoms such as fatigue, nausea, pain, anxiety,
insomnia, and dyspnea can undermine rehabilitative efforts
 Pain and fatigue presents most consistent and challenging obstacles to successful
rehabilitation

9. FATIGUE
 Fatigue is most common symptom experienced by cancer
patients
 Prevalence ranges from 70% to 100%
 Contingent on type and stage of cancer

10. Criteria for Cancer-Related Fatigue
(International Classification of Diseases)
 Diminished energy
 Increasing need for rest
 Limb heaviness
 Diminished ability to concentrate
 Decreased interest in engaging in normal activities
 Sleep disorder
 Inertia
 Emotional lability as a result of fatigue
 Perceived problems with short-term memory
 Post exertional malaise exceeding several hours

11. Reversible sources of cancer fatigue
 Anemia
 Insomnia or lack of restorative sleep
 Cytokine release (e.g., tumor necrosis
factor)
 Hypothyroidism
 Hypogonadism
 Depression
 Steroid myopathy
 Centrally acting medications
 Altered oxidative capacity
 Pain
 Adrenal insufficiency
 Cachexia
 Deconditioning

12. Interventions for Fatigue
 Restore energy balance
 Correct anemia
 Nutritional and vitamin supplementation
 Correct endocrine dysfunction (thyroid)
 Medications
 Stimulants (methylphenidate, D-amphetamine)
 Analgesics
 Antidepressants (bupropion, SSRIs, TCAs)
 Regulate sleep/wake
 Glucocorticoids
 Investigational—cytokine targeted therapy (including NSAIDs)

13. Interventions for Fatigue
 Exercise
 Aerobic exercise is best-studied form
 Individualized
 Attention to precautions
 Cachectic patients may not tolerate
 Energy conservation
 Education
 Adaptive equipment
 Psychologic/coping
 Recreational activities
 Relaxation techniques
 Support groups
 Spiritual supports, participation

14. PAIN
 Prevalence of cancer-related pain is
 28% among patients with newly diagnosed cancer
 50% to 70% receiving antineoplastic therapy
 64% to 80% with advanced disease
 Adequate pain control is an absolute requisite for successful rehabilitation
 Cancer patients generally experience multiple concurrent pain syndromes
 Thorough evaluation requires assessment of all relevant pain etiologies and
pathophysiologic processes

15.  Pain control require integrated use of anticancer treatments, agents from multiple
analgesic classes, interventional techniques, topical agents, manual approaches,
and modalities
 Majority of cancer pain is due to tumor effects, for this reason, disease-modifying,
anticancer therapy plays a critical role in pain management
 Analgesics with transdermal, parenteral, and transmucosal routes of administration
should be preferentially used when enteral route cannot be used

16. Acute Pain
 Acute pain after surgery or radiation therapy can be successfully treated
 Nerves are frequently severed, compressed, or stretched during tumor resection,
making it possible for neuropathic pain to be a major factor during postoperative
period
 Adjuvant analgesics (e.g., gabapentin) should be initiated when a neurogenic
contribution to pain is suspected
 In postoperative pain that impedes function, aggressive opioid based and anti-
inflammatory analgesia should be considered
 Acute pain control allows movement and limits immobility

17. Chronic pain
 Chronic cancer-related pain can arise from visceral or neural structures but is most commonly
associated with bone metastases
 Bone metastases occur in 60% to 84% of patients with solid tumors
 NSAIDs are considered first-line therapy for bone pain
 Opioids enhance analgesia afforded by NSAIDs and can reduce doses required for adequate
pain relief

18.  Invasive and Intraspinal Analgesic Approaches :
 Discrete neural blockade can effectively reduce pain transmitted by one or several
adjacent peripheral nerves .
 Intercostal, paravertebral, genitofemoral, ilioinguinal, and trigeminal nerve blocks
can afford dramatic relief and reduce analgesic requirements.
 Intraspinal opioid administration can reduce dose requirements and associated
side effects
 Potential benefits, however, must be weighed against added cost, required
maintenance, and risk of infection

19. Impairments in Cancer
 Cancer can invade all tissue types and regions of body, producing a wide array of
functional impairments
 Tumor related deficits generally arise as a result of pain, neural compromise, loss of
osseous or articular integrity, and invasion of cardiopulmonary structures
 Cancer-related impairments are often dynamic, characterized by improvement or
progression, depending on treatment responsiveness

