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Title: File


1
File 4
Oncology Rehabilitation Web-based Learning for
Physical Therapists Who Provide Rehabilitation
to Patients with Breast Cancer
  • Breast Cancer Rehabilitation

2
Breast Cancer Rehabilitation
  • The physical therapy profession is the ideal
    medical profession to deal with all aspects of
    establishing and following a safe and realistic
    mobility and strengthening plan of treatment for
    the breast cancer patient. This professional has
    the ability to decipher all medical information
    presented by the physician and diagnostic studies
    presented concerning the status of the breast
    cancer patient.

3
  • Role of the physical therapist when
  • treating breast cancer patients
  • Educate public of early detection
  • Educate the patient, family, physician and other
    health care providers of the need for
    rehabilitation for the patient diagnosed with
    breast cancer.
  • Follow a safe and functional rehabilitation
    program with realistic goals for each individual
  • Help improve Quality of Life
  • Promote care to decrease side effects
  • Improve patients outlook on recovery
  • Breast Cancer FYI Resources suggests, Consider
    at least one session with a physical therapist if
    you have any kind of breast cancer related
    surgery.

4
America Cancer Society, Surveillance Research,
2005 Estimated Breast Cancer In situ and Invasive
for Age Groups
  • AGE In Situ
    Invasive
  • 9,510
  • 40 and older 56,890
    201,730
  • Under 50 13,760
    45,780
  • 50 and older 44,730
    165,460
  • Under 65 37,040
    123,070
  • 65 and older 21,450
    88,170
  • ALL AGES 58,490
    211,240

(American Cancer Society, 2005)
5
THE REFERRAL FOR PHYSICAL THERAPY
6
Who is going to make the therapy referral?
  • General Practitioner
  • Internist
  • Surgeon
  • Plastic Surgeon
  • Oncologist
  • Radiation Oncologist
  • Radiologist
  • Psychiatrist
  • Pathologist
  • Nurse
  • Social Worker
  • Psychologist
  • Nutritionist
  • Chaplain
  • Family Member
  • Friend
  • Patient
  • Physical Therapist

Many choices and potential referral sources.
7
Despite potential benefits, referrals of cancer
patients for rehabilitation are often made
needlessly late or not at all.
Physician Text CANCER
MEDICINE
  • Physical therapist may need to solicit the
    benefits of cancer rehabilitation to physicians,
    other cancer team members and patients.

(Ragnarsson, 2003)
8
Could breast cancer rehabilitation be your Niche?
9
Niche
  • A place, employment, status or activity for which
    a person or thing is best fitted.
  • A specialized market

(Websters Universal Encyclopedic Dictionary,
2002)
10
What is your niche?
  • Oncology
  • Orthopedics
  • Athletics
  • Temporomandibular Dysfunction's
  • Urinary Incontinence
  • Pediatrics
  • Soft tissue work
  • Relaxation Programs
  • Administration

11
Determining your Niche
12
Make your own niche
Cancer Center
  • S Search
  • U Understand
  • C Confidence
  • C Challenge
  • E Excitement
  • S Support
  • S Succeed

Rehabilitation
13
Health Care ReformICD-9-CM Codes
14
  • HEALTH CARE REFORM

Wellness reduces Illness Wellness decreases
expense
15
Key Issues ofHealth Care Reform
  • Access to Care
  • Quality of Care
  • Prevention
  • Standard Benefits Package
  • Cost Containment
  • Education and Research
  • National Boards
  • State Autonomy
  • Workers Compensation

(APTA, 1994)
16
Helpful breast cancer ICD 9-CM codes
  • Fatigue limiting ADLs.780.7
  • Nausea limiting ADLs....787.0
  • Generalized pain limiting function780.9
  • Weakness limiting ADLs...780.7
  • Muscular wasting, disuse atrophy728.2
  • Difficulty walking..719.7
  • Lymphedema....457.1
  • Breast Pain..611.71
  • Adhesive Capsulitis....726.0

(McCormack, 2002)
17
  • For all of the expensive medical interventions,
    insurance companies should realize the benefit of
    physical therapy, to promote wellness and
    decrease sickness during and after treatment
    programs for breast cancer.
  • Mammogram
  • Biopsy
  • Pathology
  • Lumpectomy
  • Radiation
  • Modified Radical Mastectomy
  • Reconstruction
  • Chemotherapy
  • Rehabilitation
  • Insurance reimbursement for program services is
    usually very good.
  • All coding should be assigned to a patients
    functional diagnosis rather
  • than the oncology diagnosis. The diagnosis should
    be based on whatever
  • functional activities are limited and what is
    creating the limitation.

  • (McCormack, 2002)

18
Psychology and Support Issues
19
  • ARE YOU THE THERAPIST TO TREAT THE PATIENT
    DIAGNOSED WITH BREAST CANCER
  • The progress of your program will depend greatly
    upon your ability to motivate your patient.

