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Rehabilitation of the Cancer
Patient
By
Dr. Ihab Samy
Lecturer of Surgical Oncology
National Cancer Institute – Cairo, Egypt
2014
• 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.
The Rehabilitation Team
• Physiatrist.
• Physical and Occupational Therapist.
Complications of Cancer and its Treatment
• Direct Effects of Cancer.
• Paraneoplastic Effects.
• Chemotherapy.
• Radiotherapy.
• Surgery.
• Thromboembolism.
Neuromuscular Complications of
Cancer and Cancer Treatment
• Brain Dysfunction.
• Spinal Cord Dysfunction.
• Peripheral Nervous System Dysfunction.
• Myopathy.
Evaluation of Neuromuscular Disorders
• History and physical examination.
• Laboratory tests.
• MRI is usually the modality of choice for imaging the
peripheral nervous system.
• Intravenous gadolinium is useful in the identification of
peripheral nerve and plexus tumors, leptomeningeal
disease, and intramedullary spinal cord tumors as well as to
differentiate scar from tumor, exclude infection, and
identify radiation changes.
• Electrodiagnostic testing with nerve conduction studies and
needle electromyography is often extremely useful in
clarifying the etiology of symptoms.
Treatment of Neuromuscular Disorders
• Can be highly specific (injection of a median
mononeuropathy at the wrist) or extremely
general (prescription of opioids for pain).
• Specific treatments depend largely on accuracy of
diagnosis of the underlying disorder.
• For instance, severe and disabling hand pain may
be from a CNS cause (thalamic or funicular pain),
radiculopathy, plexopathy, a polyneuropathy, or a
mononeuropathy such as the median
mononeuropathy responsible for carpal tunnel
syndrome.
Bony Metastases
• Bone metastases are a common complication of cancer, found to
occur in 69% of patients with advanced breast cancer in one study.
• The primary risk of bony metastases is fracture, with subsequent
pain and disability.
• Long-bone fracture, in particular, poses a significant risk to the
patient as pain may be severe and ambulation and ADLs
compromised.
• Patients with bony metastatic disease may require protected weight
bearing, either to avoid further bony injury (e.g., in the healing
phase after radiation therapy and/or surgical stabilization of
pathologic fracture) or to assist in pain control.
• Mirels proposed a scoring system to quantify the risk of
sustaining a pathologic fracture through a metastatic lesion
in a long bone based on the site (upper limb, lower limb,
peritrochanteric), pain (mild, moderate, functional), lesion
type (blastic, mixed, lytic), and size relative to the diameter
of affected bone (less than one-third, one-third to two-
thirds, greater than two-thirds).
• Each of these four variables was given a score of 1, 2, or 3
according to the degree of risk.
• It was determined that lesions with a cumulative score of 7
or lower could be safely irradiated without risk of fracture,
but lesions with a score of 8 or higher required prophylactic
internal fixation prior to irradiation.
Spinal cord instability
• The three-column model of Denis is often used in
assessing stability.
• This model divides the spine into anterior (anterior
longitudinal ligament, anterior half of vertebral body
and disk), middle (posterior half of vertebral body and
disk, and posterior longitudinal ligament), and
posterior (posterior elements) columns.
• The lesion is considered unstable if two or more
columns are involved or, in some cases, if the middle
column alone is involved.
• Bilsky has developed a conceptual framework to guide
therapeutic decision making with respect to surgical,
radiotherapeutic, and chemotherapeutic options for spine
tumors.
• This tool for individual patient assessment is known as the
“NOMS” criteria and is based on an evaluation of the
neurologic (N), oncologic (O), mechanical instability (M),
and systemic disease (S) status of the patient.
• In this model, mechanical instability is defined simply as
movement-related pain referable to a focus of tumor.
• Instability pain is distinguished from biologic or tumor-
related pain in that is does not respond to steroids.
Lymphedema
• Lymphedema is the abnormal accumulation of protein-
rich lymph in an extremity, the trunk, or face.
