1) Physical therapy can help manage common cancer symptoms like breathlessness, fatigue, and pain through various interventions including breathing retraining, graded exercise, positioning, modalities, and therapeutic exercises.
2) Assessment of symptoms is important for physical therapy, using tools like VAS, Borg scale, and evaluating factors like respiratory function, impairment, and impact on daily activities.
3) Management of symptoms involves a multifaceted approach including medical treatment, non-pharmacological interventions, education, relaxation, energy conservation techniques, and addressing psychosocial factors. The goals are to prevent impairments, maintain function, and improve quality of life.
Presented and recorded at the Australian Pain Society Annual Scientific Meeting, April 2021 virtual event
Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM
Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. Melanie Lovell compares levels of suffering in people with cancer-related pain versus non-cancer chronic pain, highlighting differential meanings of existential or spiritual distress and mood dysfunction. Lovell outlines management approaches to cancer pain and suffering that are not responsive to analgesia, such as meaning- or peace-centred therapies.
Session Objectives:
At the end of the session, attendees will know:
– Common meanings of cancer-related pain and what meanings influence specific patient outcomes
– Common meanings of suffering in cancer-related pain and the relationship between these meanings and non-cancer chronic pain experience and mood dysfunction
– Effective approaches to diagnosis and management of cancer-related pain symptoms, including interventions based on meaning
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice
Presenter Duties
Chair: Dr Simon van Rysewyk, University of Tasmania
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Renee Xu, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Presented and recorded at the Australian Pain Society Annual Scientific Meeting, April 2021 virtual event
Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM
Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. Melanie Lovell compares levels of suffering in people with cancer-related pain versus non-cancer chronic pain, highlighting differential meanings of existential or spiritual distress and mood dysfunction. Lovell outlines management approaches to cancer pain and suffering that are not responsive to analgesia, such as meaning- or peace-centred therapies.
Session Objectives:
At the end of the session, attendees will know:
– Common meanings of cancer-related pain and what meanings influence specific patient outcomes
– Common meanings of suffering in cancer-related pain and the relationship between these meanings and non-cancer chronic pain experience and mood dysfunction
– Effective approaches to diagnosis and management of cancer-related pain symptoms, including interventions based on meaning
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice
Presenter Duties
Chair: Dr Simon van Rysewyk, University of Tasmania
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Renee Xu, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Narrative medicine as a tool to detect the burden of illness: an application to myelofibrosis. Progetto realizzato da ISTUD per Novartis. Presentazione di Maria Giulia Marini.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
End of life issues in advanced heart failure manalo palliative careDr. Liza Manalo, MSc.
Why aren’t countries accountable to commitment on end of life (#EOL) care for vulnerable people?
For lack of know-how. This presentation aims to teach cardiologists how to provide good palliative care to their patietnts.
June 1, 2018
Historically and across societies people with disabilities have been stigmatized and excluded from social opportunities on a variety of culturally specific grounds. These justifications include assertions that people with disabilities are biologically defective, less than capable, costly, suffering, or fundamentally inappropriate for social inclusion. Rethinking the idea of disability so as to detach being disabled from inescapable disadvantage has been considered a key to twenty-first century reconstruction of how disablement is best understood.
Such ‘destigmatizing’ has prompted hot contestation about disability. Bioethicists in the ‘destigmatizing’ camp have lined up to present non-normative accounts, ranging from modest to audacious, that characterize disablement as “mere difference” or in other neutral terms. The arguments for their approach range from applications of standards for epistemic justice to insights provided by evolutionary biology. Conversely, other bioethicists vehemently reject such non-normative or “mere difference” accounts, arguing instead for a “bad difference” stance. “Bad difference” proponents contend that our strongest intuitions make us weigh disability negatively. Furthermore, they warn, destigmatizing disability could be dangerous because social support for medical programs that prevent or cure disability is predicated on disability’s being a condition that it is rational to avoid. Construing disability as normatively neutral thus could undermine the premises for resource support, access priorities, and cultural mores on which the practice of medicine depends.