20

COPING DISCS
In each dish place the name of a family member
that you could live without.Pretty tough!
Just an idea of how cancer patients and families
may think.
21
  • Your patient is coping with
  • Illness
  • Changes
  • Next holiday could be last
  • Medical environment and caregivers
  • Self Image
  • Relations coping with illness
  • Future
  • If in remission.....When will it return?

22
Common fears of cancer patients
The 5 Ds
  • Death
  • Disfigurement
  • Disability
  • Dependence
  • Disruption of Relationships

(Source unknown)
23
Criteria for Depression
  • Persistent low mood (4 weeks)
  • Inability to enjoy oneself
  • Repeated or early waking
  • Impaired concentration
  • Guilt, self blame or burden
  • Irritability and anger for no reason
  • Loss of interest
  • Agitation
  • Suicidal

24
How patients and families may cope
  • Laughter can keep you from feeling bad.
  • Notice those that might be worse off.
  • Fight with those around.
  • Important to have knowledge of illness.
  • Refuse to believe that it can happen.
  • Turn to others for support.
  • Stay busy to decrease time to worry.
  • Go over problems in mind.
  • Avoid illness as topic of conversation.
  • New faith in this experience.

(Snyder, 1992)
25
  • SELF ESTEEM
  • WIGS that guarantee the hair will look so much
    like the original hair that the patient is the
    only one to know it is a wig.
  • NATURAL
  • 1-800-272-2424
  • HAT DESIGNS for hair loss.........
    1-215-247-8777

26
  • CAREGIVERS (Survey of 225 Families)
  • 49...Experienced prolonged depression
  • 74...Found unknown inner strength
  • 69...Frustrated
  • 43...Sad with experience
  • 39...Associated care with love
  • 46...Felt appreciated
  • 30...Felt taken for granted
  • Caregiving and Cancer, should be reviewed to
    promote this challenge at
  • http/www.utmb.edu/insights/Outreach/Caregiving_an
    d_Cancer ppt

27
  • American Cancer Society (ACS)
    1-800-ACS-2345
  • National Cancer Institute (NCI)
    1-800-4-CANCER
  • Equal Employment Commission
    1-800-872-3362
  • State Dept. of Vocational Rehab.
  • Support Guide
  • National Lymphedema Network
    1-800-541-3259
  • Job Accommodation 1-800-526-7234
  • National Coalition for Cancer Survivorship
    1-301-650-8868

28
  • AMERICANS WITH DISABILITIES ACT

Legal Protection For Cancer Patients Against
Employment Discrimination
29
Dealing with Pain
30
PAIN Be prepared to deal with patients
reporting pain and inform their physicians of the
benefits of exercise.

31
  • PAIN
  • Agency for Health Care Policy and Research
    Guidelines for Cancer Pain
  • Promotes communication between the patient and
    the health care provider dealing with pain.
  • The American Cancer Society estimates that 70 to
    90 of cancer patients will experience pain
    during some phase of their disease or treatment.

(www.mskcc.org, 1999)
32
PAIN
  • Document location and description of pain.
  • Rate worse pain, using a 1-10 scale.
  • Time pain is increased and decreased.
  • What increases and decreases pain.
  • This documentation will allow you to objectively
    assess changes in pain.

(Hassler, 1994)
33
Why cancer pain?
  • Biological mechanism
  • Bone destruction
  • Obstruction
  • Infiltration or Compression
  • Infiltration or Distention
  • Inflammation, Infection and
  • necrosis of tissue.


(Otto, 2004)
34
Pain Medications
  • Soft tissue Nonsteroidal
    Anti-inflammatory (NSAI)
  • Bone NSAI
    (Prednisolone)
  • Compression of nerves (Dexamethasone)
  • Muscle spasm (Diazepan or
    Baclofen)
  • Fungal tumor
    Antibiotics
  • Cellulitis
    Systemic

35
  • Management of Cancer Pain
  • Evaluation
  • Physical and Neurological Exam
  • Differential Diagnosis
  • Pain history and pattern
  • Present and past medication
  • X-Rays, MRI, CT, EMG, lab results
  • Nutrition history and interventions
  • Functional evaluation
  • Realistic Goals
  • Plan management (Ca / pain / psych)
  • Focus on patient and family

(Otto, 2004)
36
Pain Management A vicious
cycle
  • Which modalities are best suited for the patient
    diagnosed with cancer?
  • List Modalities
  • List considerations
  • List safety

37
Pain FatigueAnxiet
y Depression
A Vicious Cycle
38
  • Listed Physical Therapy Modalities
  • Cutaneous Stimulation
  • Heat
  • Cold
  • Massage, Pressure , and Vibration
  • Exercise
  • Repositioning
  • Immobilization
  • Counter stimulation
  • Transcutaneous Electrical Nerve Stimulation
  • Acupuncture

(Pfalzer, 1992)
39
Time Out Test
  • As far as specialization, what is an advantage of
    being a physical therapist?
  • Wellness can decrease medical cost? T / F
  • A patient diagnosed with breast cancer, only
    thinks about their diagnosis? T / F
  • As a physical therapist, you might note signs of
    depression? T / F
  • What are considered the 5 fears of a cancer
    patient?
  • By supplying information concerning support
    organizations, you can help decrease patient
    stress? T/F
  • The pain cycle can lead to what other
    complications?