• If untreated, the accumulation of protein-rich
lymphatic fluid can result in fibrotic deposition with
progressive sclerosis further worsening the
lymphedema and ultimately resulting in elephantiasis.
• Primary lymphedema is due to aplastic or hypoplastic
development of the lymphatics, whereas secondary
lymphedema is usually the result of infection, tumor, or
lymphatic injury.
• Lymphedema is not usually a painful condition
but can cause a feeling of extremity heaviness or
constriction.
• Improved cancer treatment approaches diminish
but do not prevent the development of
lymphedema.
• Thus, at-risk patients should be educated about
lymphedema and its complications, including
cellulitis.
• Risk-reduction strategies include skin care and
protection, avoiding venipuncture, blood
pressure measurements, or constricting clothing
to the affected region.
• Manual therapies are the standard of care for lymphedema.
• Complex decongestive therapy (CDT), a combination of manual
therapies, is performed by certified lymphedema therapists who
have specialty training beyond their core therapy backgrounds.
• Phase I CDT is used to treat the initial edema and exacerbations. It
combines manual lymphatic drainage and compression bandaging.
• Manual lymphatic drainage is a highly specialized gentle message
technique to enhance the distal to proximal lymph transport.
• This is performed 5 to 7 days a week. Following each session, the
limb/region is wrapped with multiple layers of short-stretch
bandages and exercises are performed.
• The bandages are worn approximately 21 to 23 hours per day, until
the next session. Phase I continues until maximal volume reduction
is achieved.
• A compression garment is prescribed during the period
of transitioning from phase I to phase II of CDT.
Garments vary in pressure, design, and price.
• Resistance exercise including weight lifting does not
increase the risk of or exacerbate symptoms of
lymphedema.
• It is advisable that resistive strength training programs
should be performed while wearing a compression
garment.
• Comprehensive treatment of lymphedema should
address weight control because of the association
between increased body mass and lymphedema.
• Diuretics may have a role in treating lymphedema of
mixed origin (i.e., cardiogenic and lymphedema) but
are not recommended for long-term use.
• Antibiotics including second-generation cephalosporins
and penicillins are commonly used to treat cellulitis
associated with lymphedema.
• Patients who have had multiple cellulitic infections may
need to receive prophylactic antibiotics.
• Surgeries including debulking, bridging, and recreation
of lymphatic channels are not commonly performed
because of limited success rates and/or high rates of
recurrence or complications.
Rehabilitation Interventions
• Therapeutic Exercise.
• Therapeutic Modalities.
• Orthotics and Prosthetics.
• Nonpharmacologic Pain Management.
Therapeutic Exercise
• Avoid effects of deconditioning, which include
muscle weakness and atrophy, loss of
cardiopulmonary fitness, and decreased
efficiency of energy metabolism at a cellular
level.
• Improved immune effects  increases in natural
killer cell cytolytic activity, monocyte function,
proportion of circulating granulocytes, and
decrease in duration of neutropenia.
• Improved quality of life.
• Decreased depression and anxiety.
• Reduced fatigue and body weight.
• Enhanced cellular function and cell counts.
• Decreased hospital length of stay.
• Effect on fatigue is favorable but variable
[more immediate (same day) than sustained].
• Weight reduction [Body mass index is directly
proportional to tumor recurrence rates and
all-cause mortality. Obesity is also a risk factor
for lymphedema].
• An appropriate exercise program should be
visited in all cancer patients, with the
exception of those with cachexia.
• Cachexia is defined as more than 25% loss of
lean bone mass or a body mass index 10% or
less below normal range.
• Low- to moderate-intensity home-based
aerobic exercise is associated with reduced
fatigue in women receiving chemotherapy for
breast cancer.
Therapeutic Modalities
• Physical modalities are nonpharmacologic
agents used to produce a therapeutic effect in
tissues.
• They include heat, cold, and electrotherapy.
• They are frequently used to reduce pain,
facilitate stretch, aid in wound care, and
introduce medications such as corticosteroids.