20. Bone Metastases
 Bone metastases are important source of cancer related impairment and a critical
consideration in rehabilitation
 Highly prevalent because bone is most common site of metastatic spread, and
most frequently from cancers lung, breast, and prostate
 Of greatest physiatric concern are lesions involving spine and long bones
 These structures are critical for weight-bearing and mobility, and are most prone to
fracture

21.  Managed with medications, radiopharmaceuticals, orthoses, radiation therapy,
and/or surgical stabilization
 Bisphosphonates are primary medications, these agents relieves pain and mitigates
spread and progression of bone metastases
 Can reduce risk of vertebral fracture, nonvertebral fracture and hypercalcemia
 Radiopharmaceuticals such as strontium-99 are used to manage severe, refractory
pain associated with widely disseminated bone metastases
 Internal fixation and prosthetic replacements are most effective ways of relieving
pain and restoring function in patients with pathologic fractures

22. Rehabilitation of Bone Metastases
 Integrated cross-disciplinary, long-term management plan offers patients best
chance of preserved comfort and function
 Rehabilitative approaches can be grouped into
 use of orthoses
 assistive devices
 therapeutic exercise
 environmental modification
 All essentially de-weight or immobilize compromised bones

23. Orthoses
 Use of thoracolumbosacral or spinal extension orthoses, such as cruciform anterior
spinal hyperextension or Jewett braces.
 Orthoses limit spinal flexion, thereby reducing loads on anterior vertebrae to
protect against compression fractures
 Orthoses can also be used to protect and de-weight sites of fracture or impending
fracture
 Extreme caution must be used in patients with diffuse bone metastases while
redistributing weight and loading patterns
 Assistive devices and instruction in compensatory strategies might similarly unload
compromised bones

26.  Canes, crutches, and walkers are frequently used to minimize fracture risk
 Patients should be instructed to minimize forces by performing activities close to
body, which limits torque on long bones

27.  A comprehensive exercise program should include postural and balance training,
as well as truncal strengthening
 Simple environmental modifications can significantly reduce patients’ fracture risk
 Throw rugs and other hazards that increase fall risk should be removed
 Railings can be added to stairwells and bathrooms as appropriate

28. Aerobic Conditioning and Resistive Exercise
 Exercise studies performed in cancer population have consistently substantiated
gains in cardiopulmonary fitness, fatigue, quality of life, depression, and anxiety
 Benefits of exercise may extends on immune function, such as improved natural
killer cell activity, monocyte function, proportion of circulating granulocytes, and
duration of neutropenia
 Physical activity appears to exert a protective effect against development of some
types of cancers, most notably colon and breast cancers

30. Flexibility Exercises
 Activities to enhance ROM are critical for rehabilitation of postsurgical and post
radiation soft tissue contractures
 Patients is provided with a series of active-assisted ROM activities that target all
affected muscle groups, with emphasis placed on restricted planes of motion and
instructions to hold each stretch for three to five deep breaths

31. Cardiopulmonary Metastases
 Lung, pleural, and pericardial metastases involving heart and lungs can produce
dramatic and abrupt reductions in patients’ stamina and functional status
 Type and efficacy of anticancer treatment depend on primary tumor, number and
location of metastases, previous antineoplastic therapies, overall medical condition
of patient, and degree of associated symptomatic distress

32. Rehabilitation of Cardiopulmonary Dysfunction
 Exertional intolerance resulting from cardiopulmonary factors occurs commonly among
cancer patients
 Malignant pleural effusions should be evacuated when patients become symptomatic
 Supplemental oxygen should be initiated as soon as dyspnea becomes function-limiting
 Incremental aerobic conditioning with supplemental oxygen as needed usually
produces a reduction in exertional intolerance
 Improvements in stamina and perceived exertion are due to muscle-training effects

33. Skin metastases
 Dermal metastases occur in 5.3% of patients and are most common in breast
cancer
 Malignant wounds should be managed with nonadherent, bacteriostatic,
hyperabsorbent dressings (e.g., SilvaSorb or Aquacel Ag)
 Associated pain must be managed aggressively to minimize adverse functional
consequences
 Proactive range of motion (ROM) activities can prevent formation of contractures in
joints, facilitating hygiene and autonomous selfcare

35. Breast cancer
 Functional impairments unique to breast cancer patients are developed after
surgical procedures for tumor removal and breast reconstruction
 Persistent deficits in shoulder ROM occur in as many as 35% of patients after ALND
 Axillary web syndrome refers to presence of taut, palpable cords originating in
axilla and extending distally along anterior surface of arm, often below elbow
 Clinical relevance of axillary web syndrome arises from its potential for painful
restrictions in shoulder ROM