ANSWERS You can pick your individual field of
interest True False True Death,
Disfigurement, disability, dependency and
disruption of relationships True Fatigue,
anxiety and/or depression.
40
LIVING A QUALITY LIFE THROUGH REHABILITATION
41
Mission Statement
  • Through emotional support, education,
    rehabilitation, and exercise we strive to empower
    the patient diagnosed with cancer to maintain and
    improve their quality of life.

(Coleman Consulting, 1997)
42
Philosophy
  • Physical rehabilitation should be synonymous with
    cancer care. Loss of strength and function, as
    well as overall physical fitness must be restored
    in order to maintain quality of life. Our aim is
    to assist the patient diagnosed with cancer with
    education, exercise and support throughout the
    treatment and recovery periods. Promotion of
    wellness allows an individual the opportunity to
    meet future health challenges.

(Coleman Consulting, 1997)
43
Rehabilitation Options
  • Prevention Prevent functional loss in early
    stages of diagnosis.
  • Restorative Reach maximal function when physical
    impairment or disability are present.
  • Supportive Increase self care and mobility for
    the patient with progressive cancer and
    impairment. Teach energy saving methods.
  • Palliative Comfort and function for those
    patients diagnosed with terminal conditions.

44
General Goals
  • Prevent Deconditioning
  • Maximal functional skills
  • Emotional Support to patient and family
  • Education of patient of condition
  • Treatment and Home Program
  • Assist in Pain and Symptom Control
  • Assist in Health Promotion

45
Specific Goals
  • Increase Strength and Endurance
  • Decrease nervousness, irritability anxiety
  • Increase attention span and concentration
  • Improve Posture
  • Maintain or Improve ROM flexibility
  • Promote independence (gait/transfer/ADLs)
  • Development of disease education, including
    treatment program.

46
Evaluation Tools
47
Evaluation Scales
  • Functional Independence Measure (FIM)
  • Karnofsky Performance Status Scale
  • Zubrod Performance Scale

48
FIM
  • 7 Complete Independence (Timely, Safely) NO
    ASSISTANCE
  • 6 Modified Independence (Device)
  • Modified Dependence
    HELPER
  • 5 Supervision
  • 4 Minimal Assist (Subject 75)
  • 3 Moderate Assist (Subject 50)
  • Complete Dependence
  • 2 Maximal Assist (Subject 25)
  • 1 Total Assist (Subject 0)
  • ADMIT / DISCHARGE / FOLLOW-UP
  • Self Care / Sphincter Control / Mobility /
    Locomotion / Communication / Social Cognition

49
Karnofsky
Specific
General
  • 100 Normal, no complaints, No evidence of
    disease
  • 90 Able to carry on normal activity minor signs
    or symptoms of disease
  • 80 Normal activity with effort, some signs or
    symptoms of disease
  • 70 Cares for self, unable to carry on normal
    activity or to do work.
  • 60 Requires occasional assistance of others,
    but able to care for most needs
  • 50 Requires considerable assistance from
    others, frequent medical care
  • 40 Disabled, requires special care
  • 30 Severely disabled, death not certain
  • 20 Very sick, hospital, need support
  • 10 Moribund
  • 0 Dead
  • Able to carry on normal activity, no special care
    needed.
  • Unable to work, able to live at home and
    care for most personal needs, varying amount of
    assistance
  • Unable to care for self, requires
    institution or hospital care for disease that may
    be rapidly progressing

(Abraham, 2005)
50
Important information to obtain when evaluating
the cancer patient
  • Medical Information
  • Primary diagnosis / Stage of disease / Surgery /
    Chemo / Radiation / Blood counts / Prognosis
  • Physical Exam
  • Mental status / Vital signs / Strength / ROM /
    Reflexes / Pain
  • Mobility State
  • Bed mobility / Balance / Transfers / Ambulation /
    Assistive devices
  • Psychological State
  • Coping skills
  • Social State
  • Family / Job / Recreation
  • Home Environment

51
Lab values and guidelines
52
Rehabilitation Treatment Plan
  • Bone Marrow Transplant Complications
  • Decreased mobility and joint ROM
  • Decreased endurance
  • Increases fatigue
  • Decreased strength
  • Increased pain
  • Decreased function
  • Decreased motivation
  • Decreased pulmonary function

(Koczur, 1996)
53
  • Guidelines when establishing a treatment plan
  • Platelet Counts
  • No anti-gravity exercise
  • No resistive exercise
  • 25-50,000 Support and Restoration (SR)
  • sub-maximal isometrics
  • isotonic exercise (light
    weights)
  • no prolonged stretching
  • no low speed isokinetics
  • 50,000 Restoration and Prevention (RP)
  • Most programs acceptable