The “mere difference” vs. “bad difference” debate can have serious implications for legal and policy treatment of disability, and shape strategies for allocating and accessing health care. For example, the framing of disability impacts the implementation of the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, and other legal tools designed to address discrimination. The characterization of disability also has health care allocation and accessibility ramifications, such as the treatment of preexisting condition preclusions in health insurance. The aim of this conference was to construct a twenty-first century conception of disablement that resolves the tension about whether being disabled is merely neutral or must be bad, examines and articulates the clinical, philosophical, and practical implications of that determination, and attempts to integrate these conclusions into medical and legal practices.
Learn more: http://petrieflom.law.harvard.edu/events/details/2018-petrie-flom-center-annual-conference
Narrative medicine as a tool to detect the burden of illness: an application to myelofibrosis. Progetto realizzato da ISTUD per Novartis. Presentazione di Maria Giulia Marini.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
End of life issues in advanced heart failure manalo palliative careDr. Liza Manalo, MSc.
Why aren’t countries accountable to commitment on end of life (#EOL) care for vulnerable people?
For lack of know-how. This presentation aims to teach cardiologists how to provide good palliative care to their patietnts.
June 1, 2018
Historically and across societies people with disabilities have been stigmatized and excluded from social opportunities on a variety of culturally specific grounds. These justifications include assertions that people with disabilities are biologically defective, less than capable, costly, suffering, or fundamentally inappropriate for social inclusion. Rethinking the idea of disability so as to detach being disabled from inescapable disadvantage has been considered a key to twenty-first century reconstruction of how disablement is best understood.
Such ‘destigmatizing’ has prompted hot contestation about disability. Bioethicists in the ‘destigmatizing’ camp have lined up to present non-normative accounts, ranging from modest to audacious, that characterize disablement as “mere difference” or in other neutral terms. The arguments for their approach range from applications of standards for epistemic justice to insights provided by evolutionary biology. Conversely, other bioethicists vehemently reject such non-normative or “mere difference” accounts, arguing instead for a “bad difference” stance. “Bad difference” proponents contend that our strongest intuitions make us weigh disability negatively. Furthermore, they warn, destigmatizing disability could be dangerous because social support for medical programs that prevent or cure disability is predicated on disability’s being a condition that it is rational to avoid. Construing disability as normatively neutral thus could undermine the premises for resource support, access priorities, and cultural mores on which the practice of medicine depends.
The “mere difference” vs. “bad difference” debate can have serious implications for legal and policy treatment of disability, and shape strategies for allocating and accessing health care. For example, the framing of disability impacts the implementation of the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, and other legal tools designed to address discrimination. The characterization of disability also has health care allocation and accessibility ramifications, such as the treatment of preexisting condition preclusions in health insurance. The aim of this conference was to construct a twenty-first century conception of disablement that resolves the tension about whether being disabled is merely neutral or must be bad, examines and articulates the clinical, philosophical, and practical implications of that determination, and attempts to integrate these conclusions into medical and legal practices.
Learn more: http://petrieflom.law.harvard.edu/events/details/2018-petrie-flom-center-annual-conference
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Out-patient Primary and Specialty Palliative CareMike Aref
Presentation on primary and specialty palliative care, covering what is palliative care, basics of primary palliative care including pain and symptom management, and referral criteria for out-patient specialty palliative care.
LRI05 - Self Help for Distress in Cancer - Is It Time For An RCT [Oct 2005]Alex J Mitchell
This is an academic presentation from 2005 outlining the case for a randomized controlled trial of a self-help programme to help people deal with distress and depression following the diagnosis of cancer
Pain Management in the Context of an Opioid Epidemic: Considerations and Tool...VITAS Healthcare
This presentation details how to conduct a comprehensive pain assessment, considerations when prescribing analgesics, and when opioids may be appropriate.
Incidence and demography of low back pain in physiotherapy OPD a retrospective data driven analysis and review of literature about suggested strategies for low back pain management.
