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Cancer Rehabilitation. integrating rehabilitation with oncology. a model of care. cancer survivorship. rehabilitation care in low resource area. Mrinal Joshi. Rehabilitation Research Center. Jaipur.

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  1. 1. Cancer Rehabilitation Mrinal Joshi Director, Rehabilitation Research Center Senior Professor & Unit Head, Department of Physical Medicine & Rehabilitation
  2. 2. Rhinoceros Syndrome
  3. 3. Cancer Rehabilitation A concept that is defined by the patient and involves helping a person with cancer to obtain maximum physical, social, psychological, and vocational functioning within the limits imposed by the disease and its treatment.
  4. 4. 52% had psychological problems, 35% had generalised weakness, 30% had ADL problems, 25% had difficulties with ambulation, 7% had deficits in transfer & 7% had deficits in communication
  5. 5. Dr J Herbert Dietz stated in 1974 “This trend towards increased and improved life expectancy is having an important impact on concepts of caring of the cancer patients; how best we can help these patients readapt to society?” A history of cancer rehabilitation. DeLisa J A. Cancer Vol 92, Issue S4, 15th Aug 2001, 970-974
  6. 6. Cancer Rehabilitation Approaches • Preventive, when the disease can be predicted and appropriate prior training can reduce the severity of its effect • Restorative, when the disability can be expected to result in only minimal or residual handicap • Supportive, when the disability must be tolerated and appropriate gains made toward control of problems and improvement in performance • Palliative, when there is advanced disease and the basic disability cannot be corrected, but training can aid performance A history of cancer rehabilitation. DeLisa J A. Cancer Vol 92, Issue S4, 15th Aug 2001, 970-974
  7. 7. Impairments associated with surgery & chemotherapy • Impaired postoperative healing • Neurologic deficits • Musculoskeletal disorders due to maladaptive movement • Peripheral neuropathy • Cognitive dysfunction • Cardiomyopathy • Pulmonary fibrosis
  8. 8. Impairments associated with radiation therapy • Desquamation of dermis • Muscle hypertonicity • Tissue necrosis & fibrosis • Delayed radiation myelopathy • Delayed brachial & lumbar plexopathy • Delayed encephalopathy • Cerebral atrophy
  9. 9. • Constitutional symptoms • Fatigue & pain • Functional decline • Impairments caused by tumour effects • Bone metastases • Brain Tumours: primary & metastases • Epidural spinal cord compression • Brachial & lumbar plexopathy • Paraneoplastic syndromes • Cadiopulmonary metastases BUT THIS 70s momentum failed to progress due to lack of education, prioritise or PMR’s bias towards other field
  10. 10. Much of the disability associated with advanced cancer can be addressed. One of the central question of this review was “why does functional loss in patients with cancer fail to trigger rehabilitation referrals”?
  11. 11. Willingness to refer/accept a patient with advanced cancer regardless of estimated prognosis, only 8.4% of oncologists were willing in contrast to 15.1% physiatrists reported as 35% willing to accept the referrals.
  12. 12. Survivorship & Rehab • Attention focuses on special needs of disease free cancer survivors • Model of care to maximise health and well being of survivors • Effective symptom management, prevention of late effects and health promotion • Shift from hospital based to physician based • Poor integration in current tertiary program • Poor trainee exposure • Comprehensive model instead of fragmented model of care
  13. 13. Survivorship & Rehab • HRQOL is much worse in cancer survivors • Leading cause is physical disability • Rehab potential screening • GOAL setting • SMART goals • Identification of appropriate health professionals
  14. 14. Oncology-Rehabilitation Interface
  15. 15. O’Toole DM, Golden AM: Evaluating cancer patients for rehabilitation potential. West J Med 1991 Oct; 155:384-387
  16. 16. Cancer Rehab & Palliative Care • Subspecialties are similar in many respect • Managing cancer related or treatment related symptoms • Improving HRQOL • Lessening care giver burden • Valuing patient centred care • Shared decision making • Goals are often aligned but different specialised skills & approaches • Rehab physicians tend to focus more on functions
  17. 17. • A medical intervention can be considered futile if it has little or no chance of achieving the intended outcome. • It is not uncommon for the rehabilitation team to feel that the patient and/or the patient's family has “unrealistic” or unachievable goals. In those cases, we try to help them reshape and reframe goals to match what we know about patients' impairments and prognosis for recovery. If that is not possible, where does it leave us?
  18. 18. DRS Admission n Mr X referred from RAH n Following functional decline medical condition
  19. 19. Presenting Complaint n Difficulty in swallowing n Difficulty in speech n Falls n Excessive salivation
  20. 20. HPC n History of recurrent 4th ventricle subependymoma n Recurrent aspiration n 7th, 9th,10th &12th palsy n Dysphagia n Tracheostomy
  21. 21. Medical Problem List n Drooling n Orthostatic Hypotension n Dysphagia n Dysarthria n Dysphonia n Cough after swallow n Abnormal Gag Reflex n 9th , 10th & 12th Palsy
  22. 22. Spasticity Clinic Evaluation @ RGH n 13/5/08: using 10 boxes of tissue/week, distressed with drooling n 21/5/08: B/L parotid & submandibular salivary glands injected with 40 Units of botulinum toxin A under ultrasound guidance
  23. 23. Oncology Rehab • DG • Grey zone lymphoma • Treated by MGH Oncology team • 3 CHOP + Prednisolone
  24. 24. Problem List • Feels better after chemotherapy • Disabling neuropathic pain both lower limbs • Distal sensory loss both lower limbs • Distal motor weakness - unsteady slapping gait • Unsteady gait • Confined to bed • Not able to attend job responsibilities • Financial distress
  25. 25. Interventions • TCAs & Anti-convulsants • Silicon gel socks and inserts • Ankle Foot Orthosis • Physical therapy for motor weakness & gait training • Gait aid - walking stick • Able to walk with minimal discomfort • Plans return to work , part time • Feels better and confident • Family is happy with the outcome