Cancer Rehabilitation

1. Gina Beecher, DPT, CBIS
Courtney Huber, MS, CCC-SLP, CBIS
Sue Sandahl, MA, OTR/L, CBIS
On The Horizon of Oncology Nursing:
Updates and Current Treatment 2016
Cancer Rehabilitation:
An Interdisciplinary Approach

2. CONFIDENTIAL
On With Life – Our History
• Started 25 years ago by 8 families who came
together to support their loved ones with TBI
• Inpatient rehabilitation
• Long term care
– Glenwood, IA
• Supported community living
• Neuropsychology
• Outpatient Therapy

3. CONFIDENTIAL
Presentation Objectives
1) Participants will learn the role of interdisciplinary
rehabilitation (PT/OT/SLP/Case Management) in
the treatment of different cancer types.
2) Participants will learn the difference between
courses of rehabilitation depending on a person’s
personal goals and medical prognosis.
3) Participants will learn of resources for
rehabilitation services in the local area.

4. CONFIDENTIAL
Cognitive Rehab for “Chemobrain”
• Research suggests that for
extracerebral cancers,
neurocognitive deficits may be
present without the presence of
brain mets and before treatment
has been initiated
• Common treatments, while effective
in treating the cancer, have a
neurotoxic effect
• In some people, the neurocognitive
impairments do not resolve
following medical treatment

5. CONFIDENTIAL
Cognitive Rehab for “Chemobrain”
• Common neurocognitive deficits
secondary to extracerebral cancer:
– Memory changes
– Decreased attention (distractible;
unable to multitask or shift between
tasks)
– Slowed mental processing
– Changes in executive function
(organization; reasoning; awareness
of deficits)
– Difficulty with word-finding
– Fatigue
– Motor coordination

6. CONFIDENTIAL
Cognitive Rehab for “Chemobrain”
• Unfortunately, few survivors receive treatment for
cognitive deficits secondary to extracerebral cancer
– Primary cancer centers rarely offer cognitive rehabilitation
– Traditional rehabilitation centers do not target marketing
to this population due to concerns related to poor
prognosis
– Survivors may be ashamed to admit to continued
problems due to surviving a horrible disease

7. CONFIDENTIAL
Cognitive Rehab for “Chemobrain”
• Comprehensive neuropsychological
testing is indicated for differential
diagnosis of cognitive changes vs.
mood disturbances, aging, or
neurodegenerative disease
• Neuropsychological testing may be
useful prior to beginning medical
treatment to establish cognitive
baseline and compare to status
during and following treatment
• Neuropsychological assessment is
allowing for investigation of
neurocognitive outcomes in clinical
trials of new antineoplastic agents

8. CONFIDENTIAL
“Prehabilitation” for “Chemobrain”?
• Cognitive rehabilitation prior to medical
treatment fits with the 3 key purposes of
prehabilitation:
– Protect the brain from further neurocognitive
compromise associated with progression of
disease and cancer treatment
– Implement compensatory behavioral
strategies designed to circumvent probable
problems before they progress to life-limiting
disabilities
– Decrease patient and caregiver distress by
introducing supportive counseling and
psychoeducational programs
• Potential outcomes
– Increased QOL for survivors/families?
– Health care cost savings by reducing severity
of disability?

9. CONFIDENTIAL
Cognitive Rehab for “Chemobrain”
• Many of the same compensatory
techniques used in acquired brain
injury rehabilitation can be applied to
cancer rehabilitation
• Skilled rehabilitation therapies
(speech-language pathology;
occupational therapy) is indicated to
train survivors and their family
members on use of these
compensatory approaches
• At this time, there is no evidence to
support drill-oriented approaches for
remediation of memory or attention
function

10. CONFIDENTIAL
Case Study – C. P.
• 55 year old woman, referred to OWL for cognitive impairment
• 3 years prior, was treated for breast cancer with chemotherapy
• Noted worsening memory, attention, and executive function
throughout treatment without resolution of symptoms when
treatment ended
• MRI ruled out brain mets
• Cognitive changes resulted in her being terminated from her
job of 11 years
• Tried to return to work on multiple occasions; unable to hold a
job for more than 2 weeks
• Relevant medical history: peripheral neuropathy;
anxiety/depression; stomach ulcers; hypothyroidism