Under 50,000 can increase the risk of bleeding
(Hicks, 1990)
54
Continual Guidelines
  • Hematocrit (Hct.) / Hemoglobin (Hb.)
  • range of motion
  • no aerobics
  • no isotonics
  • 25-35/10-12 Support Restoration
  • low impact and intensity
  • aerobics (bike ergometer)
  • Isometrics
  • modified isotonics
  • 35/12 Restoration Prevention
  • most programs acceptable

(Hicks, 1990)
55
Additional Guidelines
  • PFTs (Cardio-Pulmonary function impairment)
  • 50 capacity PS
  • No aerobics
  • 50 75 SR
  • Low intensity aerobics
  • 75 RP
  • Most programs acceptable
  • Metastatic or bone tumor
  • 50 cortex involved PS
  • No exercise
  • Non-weightbearing
  • 25-50 SR
  • Partial weight bearing
  • Range of motion (No stretching)
  • 0-25 RP
  • Full weight bearing

(Hicks, 1990)
56
Time to think ExerciseThe best way to ensure
desired outcomes from exercise is to recognize
the needs, limitations and capabilities of each
individual. Remember your patients need for
required cardiovascular, pulmonary or muscle
strength or endurance training.By enhancing
everyday performance activities, your patient
will improve mobility and independence Improve
and maintain posture and muscle balance show an
awareness of injury prevention and promote
physical and mental relaxation.
57
Start to establish an exercise program.
(Slide donated with permission to show by Ronald
H. Schuster, MD Board Certified Plastic Surgeon)
58
EXERCISE
  • Capacity depends on
  • Physical Condition
  • Stage and Type of Cancer
  • Treatment Program
  • Side Effects
  • General Health
  • A fitness program differs for a mastectomy
    patient compared to late stage lung Ca.
  • Exercise brings about immediate or acute
    physiological responses as well as long term or
    chronic responses.

59
  • General Oncology Rehabilitation
  • Function / Cardio-Endurance / Energy Conservation
    / Pain Management / Strength - Balance /
    Education.
  • 1st Visit...Eval. / OOB 1 hr. / energy
    conservation / Deep breathing.
  • 2nd Visit..OOB safe home techniques / Vital signs with
    ambulation 20-40' / Cool down.
  • 3rd Visit..OOB 2-3 hrs. 2-3 X/day / Continue
    energy conservation / Ambulate as tol./ Home
    Program / Eval home.

My Niche
60
Benefits of Regular Exercise
  • Weight loss and decreased body fat
  • Lower risk of cardiovascular disease and cancer
  • Lowers blood pressure
  • Decrease insulin use in diabetics
  • Prevents Osteoporosis
  • Lowers serum cholesterol
  • Slows aging of heart and lungs
  • Reduces back pain
  • Improves self-image

(www.healthclubs.com, 2006)
61
Benefits of Exercise with Cancer
  • Increase
  • Accumulation of muscle protein
  • Joint mobility
  • Strength
  • Decrease
  • Edema
  • Pain
  • Anxiety
  • Depression
  • Enhance Immune Function
  • Decrease Infection susceptibility

(www.sportsmedicine.about.com, 2006
62
General Breast Cancer DiagnosisExercise You
Decide?
  • Aerobic (Walk, Jog, Cycle or Swim)
  • Increase heart rate
  • Increase lung capacity for O2 intake
  • Increase O2 to muscles
  • Increase metabolism to control weight
  • Decrease in blood cholesterol
  • Increase in bone strength
  • Increase in endurance

63
Decide?
  • Anaerobic (Weight lifting or Sprinting)
  • Short burst of intense activity
  • Develop muscles
  • Develop strength
  • Develop speed
  • Develop power

64
Walking
  • Excellent choice of Exercise
  • Increase lung function
  • Stimulates bone growth and strengthens leg and
    back musculature
  • METS to LE or back may eliminate running but
    walking may be approved (Less trauma)
  • In pool gentle yet stimulates heart lungs
  • Consult M.D. when dealing with metastasis

65
Swimming
  • Good choice with pain of spine, hips or pelvis
    possibly due to metastasis
  • Increase aerobic capacity if performed far and
    fast enough
  • Stretches muscles and lung capacity
  • Strengthening against water resistance
  • Consult M.D. when dealing with METS

66
Stretching Yoga
  • Increased flexibility and decreased muscle
    tension
  • Increased circulation
  • Well stretched muscles require less energy for
    movement
  • Important for shortened muscles from rest (Slow
    stretch prevents muscle tear)
  • Yoga and deep breathing promote an emotional edge
    due to body awareness.

67
Exercise Facts
  • Exercise builds muscle tissue, strengthens the
    heart, increases lung capacity to take in oxygen
    and improves circulation.
  • Exercisers report increased energy and stamina
    with decreased deconditioning.
  • Stretching, Yoga, Walking Swimming stimulate
    muscles circulation without stress.