37.  In severe cases, cords tether the humerus, preventing full shoulder flexion or
abduction
 Pain generally responds to NSAIDs, but opioid analgesics might be necessary
during passive and active assisted ROM if pain is severe
 Therapy involves incremental ROM activities, topical heat, manipulation to soften

38.  Surgical community has increasingly recognized need for rehabilitation after TRAM
flap breast reconstruction
 It denervate and disrupts integrity of abdominal wall, producing significant deficits
in truncal stability, particularly during functional transfers
 Goals of post-TRAM rehabilitation are to
 prevent subdermal fibrosis and adhesions,
 restore truncal alignment
 minimize stress on the lumbar spine
 optimize proprioceptive acuity in residual abdominal muscles
 encourage normal muscle recruitment patterns

40. Head and Neck Cancer
 Combined modality therapy for head and neck cancer has afforded improved cure
rates and reduced normal tissue compromise
 Treatment of head and neck cancer continues to produce some of most
challenging impairments within scope of cancer rehabilitation
 Many of impairments directly undermine patients’ ability
 to socialize because of facial dysmorphism,
 loss of spontaneous or intelligible speech
 inability to eat normally

41.  Common rehabilitation problems include
 spinal accessory nerve palsy
 radiation-induced xerostomia
 soft tissue contracture of neck and anterior chest wall soft tissues
 Dysphagia
 dysphonia, and
 myofascial dysfunction

42.  Spinal Accessory Nerve Palsy: Integrity of spinal accessory nerve can be easily assessed by
side-to-side comparison of resisted end-range forward flexion of shoulder
 Some degree of weakness can be elicited in most patients on the side of the neck dissection
 Important elements of spinal accessory nerve rehabilitation include: –
 Prevention of frozen shoulder through active ROM and active/assisted ROM
 Prevention of anterior chest wall flexibility deficits
 Strengthening of alternate scapular elevators and retractors
 Neuromuscular retraining : Preservation of trapezius muscle tone through electrical
stimulation if reinnervation is anticipated
 Postural modification : Instruction in shoulder support to allow recovery of the levator
scapulae

43. Spinal accessory nerve palsy

44. Cervical Contracture:
 Progressive fibrosis of anterior and lateral cervical soft tissue can be highly
problematic for head and neck cancer patients
 Proactive ROM in all planes of neck motion should be initiated as soon as safely
possible
 Cervical ROM can continue throughout radiation therapy in the absence of
significant skin breakdown
 Ranging activities should ideally begin immediately after surgery and before
radiation
 Stretches should be held for five deep breaths and repeated between 5 and 10
times per session

45. Aphonia and Dysphonia
 Impaired vocal communication occurs in majority of head and neck cancer patients
at some point during treatment
 Many conditions other than total laryngectomy can compromise phonation
 radiation-induced laryngeal or pharyngeal swelling and fibrosis,
 tracheostomy
 partial or total glossectomy
 reduced oral excursion secondary to trismus
 copious secretions and
 neurogenic pharyngeal or laryngeal paralysis

46.  Various approaches to restore communication can be used depending on anticipated
duration, severity, and nature of deficit
 Most common compensatory strategies used by acutely voiceless adults include
 mouthing words
 Gestures
 Writing and
 head nods

47. Lymphedema Management
 Lymphedema is a chronic and currently incurable condition that frequently
complicates cancer therapy
 After resection or irradiation of lymph nodes and vessels, lymphatic congestion can
develop in any region of body drained by affected structures
 If congestion becomes sufficiently severe, swelling can result from accumulation of
protein-rich fluid
 Complete (or complex) decongestive therapy (CDT) represents current international
standard of care for lymphedema management

48.  CDT is intensive integration of manual approaches and is able to achieve and
maintain substantial volume reduction for majority of lymphedema patients
 Initial phase I, Reductive, has its primary goal in decreasing lymphedema volume
 Patients receive approximately 45 minutes of manual lymphatic drainage (MLD),
followed by application of compression bandages and performance of remedial
exercises
 In phase II, compressive garments are used during day, with application of
compressive bandages overnight

49. Lymphatic drainage Compression garments

50.  Compression garments achieve the following: –
 Improve lymphatic flow and reduce accumulated protein
 Improve venous return
 Properly shape and reduce size of limb
 Maintain skin integrity
 Protect limb from potential trauma