• Heat includes superficial and deep-heating modalities.
• Superficial heat is applied to the surface of the skin to achieve the
maximum tissue temperatures in skin and subcutaneous fat.
• Heat should not be applied to an area of acute trauma and
inflammation and in patients with bleeding diatheses, edema,
peripheral vascular disease, large scars, impaired sensation, or
cognitive or communication deficits that impair their ability to
report pain.
• Superficial heat is applied using heating pads, moist compresses,
hydrocollator packs, paraffin baths, and whirlpool baths.
• Deep heat is directed to heat muscle, tendons, ligaments, or bone.
It is most commonly applied using ultrasound waves.
• Deep-heat modalities are generally avoided to an area where active
regional malignancy exists for fear of causing tumor growth.
• Medication such as 1% lidocaine or
corticosteroids can be applied using
ultrasound.
• This technique is known as phonophoresis,
and is often used to treat tendonitis, bursitis,
scar tissue, neuromas, and adhesions that may
be complications associated with cancer or its
treatment.
• Cold modalities, also known as cryotherapy, are often
used to treat acute pain and inflammation associated
with musculoskeletal disorders, as well as myofascial
pain, spasticity, and emergent care of minor burns.
• Cryotherapy is the treatment of choice for acute
trauma and inflammation.
• It can also be used in patients with bleeding diathesis
and large scars.
• Cryotherapy should not be used in cold-intolerant
patients or those with cryoglobulins, cold
hypersensitivity, and Raynaud disease.
• Transcutaneous electrical nerve stimulation (TENS) is
the most common form of electroanalgesia and enjoys
widespread use although its effectiveness in both acute
and chronic pain conditions remains controversial in
both benign and malignant conditions.
• It has been used to help reduce neuropathic and
nociceptive pain conditions.
• It is applied by placing one to four electrode pads
surrounding the area of pain.
• Not be delivered over or near a malignancy unless it is
being used in patients with terminal cancer.
Orthotics and Prosthetics
• A wheeled walker usually suffices for individuals with balance
impairment or with mild weakness and allows a quicker cadence than
a standard walker, which must be manually lifted between steps.
• However, a standard walker is needed when more severe weakness is
present or when protected weight bearing is needed.
• Patients with foot drop will often benefit from an Ankle Foot Orthosis
[AFO], which helps to restore a more normal gait pattern by allowing
the foot to clear the ground without hiking the hip.
• Knee immobilizers are often useful to control knee flexion in patients
with femoral neuropathy or lumbar plexopathy.
Nonpharmacologic Pain Management
• The primary goal of this approach is to limit the
impact of pain on function and minimize
disability.
• The emphasis of nonpharmacologic pain
management may be of particular benefit in
elderly patients who may not tolerate
medications well.
• Historically, direct tumor spread is thought to
account for most cancer pain.
• Psychological strategies, such as guided imagery,
hypnotherapy, biofeedback, and deep breathing, can be
effective.
• Pain may respond to physical therapy to improve muscle
strength and condition as well as improve joint ROM.
• Physical modalities including heat, cold, and electrotherapy
may be of benefit where appropriate.
• Aerobic exercise has been shown to improve mental
outlook and may result in an improved ability to cope with
pain in a variety of clinical settings including cancer.
• Splinting or assistive devices may help achieve protected
weight bearing.
• Neuropathic pain may benefit from
desensitization measures such as vibration or
tapping.
• Topical agents such as anesthetic (lidocaine)
patches or chili pepper extract–based ointments
(capsaicin) can be tried (the latter should not be
applied to the face).
• Injection of corticosteroid or viscosupplements
into arthritic or inflamed joints may help decrease
pain and improve function in some patients.
• Complementary therapies such as
acupuncture, mind-body techniques, and
massage therapy may help with a variety of
cancer and cancer treatment-related
symptoms including pain.