68
Psychological Benefits
  • Increase feeling of well being
  • Give patient sense of control
  • Improve self-esteem
  • Enhances Coping
  • Increased attention span concentration
  • Decrease Anxiety
  • Decrease Depression
  • Increase Strength, Mobility Fitness

(Gavin, 2006)
69
Functional Assessment
  • Must obtain measurable benefits (Outcomes)
  • Rehabilitation judged by functional ability that
    results from treatment
  • Assess function by monitoring changes in activity
    of self care, mobility, and communication.

70
Accurate documentation promotes future progress
71
  • Documentation
  • Focus on function
  • Use vital signs for an objective measure
  • Focus on short term goals REALISTIC GOALS
  • Describe teaching sessions
  • Document lab values (Very Important when treating
    cancer patients)

Comisac, 1996
72
Ideal rehab candidates are those who are/were
previously in excellent health, strength and
fitness. Everyone is different and should be
treated as an individual.
73
Questions to ask ?
  • What can the patient do?
  • What do they need to do?
  • What do they want to do?

74
Examples of specific breast cancer rehabilitation
programs
75
Pre-Surgical Evaluation
  • Ideal program
  • Education of expectations
  • Introduction helps decrease anxiety fear.
  • Screen patients condition prior to medical
    intervention (Psychologically, Strength, Mobility
    Girth) .
  • Ability to initiate safe and functional
    rehabilitation program.
  • Avoid undue stress on involved extremity.

76
Post-Surgical Evaluation
  • Completed as soon as possible.
  • Teach proper elevation for comfort and edema
    control.
  • Control upper extremity flexion until drains are
    removed.
  • Teach support program
  • Compare to pre-evaluation

77
EXERCISE PROGRAM
  • Components of Exercise
  • Exercise is essential, but precautions must be
    taken
  • Range of Motion
  • Strength
  • Endurance
  • Safety
  • Contraindications

78
Safe Exercise Program
  • Common sense
  • M.D. Clearance
  • Limit before lab work / infection /fever
  • If ill from treatment Wait a day
  • Start Slowly
  • Avoid Pain
  • Caution with low blood counts
  • Avoid infections including foot care
  • Return to M.D. with persistent complaints

(Coleman Consulting, 1997)
79
Contraindications to Exercise
  • Unusual fatigue
  • Unusual weakness
  • Irregular pulse
  • Decreased heart rate with work
  • Leg pain / cramps
  • Nausea, Vomiting or Diarrhea
  • Disorientation
  • Dizziness, Blurred vision or Faintness
  • Pallor or Cyanosis
  • Dyspnea onset
  • IV chemo last 24 hrs.
  • Platelets
  • White Blood Count

(Arnall, 2005)
80
  • POSTURE
  • Shoulder depression and internal rotation with
    scapula protraction
  • Serratus Anterior weakness...Winging due to
    overstretch of long thoracic nerve.
  • Latissimus dorsi weakness overstretch of
    thoracodorsal nerve.
  • Pectoralis major/minor weakness.Minor may have
    been removed Medial pectoral nerve no longer
    innervates lateral border of pectoralis major.

81
Strength Training
  • Weight training to build musculature
  • Must control resistance and calories with proper
    monitoring
  • Machines safer than free weights to assure good
    posture and functional mobility
  • Manual resistance exercise regime may be utilized
    to promote strength

82
EXERCISE
  • Even with advanced disease exercise can help
    decrease depression, tissue loss and fatigue
  • Passive mobility program may be appropriate
  • Exercise with pain meds more beneficial
  • Guide towards individual challenges Marathon /
    Bike Ride or a Walk around the block. This will
    be established between the patient and the
    therapist.
    Be R-E-A-L-I-S-T-I-C
  • Additional study results follow, which will help
    benefit you to expand your knowledge of the
    benefits of rehabilitation for breast cancer
    survivors.

83
The Coleman 10 Step Program
  • I Individualism
  • II Physical Therapy Evaluation
  • III Ancillary Services
  • IV Patient Education
  • V Rehabilitation Program
  • VI Progress Step
  • VII Group Exercise Program
  • VIII Follow-Up
  • IX Out Reach Program
  • X Home Maintenance

(Coleman Consulting, 1997)
84
  • R E H A B I L I T A T I O N
  • Rehabilitation interventions should begin at
    bedside, getting patient OOB as soon as possible
    to work towards discharge.
  • Intense rehab after discharge is determined by
    patients life expectancy ( 1 year) and medical
    capabilities to participate (including motivation
    and mental considerations).
  • After discharge to home setting, it is important
    to assure that patient has proper equipment and
    supplies.
  • All follow-up programs must be set (including
    proper referrals) at time of discharge.