11. CONFIDENTIAL
Case Study – C. P.
• Assessment results: low average results for domains tested on
the Repeatable Battery for the Assessment of
Neuropsychological Status; significant impairment in written
and verbal reasoning on the Functional Assessment of Verbal
Reasoning and Executive Strategies
• Interpretation: mild cognitive-communication impairment
• Recommendations: speech-language pathology services at 1-
2x/week; individual counseling to address depression/anxiety;
consider neuropsychological testing for comprehensive
cognitive baseline data

12. CONFIDENTIAL
Case Study – C. P.
• Speech-Language Pathology plan of
care:
– Start use of planner as a
memory/planning/organization device
– Introduce template (Goal-Plan-Do-
Review) for task segmentation,
sequencing, and review of
performance on personal goals
– Trial organizational strategies to sort
and file paperwork that has been
“piling up” in home environment
– Identify vocational interests and
explore appropriate accommodations
for return-to-work

13. CONFIDENTIAL
Case Study – C. P.
• Treatment duration: 21 visits over period of
approximately 3 months
• Met all plan of care goals
– Consistently using planner to write daily to-
do lists, upcoming appointments,
information to remember for later, and to
reschedule tasks that were not yet
completed
– Utilized task segmentation for various
situations such as applying for jobs,
completing basic household management
tasks, and filling out complex paperwork
– Returned to work part-time as a travelling
health care provider for wellness fairs (e.g.,
flu shot clinics) and was reporting job
satisfaction
– Reported overall improved quality of life

14. CONFIDENTIAL
Rehabilitation for Non-Progressive Brain
Tumors
• Traditional Rehab
• NDT
• Neuro-IFRAH
• Aphasia/Apraxia rehab
• Vision and Vestibular rehab
• Strengthening and Activity Tolerance
• Fatigue management
• Adjust treatment intensity based on any follow-up chemo or
radiation treatments

15. CONFIDENTIAL
Case Study – J.R.
• JR is a 23 year-old male who lived with his parents and
worked full time in an accounting job. He was independent in
all ADL, IADL, work, mobility, and driving.
• He began noticing changes in June 2016 when his right leg
was not working properly and led to his involvement in a car
accident. He was also experiencing signs and symptoms of a
stroke.
• He was diagnosed with Neoplasm of the brain and cerebral
cysts, s/p resection of a left fronto-parietal benign tumor July
2016. He discharged to home with his mother six days post-
surgery. JR had residual global aphasia, right-sided weakness,
and spasticity.
• He was referred to On With Life Outpatient
Neurorehabilitation for Speech Language Pathology,
Occupational Therapy, and Physical Therapy.

16. CONFIDENTIAL
Case Study – J.R.
• Assessment Results: Aphasia and Apraxia,
Dominant RUE/RLE weakness, spasticity,
gait disturbance, Modified Independence
BADL; Moderate/Maximum assistance IADL;
Driving – dependent; Work – unable.
• Recommendations: OT, PT, SLP 2-3 times
per week.
• Speech Language Pathology: Traditional
aphasia/apraxia rehab
• Physical Therapy: Traditional rehab

17. CONFIDENTIAL
Case Study – J.R.
• Goal: JR’s main goals were to return
to driving and work as work was a
significant priority for him.
• Occupational Therapy Plan of Care:
– RUE gross and fine motor control
retraining including modified
constrain-induced treatment,
keyboarding and mousing
– Dynavision: Visual-motor reaction
time assessment and retraining in
preparation for return to driving
– Therapeutic exercise for
strengthening RUE
– BADL retraining specifically for
donning RLE orthotic

18. CONFIDENTIAL
Case Study – J.R.
• Treatment Duration: OT 23 treatments, PT
23 treatments, SLP 20 treatments
• JR met all OT goals
– Mod I in all BADL/IADL
– Improved RUE strength from 2-3/5 to 4-5/5
– Improved RUE grip from 31.6# to 62.5#
– Improved RUE 9-Hole Peg Test from unable
to 56.14 seconds
• Returned to driving – initially with
supervision adult passenger, then
independently
• Returned to work initially at 4 hours per
day and gradually worked up to 8 hours
per day
• OT, PT, SLP and Office Case Manager
collaborated with JR regarding return to
work and driving readinesss.