• In severe cases, neurosurgical procedures,
such as intrathecal pumps, dorsal column
stimulation, and neuroablative procedures
(neurectomy, rhizotomy, cordotomy) can be
considered.
Thank You

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Rehabilitation of the cancer patient

  • 1. Rehabilitation of the Cancer Patient By Dr. Ihab Samy Lecturer of Surgical Oncology National Cancer Institute – Cairo, Egypt 2014
  • 2. • 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.
  • 3. The Rehabilitation Team • Physiatrist. • Physical and Occupational Therapist.
  • 4. Complications of Cancer and its Treatment • Direct Effects of Cancer. • Paraneoplastic Effects. • Chemotherapy. • Radiotherapy. • Surgery. • Thromboembolism.
  • 5. Neuromuscular Complications of Cancer and Cancer Treatment • Brain Dysfunction. • Spinal Cord Dysfunction. • Peripheral Nervous System Dysfunction. • Myopathy.
  • 6. Evaluation of Neuromuscular Disorders • History and physical examination. • Laboratory tests. • MRI is usually the modality of choice for imaging the peripheral nervous system. • Intravenous gadolinium is useful in the identification of peripheral nerve and plexus tumors, leptomeningeal disease, and intramedullary spinal cord tumors as well as to differentiate scar from tumor, exclude infection, and identify radiation changes. • Electrodiagnostic testing with nerve conduction studies and needle electromyography is often extremely useful in clarifying the etiology of symptoms.
  • 7. Treatment of Neuromuscular Disorders • Can be highly specific (injection of a median mononeuropathy at the wrist) or extremely general (prescription of opioids for pain). • Specific treatments depend largely on accuracy of diagnosis of the underlying disorder. • For instance, severe and disabling hand pain may be from a CNS cause (thalamic or funicular pain), radiculopathy, plexopathy, a polyneuropathy, or a mononeuropathy such as the median mononeuropathy responsible for carpal tunnel syndrome.
  • 8. Bony Metastases • Bone metastases are a common complication of cancer, found to occur in 69% of patients with advanced breast cancer in one study. • The primary risk of bony metastases is fracture, with subsequent pain and disability. • Long-bone fracture, in particular, poses a significant risk to the patient as pain may be severe and ambulation and ADLs compromised. • Patients with bony metastatic disease may require protected weight bearing, either to avoid further bony injury (e.g., in the healing phase after radiation therapy and/or surgical stabilization of pathologic fracture) or to assist in pain control.
  • 9. • Mirels proposed a scoring system to quantify the risk of sustaining a pathologic fracture through a metastatic lesion in a long bone based on the site (upper limb, lower limb, peritrochanteric), pain (mild, moderate, functional), lesion type (blastic, mixed, lytic), and size relative to the diameter of affected bone (less than one-third, one-third to two- thirds, greater than two-thirds). • Each of these four variables was given a score of 1, 2, or 3 according to the degree of risk. • It was determined that lesions with a cumulative score of 7 or lower could be safely irradiated without risk of fracture, but lesions with a score of 8 or higher required prophylactic internal fixation prior to irradiation.
  • 10. Spinal cord instability • The three-column model of Denis is often used in assessing stability. • This model divides the spine into anterior (anterior longitudinal ligament, anterior half of vertebral body and disk), middle (posterior half of vertebral body and disk, and posterior longitudinal ligament), and posterior (posterior elements) columns. • The lesion is considered unstable if two or more columns are involved or, in some cases, if the middle column alone is involved.
  • 11. • Bilsky has developed a conceptual framework to guide therapeutic decision making with respect to surgical, radiotherapeutic, and chemotherapeutic options for spine tumors. • This tool for individual patient assessment is known as the “NOMS” criteria and is based on an evaluation of the neurologic (N), oncologic (O), mechanical instability (M), and systemic disease (S) status of the patient. • In this model, mechanical instability is defined simply as movement-related pain referable to a focus of tumor. • Instability pain is distinguished from biologic or tumor- related pain in that is does not respond to steroids.