85
Follow a safe post-operative breast
cancer program
  • Remember to
  • Review diagnosis
  • Medical interventions
  • Safe technique
  • Contraindications
  • Motivate
  • Acknowledge
  • Research
  • Other programs
  • Realistic goals

86
Rehabilitation examples to remember
  • Protocols for individual
  • Protocols depending on medical intervention

87
  • Breast Cancer
  • Therapy begins 2-5 days post-op.
  • Deep breathing relaxation are beneficial
  • Range of motion (gentle)
  • Movement with support as needed
  • Isometrics of involved elbow/ wrist/ hand
  • Once drains removed increase exercise (active
    shoulder mobility)
  • Home exercise program to promote independent plan
  • Possible complications that need to be prevented
    include Inflammation, scar formation, obesity,
    thrombophlebitis, and poor arm position.

88
  • BREAST CANCER
  • GOALS
  • FUNCTIONAL
    EMOTIONAL

    COSMETIC
  • FUNCTIONAL
    Shoulder Range of Motion
    Neurological Changes Postural
    Deficits Skin Integrity Possible Lymphedema
    ADL's

89
Post-Surgical Rehabilitation TRAM
  • Immediate Post-operative
  • Distal hand exercise to assist shoulder
    stabilization.
  • Incisional splinting techniques to increase
    comfort with movement
  • Day 2 or 3
  • Reach to opposite shoulder knee
  • ADLs with active range per individual

(Grant, 1994)
90
Post-operative
  • Two to four weeks according to M.D.
  • Active / Passive ROM to involved shoulder
    including overhead stretch
  • Gentle resistive exercise
  • Progressive cardiovascular fitness program
    performed within safe limitations

(Grant, 1994)
91
Post-operative
  • Six weeks (depending on patient)
  • Aggressive stretching and strengthening of
    shoulder
  • Strengthening of trunk and abdominals
  • Cardiovascular cross training
  • Return to work activities (Assimilation)
  • Arm edema maintenance / prevention
  • Scar tissue management (Decrease adhesions)
  • Fitness through other medical interventions.

(Grant, 1994)
92
Post-operative
  • Long Term Management
  • Maintain stretching and muscle tone, especially
    in radiated areas.
  • Posture management program
  • Quality of Life fitness program
  • Awareness of any problems

(Grant, 1994)
93
Post-Operative TRAM
(Slide donated with permission to show by Ronald
H. Schuster, MD Board Certified Plastic Surgeon)
94
Free Flap technique
(Slide donated with permission to show by Ronald
H. Schuster, MD Board Certified Plastic Surgeon)
95
Education
  • We must educate the patient, family, community,
    physician and other health care providers of the
    benefits of rehabilitation for the patient
    diagnosed with cancer.

96
Supply educational materials
97
General breast cancer programs used in my
facility to promote safe techniques with
functional mobility and activities of daily
living
98
OUT-PATIENT ONCOLOGY REHABILITATION
  • Patient care management
  • Promote wellness
  • Cost effective protocols
  • Decrease risk of adverse outcomes
  • Provide forgotten rehab Program
  • Establish continual case studies
  • Provide continual education programs

(Coleman Consulting, 1997)
  • .

99
  • BREAST WELLNESS CENTER
  • Comprehensive care dealing with the total
    patient, not just the diagnosis
  • Treatment program discussed with pt.
  • Sensation change
  • Shoulder mov't guidelines
  • Lymphedema
  • Posture
  • Prosthesis
  • Lifting precautions
  • Fatigue
  • Exercise Guide
  • UE Elevation
  • Deep Breathing
  • Elbow/Shoulder controlled program
  • Capsular Exercise
  • Active Exercise
  • Functional Shoulder


(Designed by Coleman Consulting)
100
Breast Center in Health Club
(Public Relations Photo Breast Wellness Center)
101
Gradual mobility
(Public Relations Photo Breast Wellness Center)
102
Control exercise
( Public Relations Photo Breast Wellness Center)
103
Posture and mobility
(Public Relations Photo Breast Wellness Center)
104
Program Development
  • As you gain expertise and physician confidence,
    you will also note an increase in patient
    compliance.

105
  • Tips for building an Oncology Rehabilitation
    program
  • Increase visibility of rehabilitation into
    oncology treatment plans with early intervention
    to prevent functional decline and, increase the
    ability to restore a quality life.
  • Increased involvement in clinical studies to
    include outcomes for the oncology patient.
  • Organization of Rehab team to assure quality of
    care to promote functional outcomes.
  • Progress treatment plans to map out vocational
    and psychological programs.

(Coleman Consulting, 1996)
106
Research supporting physical therapy
rehabilitation
  • Promotion of a quality life for patients
    diagnosed with breast cancer

107
Research completed by Drum and group in the
Medical Science of Sports and Exercise, 2003
  • Case study of female diagnosed with breast
    cancer, age 29 receiving a modified radical
    mastectomy and at age 57 same procedure to
    opposite breast. Chemotherapy and radiation
    followed second surgery.
  • Following medical interventions presented,
    patient followed a six month exercise program at
    the University of Colorado.
  • Increased muscle strength, cardiovascular
    function and attenuating career related fatigue
    and depression.
  • Suggest health professionals collaborate with
    rehabilitation to increase work capacity to
    progress a quality life for the patient diagnosed
    with breast cancer.