19. CONFIDENTIAL
Rehabilitation for Aggressive Brain Tumors
• Anticipates and prevents suffering in order to ensure
maximal quality of life (as they define and interpret it)
• Can increase tolerability of treatments,
decrease need for
hospitalization, and increase
patient and family satisfaction
• Help them to make the most
of each day
• Frequent re-assessment of
symptoms
• Treatment of pain

20. CONFIDENTIAL
Case Study – M.R.
• 58 year old female, referred to OWL for
OT/PT/SLP following diagnosis of
glioblastoma (right frontal) one month
prior to evaluation date
• Undergoing radiation and
chemotherapy treatment
• Experiencing left sided weakness
resulting in decreased mobility and a
recent fall at home
• PMH significant for Spinal fusion C5-6,
breast lumpectomy, factor V mutation
(currently with blood clot in left lower
leg), migraines, depression
• M.R. states she is retired but previously
very active, working out and watching
young grandchildren once a week

21. CONFIDENTIAL
Case Study – M.R.
• Assessment results: Bilateral LE weakness
(L>R) and left UE weakness, walking up to 40
feet without assistive device minimal
assistance, impaired midline perception, Berg
9/56, TUG 57 seconds, SBA – min A for ADL’s
• Recommendations: OT 1-2x week, PT 2-3x
week for treatment of deficits to improve
functional mobility for ADL’s, SLP one visit
eval and DC

22. CONFIDENTIAL
Case Study – M.R.
• Patient goals: increase independence,
improve strength, return to baking
• Physical therapy plan of care:
– gait training – adding assistive devices, AFO
as needed, family training to assist with
mobility
– transfer training – initially increasing
independence, then needing more family
training on transfers, bed mobility, body
mechanics
– therapeutic exercise – educating M.R. and
spouse on safe strengthening and
endurance exercises for home
– MAIN FOCUS – maximize function as long as
possible working towards a family goal for
M.R. to stay home as long as possible

23. CONFIDENTIAL
Case Study – M.R.
• Benefit of multidisciplinary
approach
– SLP – evaluated and educated
– OT – evaluated and treated for
6 visits to increase strength and
activity tolerance for ADL’s
– PT – gait, transfer training,
family education
– CM – provided family
education, counseling,
coordination with hospice

24. CONFIDENTIAL
Case Study – M.R.
• Physical therapy treatment duration: 24
visits in a little under 3 months
• During that time cancer progressed
despite the chemo/radiation treatment
• M.R. was discharged with hospice services
and passed away 3 months following
discharge

25. CONFIDENTIAL
Utilizing Rehabilitation Resources
• Physician’s order
– If not sure what services are needed, request
PT/OT/SLP eval/treat
– If skilled rehabilitation services are not indicated,
evaluating clinician will provide
recommendations, education, and discharge
– If skilled rehabilitation services are indicated,
clinician creates discipline-specific plan of care
and submits to the physician

26. CONFIDENTIAL
Questions?
If you have specific questions regarding this
presentation or our referral process, please contact us!
Tammy Miller, Outpatient Clinic Manager
tmiller@onwithlife.org
(515) 289-9662
Gina Beecher, Physical Therapist
gbeecher@onwithlife.org
(515) 289-9643
Courtney Huber, Speech-Language Pathologist
chuber@onwithlife.org
(515) 289-9641
Sue Sandahl, Occupational Therapist
ssandahl@onwithlife.org
(515) 289-9644

27. CONFIDENTIAL
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28. CONFIDENTIAL
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