  • 12. Lymphedema • Lymphedema is the abnormal accumulation of protein- rich lymph in an extremity, the trunk, or face. • If untreated, the accumulation of protein-rich lymphatic fluid can result in fibrotic deposition with progressive sclerosis further worsening the lymphedema and ultimately resulting in elephantiasis. • Primary lymphedema is due to aplastic or hypoplastic development of the lymphatics, whereas secondary lymphedema is usually the result of infection, tumor, or lymphatic injury.
  • 13. • Lymphedema is not usually a painful condition but can cause a feeling of extremity heaviness or constriction. • Improved cancer treatment approaches diminish but do not prevent the development of lymphedema. • Thus, at-risk patients should be educated about lymphedema and its complications, including cellulitis. • Risk-reduction strategies include skin care and protection, avoiding venipuncture, blood pressure measurements, or constricting clothing to the affected region.
  • 14. • Manual therapies are the standard of care for lymphedema. • Complex decongestive therapy (CDT), a combination of manual therapies, is performed by certified lymphedema therapists who have specialty training beyond their core therapy backgrounds. • Phase I CDT is used to treat the initial edema and exacerbations. It combines manual lymphatic drainage and compression bandaging. • Manual lymphatic drainage is a highly specialized gentle message technique to enhance the distal to proximal lymph transport. • This is performed 5 to 7 days a week. Following each session, the limb/region is wrapped with multiple layers of short-stretch bandages and exercises are performed. • The bandages are worn approximately 21 to 23 hours per day, until the next session. Phase I continues until maximal volume reduction is achieved.
  • 15. • A compression garment is prescribed during the period of transitioning from phase I to phase II of CDT. Garments vary in pressure, design, and price. • Resistance exercise including weight lifting does not increase the risk of or exacerbate symptoms of lymphedema. • It is advisable that resistive strength training programs should be performed while wearing a compression garment. • Comprehensive treatment of lymphedema should address weight control because of the association between increased body mass and lymphedema.
  • 16. • Diuretics may have a role in treating lymphedema of mixed origin (i.e., cardiogenic and lymphedema) but are not recommended for long-term use. • Antibiotics including second-generation cephalosporins and penicillins are commonly used to treat cellulitis associated with lymphedema. • Patients who have had multiple cellulitic infections may need to receive prophylactic antibiotics. • Surgeries including debulking, bridging, and recreation of lymphatic channels are not commonly performed because of limited success rates and/or high rates of recurrence or complications.
  • 17. Rehabilitation Interventions • Therapeutic Exercise. • Therapeutic Modalities. • Orthotics and Prosthetics. • Nonpharmacologic Pain Management.
  • 18. Therapeutic Exercise • Avoid effects of deconditioning, which include muscle weakness and atrophy, loss of cardiopulmonary fitness, and decreased efficiency of energy metabolism at a cellular level. • Improved immune effects  increases in natural killer cell cytolytic activity, monocyte function, proportion of circulating granulocytes, and decrease in duration of neutropenia.
  • 19. • Improved quality of life. • Decreased depression and anxiety. • Reduced fatigue and body weight. • Enhanced cellular function and cell counts. • Decreased hospital length of stay. • Effect on fatigue is favorable but variable [more immediate (same day) than sustained]. • Weight reduction [Body mass index is directly proportional to tumor recurrence rates and all-cause mortality. Obesity is also a risk factor for lymphedema].
  • 20. • An appropriate exercise program should be visited in all cancer patients, with the exception of those with cachexia. • Cachexia is defined as more than 25% loss of lean bone mass or a body mass index 10% or less below normal range. • Low- to moderate-intensity home-based aerobic exercise is associated with reduced fatigue in women receiving chemotherapy for breast cancer.
  • 21. Therapeutic Modalities • Physical modalities are nonpharmacologic agents used to produce a therapeutic effect in tissues. • They include heat, cold, and electrotherapy. • They are frequently used to reduce pain, facilitate stretch, aid in wound care, and introduce medications such as corticosteroids.