2. 2
參考資料
1. Michael DS, Michael WO. editors. Cancer Rehabilitation
Principles and Practice. New York: Demos Medical Publishing 2009
2. Jane R, Karen R, Nicola M, Jill C, Sian L, editors. Rehabilitation in
Cancer Care. Wiley-Blackwell 2008
3. Hermann D. Rehabilitation and palliation of Cancer patients.
Springer-Verlag France, Paris 2007
4. Rehabilitation Oncology ( Oncology Section American Physical
Therapy Association )
5. Physiotherapy Research International
6. Physical Therapy
7. Palliative Medicine
3. 3
“Quality of Life”
This is part of Comprehensive Cancer Care
Rehab Goals Based on Many Factors
Prognosis
Treatment
Co-morbidity / Impairment
Pain
Psychosocial Distress
Socioeconomic Background
Personal “Re-prioritization”
4. 4
Continuous Redefining of Treatment
Success and Functional Goals
Prognosis:
relative to stage / type of static or dynamic lesion(s)
Concurrent anti-neoplastic treatment
Medical co-morbidity – functional impairments
Degree of pain and psychosocial distress
Socioeconomic background – domestic and financial
resources to facilitate participation in goals
Personal “re-prioritization” – Symptom versus Disease
Oriented Care
5. 5
Avoid functional morbidity resulting
from cancer and/or its treatment
Stretch irradiated soft tissue
Protect skin with chemotherapy-induced
neuropathies
Aggressive post-thoracotomy chest PT and
shoulder range of motion
Prevent pathologic fractures with braces
6. 6
Restore pre-morbid level of function when
long-term impairment anticipated
Post-axillary dissection -- preserve ROM and
strength of shoulder; prevent extremities-edema
Post-BMT – aerobic reconditioning
Post-XRT of bone – prevent pathologic fracture
with mobility / ADL retraining
7. 7
Maximize function when long-term
impairment, disability, and/or handicap
result from cancer and its treatment
– Gait retraining after limb salvage
– Cognitive remediation after brain tumor
resection / irradiation
– Optimization of shoulder function after
Spinal Accessory Nerve sacrifice
8. 8
持續進行
• Staging work-up repeated
• Further treatment based on, age, stage, type of malignancy, prior
treatment response, patient interest in anti-neoplastic therapy,
potential for cure
• Aggressive high-dose CTX/XRT with high incidence of cumulative
toxicity (cardiac, neurological, wound healing, etc.)
• Preserve: mobility, community integration, and autonomous self-care:
– W/C or scooter, assistive devices
– Resistive exercise
– Energy conservation / Compensatory strategies
– Environmental control devices
9. 9
持續進行 (ㄧ)
• Selection factors
Severity of disability, extent and activity of disease,
family physical and emotional capability to participate
in care, prognosis
Benefits of continued rehab balanced against
progressive nature of disease
Flexible goals/duration due to evolving needs of the
patient and family
Emotional, functional, and spiritual support
10. 10
持續進行 (二)
• Integrated program based on preventive, restorative, supportive,
and palliative needs: 80% of treated patients demonstrated
measurable benefits and 68% showed moderate or marked
improvement or became fully independent
• Goal: Predict & properly treat those at greatest risk for
functional decline ….. To add ‘life to years’, not just ‘years’
• Increase aerobic condition, strength, flexibility, and mechanical
efficiency effect immune status and/or cytokine regulation
11. 11
Breathlessness
A subjective experience of breathing discomfort …interaction
physiological, psychological, social and environmental factors, induce
secondary physiological and behavioral responses. ( American Thoracic Society )
Cancer-related breathlessness
the cancer itself
cancer treatment
concurrent conditions: COPD, heart failure and
systemic illness
individual perception: anxiety, behavioral response
12. 12
Causes of breathlessness
Pulmonary : loss of functional lung tissue / M
obstruction of airway / M
loss of lung elasticity / M
Non-pulmonary : weakness of respiratory muscles / M
elevation of the diaphragm / M
defects of the circulatory system / M,C
anemia / C
metabolic disorders and renal
disease / C
anxiety or fear / E
* M: mechanical, C: chemical, E: emotional factors
13. 13
Assessment of breathlessness
• Medical and physical, social and occupational,
spiritual and psychological assessment