(Drum, 2003)
108
Study by Holmes in the American Medical
Association Journal in 2005
  • Study followed the health of 122,000 female
    nurses, 2,167 were diagnosed with breast cancer.
  • The physical activity of the subjects was
    recorded. This activity was measured up to 16
    years, most subjects walked for exercise.
  • Breast cancer survivors that exercised 3-5 hours
    per week lived longer than those that had minimal
    activity. Also noted those who completed regular
    exercise were less likely to die from their
    breast cancer.
  • Patients will receive major benefits from modest
    exercise.

(Holmes, 2005)
109
Mastros study published in the American Medical
Association website 2004
  • Study of 49 women with breast cancer, 28 were
    assigned to a six month exercise program.
  • Blood testing was used to determine immune
    response.
  • Revealed that breast cancer patients that
    completed an assigned six month exercise program
    had better immune response and less inflammatory
    complications.
  • Appropriate exercise can help breast cancer
    survivors strengthen their immune system with
    exercise.

(Mastro, 2004)
110
Following numerous searches in the medical
library and database search engines, no
remarkable negative changes with exercise
following the diagnosis of breast cancer were
noted.
111
Research by Winningham
  • Exercise may enhance Quality of Life
  • Interval Aerobic Training (Rest Exercise)
    enhances cardiovascular efficiency, overall
    functional ability and reduces incidence rates of
    nausea from chemotherapy.
  • Heavy prolonged exertion associated with hormonal
    and biochemical changes can have a detrimental
    effect on the immune system

(Winningham, 1989)
112
Research by Segar
  • Regular aerobic cycling decreased depression and
    anxiety as well as increased self esteem.

(Segar, 1998)
113
Research by Pinto
  • Surveyed 72 Stage I and II breast cancer
    patients. Those who exercised reported less
    depression and enhanced Quality of Life compared
    to the sedentary control group.

(Pinto, 1998)
114
Research by Durak
  • Health Club Study
  • Breast cancer program Aerobic exercise / PREs
    on machines 2x/wk for 20 weeks
  • Results
  • CA pts. Showed
  • 60 increase in upper body strength
  • 31 increase in lower body strength
  • 35 increase in aerobic machines
  • Progress ADLs, Strength Endurance
  • Decreased Pain and Decreased Nausea

(Durak, 1997)
115
Research by Bernstein
  • Women who have been physically fit for many years
    reduce their incidence of breast cancer.
  • 3.8 hours of exercise per week reduces risk

(Bernstein, 1995)
116
.Additional research on the benefits of exercise
for the breast cancer patient is becoming
available.
  • Support of the benefits of exercise are to
    increase functional capacity, decrease body fat,
    increase lean muscle mass, decrease nausea
    fatigue, improve quality of life.
  • American College of Sports Medicine guidelines
    for exercise following breast cancer Frequency
    3-7 days /week Intensity 40-80 aerobic
    capacity Duration 20-40 min. of aerobic
    activity. Suggest normal fitness
    assessment heart rate, blood pressure, body
    composition, strength, flexibility, aerobic
    capacity.
  • ONLY BENEFITS REPORTED

(ACSM, 1997)
117
  • Harvard Medical asst. professor Michelle
    Holmes,MD, studied 3,000 women noting little
    exercise increases chances of surviving breast
    cancer. 3 MET (Metabolic equivalent task) hrs.
    per week of 2 to 2.9 miles per hour for 1 hour
    decreases risk of dying from breast cancer by one
    half.
  • Anne McTiernan, MD, PhD, author of Breast
    Fitness An Optimal Exercise and Health Plan for
    Reducing Your Risk of Breast Cancer, stated
    Women dont have to become athletes, just get up
    and get moving.

(www.cancer.org, 2005)
118
  • Breast Cancer FYI, suggests that a patient should
    consider at least one session with a physical
    therapist if any surgical procedures, due to
    breast cancer, have been performed
  • .
  • In the Yale Exercise Survivorship Study, it was
    revealed, despite the evidence suggesting that
    regular physical activity can decrease breast
    cancer risks and improve prognosis, efforts to
    encourage this program were not a routine part of
    cancer treatments.

119
Results of studies on exercise during breast CA
Authors
Samples
Design
Intervention
Outcome
Results
(Courneya, 2002)
120
Physical Therapy Modalities
121
Which modalities are safe in treating the patient
diagnosed with breast cancer?
  • Moist Heat
  • Cold
  • Deep Heat
  • Traction
  • Electrical Stimulation
  • TENS
  • Compression Pumps
  • Manual Therapy

(Pfalzer, 1992)
122
Progressive Relaxation Exercise
  • Close your eyes Deep Breathing
  • Image Ocean, Mountains, etc.
    See it / Hear it / Feel it
  • Contract --- Relax Mildly with 5 count
  • Forehead / Face / Neck / Shoulders / Upper Arms /
    Forearms / Hands / Chest / Abs / Gluts / Upper
    Legs / Calves / Feet
  • Deep Breathing .. Total Body contract/relax
  • Repeat total process

