CONSERVATIVE MANAGEMENT OF CANCER PATIENTS

Dr. Vinod K Ravaliya, MPT

Assistant Professor, KMPIP

Karamsad

Saturday 10th November 2012

Why needed?

Cancer survival rates >50%.

Willingness to discuss cancer and the needs of the patient.

Thrust in cancer care is not simply on survival, but on QoL of survivors.

Cancer Rehabilitation: Definition

Cancer Rehabilitation defined as helping a person with cancer to help himself or herself to obtain maximum physical, social, psychological, and vocational functioning within the limits imposed by disease and its treatment.

Cromes GF Jr. Implementation of interdisciplinary cancer rehabi- litation. Rehabil Counseling Bull 1978; 21: 230–237.

Quality of life (QOL) is defined as an individual’s perceptions of his position in life, in the context of the culture and value systems in which he lives and in relation to his goals, expectations, standards and concerns

Quality of life (QOL)

Owing to the potentially progressive nature of cancer

successful outcomes depend upon timely recognition of functional problems

and prompt referral for rehabilitation

Rehabilitation Aims:

Restorative care aims to return the individual to premorbid function with a minimum of functional impairment.

Supportive care aims to reduce functional difficulties and compensate for permanent deficits

Palliative treatment, usually of the terminal patient, works to eliminate or reduce complications, especially pain

Preventive rehabilitation would include for example, preoperative education regarding maintenance of strength and range of motion in the upper extremity following breast surgery

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Myopathies Neuropathies & Plexopathies Pain Edema Fatigue Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Chemotherapy- Side Effects

Nausea and Vomiting Fatigue Hair loss Susceptibility to infections Decrease in Blood Cell Counts Mouth sores and ulcers

Decrease in Blood Cell Counts

Exercise training : Increase total Hb and red cell mass, which enhances

oxygen-carrying capacity. Possible mechanisms: Stimulated erythropoiesis with hyperplasia of the

hematopoietic bone marrow Improvement of the hematopoietic microenvironment

induced by exercise training, and hormone- and cytokine-accelerated erythropoiesis.

Need for further investigation- chemotherapy/Radiation therapy

Acta Haematol. 2012;127(3):156-64. Epub 2012 Jan 31.Effects of exercise training on red blood cell production: implications for anemia.Hu M, Lin W.

Decrease in Blood Cell Counts

Duration of neutropenia and thrombopenia after adjuvant chemotherapy are significantly shorter in the Aerobic Exercise training group than in controls

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Radiation therapy

Skin & Soft Tissue Fibrosis Effects of Radiation

Loss of Elasticity, Vascularity & Moisture Tissue Thickening & Edema • Contracture

Management Moisturizing Creams Splinting & Orthotics Stretching Exercises

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Fatigue

Defined as the feeling of extraordinary exhaustion associated with a high level of distress, disproportionate to the patients' activity, and is not relieved by sleep or rest.

Up to 70% of cancer patients during chemo and radiotherapy

Inactivity Muscle catabolism Perpetuate Fatigue

Self care and social activities QoL

Fatigue Burden….

Oncologist. 2007;12 Suppl 1:4-10.Cancer-related fatigue: the scale of the problem.Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P, Morrow GR.

Management of Fatigue:

Bed rest or Aerobic Exercise Energy Conservation

Techniques Activity/Exercise Program Diversional Activities Rest/Sleep Patterns Stress Management Nutritional management

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathy Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Myopathy

Tumor Infiltration Paraneoplastic

Carcinomatous Myopathy & Neuromyopathy

Radiation Steroids & Other Chemotherapy

The Role of Exercise Adaptive Equipment etc.

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Neuropathy & Plexitis

Causes Neurotoxic Chemotherapy Direct Invasion – Radiation Compression – Paraneoplastic

Management Pain Control – Bracing Adaptive Devices – Other

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation-Pain

Physical Modalities– Electrical Stimulation Heat Modalities

Relative Contraindication to Therapeutic Heat

J Pain Symptom Manage. 2009 Apr;37(4):746-53. Epub 2008 Sep 14.

A cochrane systematic review of transcutaneous electrical nerve stimulation for cancer pain.

Robb K, Oxberry SG, Bennett MI, Johnson MI, Simpson KH, Searle RD.