• Observation skills: respiratory function
breathing rate, chest wall movement, breath sounds, posture
( kyphosis and scoliosis ), frequency of sighing / yawning,
surgery
• Visual analogue scale ( VAS )
• Modified Borg scale ( MBS )
• Numeric rating scale ( NRS )
14. 14
Breathlessness management
• Medical intervention: bronchodilators, corticosteroids,
benzodiazepine, morphine,O2, nebulized saline
• Non-pharmacological intervention: individual patient’s
needs ( such as breathing retaining, positioning and
carefully graded exercise ),
cognitive-behavioral approaches ( education, relaxation
and improving symptom awareness ),
alter environments ( energy conservation / modification
ADL )
16. 16
Cancer-Related Fatigue
Distress persistent, subjective sense of tiredness or exhaustion
related to cancer or cancer treatment ( NCCN, National Comprehensive Cancer Network, 2006 )
CRF: physical, psychological and cognitive components
No energy, tired, exhausted, poor concentration, memory loss,
irritable, ….
Direct effects of the tumor, treatment side effects,
anaemia, pain or deconditioning, psychosocial factors such as
anxiety and depression
17. 17
CRF- assessment
International Classification of Diseases-10
ICD-10, proposing 11 symptoms of CRF ( Cella et.al.1998 )
*Significant fatigue, diminished energy or increased need to
rest, disproportionate to any recent change in activity level
• Complains of generalised weakness or limb heaviness
• Diminished concentration or attention
• Decreased motivation or interest in usual activities
• Insomnia or hypersomnia
• Experience of sleep as unrefresing or non-restoratives
18. 18
CRF- assessment ( 1 )
International Classification of Diseases-10
ICD-10, proposing 11 symptoms of CRF ( Cella et.al.1998 )
• Perceived need to struggle to overcome inactivity
• Marked emotional reactivity ( e.g. sadness, frustration and
irritability ) to feeling fatigued
• Difficulty in completing daily tasks attributed to feeling fatigued
• Perceived problems with short-term memory
• Post-exertional malaised lasting several hours
• 6/11, 2wks/month,*, usual function, ca/ca t’x, not psychiatric
19. 19
The role of physiotherapy in the
management of CRF
• Muscle atrophy and decreased stamina are marked
components of CRF.( NCCN,2006;Mock,2004;Tomkins Stricker et al.,2004)
• Exercise has the strongest evidence base and is reported
as the most effective non-pharmacological intervention.
• Exercise program begins when the patients start
adjuvant therapy and lasts throughout the treatment.
• Low-to-moderate intensity ( 50-70%HRmax,11-13RPE )
• Progressive, Aerobic 15-30mins/day, 3-5days/week
• Exercise diary, session mode, intensity, duration, target
heart rate, symptoms experienced.
20. 20
CRF Clinical Practice Guidelines
Three main stages / physiotherapy & exercise ( NCCN,2006 )
During active treatment
high levels of fatigue / chemotherapy first 72 hours / radiotherapy course
recovery time (should be monitored) ≦30mins
swimming*
When active treatment if completed and long-term follow-up
CRF can be at its peak post-treatment / especially no exercise during t’x
short- / long-term goals 3- / 6-month, low-to-moderate intensity, aerobic / resistive,
targeting weakened areas, gradually ↑ frequency、duration、intensity, motivation /
group therapy
At end of life
progression of disease, pain, medication, depression, anemia, poor nutrition, sleep
disturbance, PT aim maintain mobility and independence /close consultation
21. 21
Cancer Pain
• Pain “ an unpleasant sensory and emotional experience
associated with actual or potential tissue damage” IASP
( international association for the study of pain )
• Cancer pain “ ..... Composed of acute pain, chronic pain, tumor-
specific pain, treatment-related pain, …psychological
responses of distress and suffering, …”
1. pain directly due to the cancer, e.g. bony metastatic disease
2. pain indirectly due to the cancer, e.g. spinal nerve root compression
by a tumor
3. pain secondary to cancer treatment, e.g. peripheral neuropathy
secondary to chemotherapy
4. pain not related to cancer or its treatment but which coexists e.g.
painful OA joint
22. 22
Cancer Pain ( 1 )
• Patients with cancer often have multiple pains and
multiple causes of pain.