Always a safe technique.
123
Modality Contraindications
  • Cold
  • Over dysvascular tissue
  • Transient increase in blood pressure
  • Delay in wound healing
  • Nerve injury
  • Peripheral Vascular Disease
  • During Radiation
  • Possible Metastasis

(Pfalzer, 1992)
124
Contraindications
  • Deep Heat
  • Over dysvascular tissue
  • Over poor sensation
  • Increase in bleeding
  • Directly over tumor
  • Over acute injury
  • Open wounds
  • Elevated temp.
  • Metal implants
  • Pacemaker or other implanted device

(Pfalzer, 1992)
125
Contraindications
  • Traction
  • Structural Changes possible pathologic fx.
  • Compression Pump
  • Active disease .. Metastasis can occur through
    pump activity
  • Manual Therapy

(Pfalzer, 1992)
126
Contraindications
  • Electrical Stimulation
  • Possibility of pathologic fractures
  • Implanted device
  • Cardiopulmonary Insufficiency
  • Active phlebitis
  • TENS
  • Implant
  • Directly over wound

(Pfalzer, 1992)
127
REHABILITATION
  • The recognition and acceptance that breast
    cancer is a treatable disease even when it is
    metastatic has helped professionals and patients
    alike accept rehabilitation efforts.



    Stephen Gudas, 1992

You have the knowledge and responsibility to
develop a plan of treatment for the patient
diagnosed with cancer.
128
ONCOLOGIC EMERGENCIES
129
Reference to the GUIDE TO PHYSICAL THERAPY
PRACTICE A.P.T.A.
  • Through the examination, the physical therapist
    identifies impairment, functional limitations,
    disabilities, or changes in physical function and
    health status resulting from injury, disease, or
    other causes to establish the diagnosis and the
    prognosis and to determine the intervention.

(www.apta.org, 2006)
130
The Guide
  • A goal and prognosis will help establish the plan
    and frequency of visits for the cancer patient.
  • Interventions to produce a change in condition
    are established by the plan of care, anticipated
    goals and desired outcome.
  • Reexamination needed to evaluate clinical
    findings to promote care or observe failure of
    response.
  • Some examples of ICD-9-CM Codes related to
    cancer
  • 232 Carcinoma in situ
  • 239 Neoplasm's of unspecified nature

(www.apta.org, 2006)
131
Physical Therapy Evaluation
  • Range of Motion
  • Manual Muscle Testing
  • Shoulder Assessment
  • Sensation Testing
  • Girth Measurements
  • Posture Analysis
  • Cardiovascular Fitness
  • Body Fat Analysis
  • Additional tools you may need for assessment
  • Skinfold caliper
  • Spirometer
  • Heart rate monitor
  • Hand grip dynamometer

132
Effective AssessmentGuidelines of Rocky Mountain
Cancer Rehabilitation Center
  • Each parameter relevant to patient progress
  • Procedures valid and reliable
  • Administrate with rigid control
  • Protect patients rights
  • Regular interval testing
  • Review and explain to patient

133
Organ Toxicity and Life Threatening Complications.
  • Problems seen
  • Hematologic (Dealing with blood and blood
    forming organs)
  • Obstruction
  • Increased Pressure / Fluid Accumulation
  • Metabolic (Dealing with chemical processes of
    living organisms)
  • Pathologic Fractures

(Kirchner, 1996)
134
Oncology Emergency Signs
  • Infection
  • Fever
  • Ecchymosis
  • Bleeding (Possible gums)
  • Headaches
  • Chest Pain
  • Dizziness
  • Fatigue
  • Insomnia
  • Swelling
  • Local or Radicular Pain
  • Neurological Deficits
  • SOB
  • Abdominal Pain / Cramp
  • Nausea / Vomiting
  • Constipation / Diarrhea
  • Hypertension / Hypotension
  • Tachycardia
  • Changes in Urine
  • Loss of Appetite
  • Blurred Vision
  • Change in Mental State
  • Seizures
  • Respiratory Changes
  • Weight Changes
  • Depression
  • Fractures
  • Coma
  • Death

(Otto, 2004)
135
Time Out Test
  • Oncology Emergencies only pertain to the elderly?
    T / F
  • The main mission for treating cancer in
    rehabilitation?
  • Palliative therapy is really not needed? T / F
  • What helps you establish your plan of treatment?
  • When was the first epidemiologic study on breast
    cancer and exercise published?
  • Functional assessments must document what?
  • Although there have been many negative changes,
    due to rehabilitation, it is still prescribed?
    T / F
  • What medical information appears important when
    working with patients diagnosed with cancer?
  • What are the advantages of pre-surgical
    evaluations?


ANSWERS False Maintain and improve Quality of
Life False Prognosis and Goals
1985 Measurable benefits False, No negative
findings Lab valuesTo many to list.
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