  • 22. • Heat includes superficial and deep-heating modalities. • Superficial heat is applied to the surface of the skin to achieve the maximum tissue temperatures in skin and subcutaneous fat. • Heat should not be applied to an area of acute trauma and inflammation and in patients with bleeding diatheses, edema, peripheral vascular disease, large scars, impaired sensation, or cognitive or communication deficits that impair their ability to report pain. • Superficial heat is applied using heating pads, moist compresses, hydrocollator packs, paraffin baths, and whirlpool baths. • Deep heat is directed to heat muscle, tendons, ligaments, or bone. It is most commonly applied using ultrasound waves. • Deep-heat modalities are generally avoided to an area where active regional malignancy exists for fear of causing tumor growth.
  • 23. • Medication such as 1% lidocaine or corticosteroids can be applied using ultrasound. • This technique is known as phonophoresis, and is often used to treat tendonitis, bursitis, scar tissue, neuromas, and adhesions that may be complications associated with cancer or its treatment.
  • 24. • Cold modalities, also known as cryotherapy, are often used to treat acute pain and inflammation associated with musculoskeletal disorders, as well as myofascial pain, spasticity, and emergent care of minor burns. • Cryotherapy is the treatment of choice for acute trauma and inflammation. • It can also be used in patients with bleeding diathesis and large scars. • Cryotherapy should not be used in cold-intolerant patients or those with cryoglobulins, cold hypersensitivity, and Raynaud disease.
  • 25. • Transcutaneous electrical nerve stimulation (TENS) is the most common form of electroanalgesia and enjoys widespread use although its effectiveness in both acute and chronic pain conditions remains controversial in both benign and malignant conditions. • It has been used to help reduce neuropathic and nociceptive pain conditions. • It is applied by placing one to four electrode pads surrounding the area of pain. • Not be delivered over or near a malignancy unless it is being used in patients with terminal cancer.
  • 26. Orthotics and Prosthetics • A wheeled walker usually suffices for individuals with balance impairment or with mild weakness and allows a quicker cadence than a standard walker, which must be manually lifted between steps. • However, a standard walker is needed when more severe weakness is present or when protected weight bearing is needed. • Patients with foot drop will often benefit from an Ankle Foot Orthosis [AFO], which helps to restore a more normal gait pattern by allowing the foot to clear the ground without hiking the hip. • Knee immobilizers are often useful to control knee flexion in patients with femoral neuropathy or lumbar plexopathy.
  • 27.
  • 28. Nonpharmacologic Pain Management • The primary goal of this approach is to limit the impact of pain on function and minimize disability. • The emphasis of nonpharmacologic pain management may be of particular benefit in elderly patients who may not tolerate medications well. • Historically, direct tumor spread is thought to account for most cancer pain.
  • 29. • Psychological strategies, such as guided imagery, hypnotherapy, biofeedback, and deep breathing, can be effective. • Pain may respond to physical therapy to improve muscle strength and condition as well as improve joint ROM. • Physical modalities including heat, cold, and electrotherapy may be of benefit where appropriate. • Aerobic exercise has been shown to improve mental outlook and may result in an improved ability to cope with pain in a variety of clinical settings including cancer. • Splinting or assistive devices may help achieve protected weight bearing.
  • 30. • Neuropathic pain may benefit from desensitization measures such as vibration or tapping. • Topical agents such as anesthetic (lidocaine) patches or chili pepper extract–based ointments (capsaicin) can be tried (the latter should not be applied to the face). • Injection of corticosteroid or viscosupplements into arthritic or inflamed joints may help decrease pain and improve function in some patients.
  • 31. • Complementary therapies such as acupuncture, mind-body techniques, and massage therapy may help with a variety of cancer and cancer treatment-related symptoms including pain. • In severe cases, neurosurgical procedures, such as intrathecal pumps, dorsal column stimulation, and neuroablative procedures (neurectomy, rhizotomy, cordotomy) can be considered.