• Coexist with other symptoms :
fatigue
nausea and vomiting
breathlessness
deconditioning (↓ social activity / support )
anxiety ( hopelessness, negative perception )
fear and depression ( pain experience, indicate
further damage / worse of disease )
23. 23
Cancer Pain - Assessment
• Description of the pain
severity, irritability, nature
terminal disease and severe pain vs no evidence of
cancer but chronic cancer-treatment-related pain
• Responses to the pain
effective pain relief as quickly as possible
cognitive-behavioral therapy to improve function
• Impact of pain on the patient’s life
25. 25
Management of cancer-related pain
The majority of cancer pain is due to tumor effects.
bone metastases : 8 Gy / radiation fraction
Medical approaches
Pharmacological approaches
Non-opioids
Opioids
Adjuvants
Radiotherapy
Physical therapy interventions
26. 26
Management of cancer-related pain ( 1 )
• Physical therapy interventions
relieve pain
improve function
improve quality of life
physical, psychosocial, lifestyle adjustment
/ educational approaches
27. 27
Management of cancer-related pain ( 2 )
• Physical approaches
therapeutic exercise
graded and purposeful activity
postural re-education
massage and soft-tissue mobilization
transcutaneous electrical nerve stimulation ( TENS )
heat and cold
28. 28
Management of cancer-related pain ( 3 )
Resulting in
Causing increased
Reduces
Causing loss of
Activity
Stiffness
Function
Pain
29. 29
American Physical Therapy Association’s
Guide to Physical Therapist Practice
• A physical therapist may use physical agents
and modalities to
• decrease neural compression
• decrease pain and swelling
• decrease soft tissue and circulatory
disorders
30. 30
American Physical Therapy Association’s
Guide to Physical Therapist Practice
• A physical therapist may use physical agents
and modalities to
• enhance airway clearance
• enhance movement performance
• enhance or maintain physical performance
31. 31
American Physical Therapy Association’s
Guide to Physical Therapist Practice
• A physical therapist may use physical agents and
modalities to
• improve joint mobility
• improve tissue perfusion
• prevent or remediate impairments、 functional
limitations、disabilities to improve physical
functions
• reduce edema
• reduce risk factors and complications
32. 32
Physical agents and modalities
Physical agents
Increase
tissue extensibility
rate of wound healing
Modulate pain
Reduce
soft tissue swelling or inflammation
Remodel scar tissue
Treat skin conditions
34. 34
Physical agents and modalities ( 2 )
• Mechanical modalities
improve circulation
increase range of motion
modulate pain
decrease and control edema
stabilize an area that requires temporary
support
38. 38
Physical agents and modalities ( 6 )
• Indications
• Precautions
• Contraindications
General precautions and absolute contraindications
*Each patient must be carefully considered on an
individual basis.*
39. 39
Physical agents and modalities ( 7 )
• Contraindications
Patient-centered surveys
1.cryotherapy to reduce the severity of oral
mucositis (C/T)
2.TNES electrodes or an electrical stimulation
band placed acupuncture points to reduce the
incidence and severity of nausea and vomiting
(C/T)
40. 40
Therapeutic Exercise in Cancer
• Goals
• ↓risk, impairments, ↑function, fitness, well-
being
preventive
restorative
supportive
palliative
41. 41
Therapeutic Exercise in Cancer ( 1 )
• Strengthening Exercise
• Aerobic Exercise
• Range of Motion and Flexibility
• Coordination and Balance Training
• Chest Physical Therapy
• Considerations
Fatigue
Pain