There is insufficient available evidence to determine the effectiveness of TENS in treating cancer-related pain. Further research is needed to help guide clinical practice, and large multi-center RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.

What Evidence Says- Does TENS relieves Cancer Pain ?

Cochrane Database Syst Rev. 2012 Mar 14;3:CD006276.

Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults.

Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG.

Despite the one additional RCT, the results of this updated systematic review remain inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.

What Evidence Says- Does TENS relieves Cancer Pain ?

What Evidence Says- Does Acupuncture relieves Cancer Pain ?

Acupuncture as an effective analgesic adjunctive method for cancer patients is not supported by the data currently available from the majority of rigorous clinical trials.

Widespread acceptance, appropriately powered RCTs needed.

Eur J Pain. 2005 Aug;9(4):437-44. Epub 2004 Nov 11.Acupuncture for the relief of cancer-related pain--a systematic review.Lee H, Schmidt K, Ernst E.

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Lymphedema

Management Elevation Active Exercises Compressive Garments & Pumps Manual Lymph Drainage,

Massage and Other Treatments

Caution: Risk of Mobilizing Tumor Cells

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Immobility

Effects of Immobility Prevention of Related Problems

Contractures – Decubiti Muscle Atrophy – Deconditioning

Role of Exercise & Mobilization

Common Rehabilitation Problems Seen in Cancer Patients

Chemotherapy/Radiotherapy Induced Side Effects Fatigue Myopathies Neuropathies & Plexopathies Pain Edema Immobility/Generalized Deconditioning Bone Destruction Depression

System Specific Problems

Rehabilitation- Bone Destruction

Evaluation X-Ray –Bone Scan – CT

Management

- Pain Unweighting Assistive Devices Surgical Considerations

- Stability- Bracing

>50% Cortical

Loss

3 cm

> 60% of Bone

Diameter

Rehabilitation- Orthotics

Splinting to Maintain Position Orthotics to Restore Function

E.g. AFO to lock the knee during stance phase

“The important thing is not how many years in your life but how much life in your years.”

~Edward J. Stieglitz

Rehabilitation of Lung Cancer

Patients with inoperable lung cancer now account for a large group of patients who use this type of medical intervention and can significantly improve the quality of life and the method shows positive impact on the survival rate.

Jastrzębski D, Ziora D, Hydzik G, Pasko E, Bartoszewicz A, Kozielski J, Nowicka J.Pulmonary rehabilitation in patients with lung cancer. Pneumonol Alergol Pol. 2012;80(6):546-554.

Abstract

METHODS:

twice-weekly sessions of aerobic exercise and weight training over an 8-week period.

functional capacity, measured by the 6-minute walk test and muscle strength, as well as quality of life, lung cancer symptoms and fatigue, measured by the Functional Assessment of Cancer Therapy-lung and Functional Assessment of Cancer Therapy-fatigue scales.

CONCLUSIONS:

Those who completed the program experienced an improvement in their lung cancer symptoms. Community-based or briefer exercise interventions may be more feasible in this population.

J Thorac Oncol. 2009 May;4(5):595-601.A structured exercise program for patients with advanced non-small cell lung cancer.Temel JS, Greer JA, Goldberg S, Vogel PD, Sullivan M, Pirl WF, Lynch TJ, Christiani DC, Smith MR.

Abstract

Lung cancer survivors exhibit poor functional capacity, physical functioning, and quality of life (QoL).

The primary outcomes focused on feasibility including eligibility and recruitment rate, loss to follow-up, measurement completion, exercise adherence, and program evaluation. Secondary outcomes addressed preliminary efficacy and included changes in muscular strength (1 repetition maximum), muscular endurance (repetitions at 70% of 1 repetition maximum), body composition (DXA scan), physical functioning (6-minute-walk-test, up-and-go, sit-to-stand, arm curls), and patient-reported outcomes including QoL (SF-36, FACT-L), fatigue (FACT-F), PRET is a feasible intervention with potential health benefits for a small proportion of lung cancer survivors in the post-treatment setting.

Lung Cancer. 2012 Jan;75(1):126-32. Epub 2011 Jun 28.Feasibility and preliminary efficacy of progressive resistance exercise training in lung cancer survivors.Peddle-McIntyre CJ, Bell G, Fenton D, McCargar L, Courneya KS.