Oncology Rehabilitation for Therapists · Certified Lymphedema Therapist [email protected]...

3/20/2019

Copyright Fisher, 2019 1

Oncology Rehabilitation for Therapists

Session II – Common Impairments and Evidence‐based Rehabilitation

Mary Insana Fisher, PT, PhDAssociate Professor

Board Certified Orthopedic Clinical SpecialistCertified Lymphedema Therapist

[email protected]

Objectives – Session II• Identify the functional impact of and evidence-based rehabilitation

strategies following surgical interventions for the most commonly occurring cancers, including reconstructive strategies frequently seen in breast cancer.

• Develop an understanding of the effect of common chemotherapeutic agents on developing morbidities related to the cardiovascular and neurological systems that the therapist must take into consideration when designing and implementing an evidence-based intervention.

• Understand how to employ evidence-based strategies to address the development of comorbidities that are the result physiological changes occurring with radiation treatment.

• Identify recommended outcome measures to be used for different cancer populations to measure baseline status and effectiveness of rehabilitation treatment.

• Learn how to implement the Prospective Surveillance Model in the treatment of individuals with cancer.

Background• 3rd party payers increasingly require health

care providers to measure clinical outcomes, and patient-reported outcome measures (PROs) are one way to do so

• Rehabilitation professionals can use the information from PROs to assist clinical decision-making and to assess the impact of the effects of rehabilitation treatment

3

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Background

• PROs, unlike clinician-based measures, are based on the patient perspective

• Complements clinician-based outcomes

• Both PROs and objective outcomes enhance treatment planning and measurement of effectiveness

4

EDGE

• Evaluation Database to Guide Effectiveness

• EDGE Task Force –convened by the Section on Research (CSM 2006)

• Identification of a core set of tests/measures for practice areas

EDGE

The bottom line is that evidence of intervention effectiveness depends on, among

other things, common use of valid and reliable tests/measures that reflect clinically

important outcomes and are responsive to change.”

Field-Fote E, Levangie P, Craik R. Towards Optimal Practice – How Can Students Contribute?” Student Assembly Pulse (Newsletter of the Student Assembly of the APTA), March 2007, p. 4

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EDGE• Academy of Oncologic Physical Therapy modified the

EDGE rating form and processes initiated by the Academy of Neurologic Physical Therapy

• 2010: BC and arm function

• To date: 29 systematic reviews of the evidence

EDGE Ratings

4

Highly Recommended

The outcome measure has excellent psychometric properties (reliability and validity AND have available data to guide interpretation) in condition of interestand excellent clinical utility (≤20 min, equip in clinic, no copyright payments, easy to score); the measure is free or reasonably accessible to a broad range of providers.

3 Recommended

The outcome measure has good psychometric properties (may lack some info about reliability, validity, responsiveness) in the population of interest and good clinical utility (>20 min, some equip, training, copyright fee);OR has excellent psychometric properties but is not free and may require access to specialized testing equipment that is beyond the means of many clinicians or clinics.

2Reasonable to

Use

Limited study in target group; the outcome measure has good or excellent psychometric properties and clinical utility in a related population, but insufficient study in target population to support higher recommendation.

1Not

Recommended

The outcome measure has poor psychometric properties and/or poor clinical utility

4Highly

Recommend

Highly recommended; the outcome measure has excellent psychometric properties and clinical utility; the measure has been used in research on individuals with or post cancer.

3 Recommend

Recommended; the outcome measure has good psychometric properties and good clinical utility; no published evidence that the measure has been applied to research on individuals with or post cancer.

2AUnable to

Recommend at this time

Unable to recommend at this time; there is insufficient information to support a recommendation of this outcome measure; the measure has been used in research on individuals with or post cancer.

2BUnable to

Recommend at this time

Unable to recommend at this time; there is insufficient information to support a recommendation of this outcome measure; no published evidence that the measure has been applied to research on individuals with or post cancer.

1Do not

RecommendPoor psychometrics &/or poor clinical utility (time, equipment, cost, etc.)

EDGE Annotated Bibliography

• Roadmap of tests and measures recommended for use–Screen–Assess–Measure intervention effectiveness

https://oncologypt.org/publications/

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PHYSICAL THERAPY

Subjective History

• Cancer history–Type

–Stage

–Treatments to date

–Previous history of ca

• Past medical history

Subjective History

• Current status–Pain

–Fatigue

–Functional report (ca specific)

–Health-related quality of life

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Subjective History

• Social history–Family

–Work

–Recreation

Functional ReportBreast Head/Neck Urogenital

DASH Neck Disability Index (NDI)

Am. UrologicalAssociation Symptom Index

Shoulder Pain and Disability Index (SPADI)

Neck Pain and Disability Scale

Pelvic Floor Distress Inventory

Shoulder Rating Questionnaire (SRQ)

DASH Pelvic Floor Impact Questionnaire

SPADI Sexual Function –Vaginal Changes Questionnaire

Neck Dissection Impairment Index

Intl Index of Erectile Function

20-item Jaw Functional Limitation Scale

Toronto Extremity Salvage Score

Objective Examination

• Typical PT tests and measures–Motion

–Strength

–Limb Volume

–Functional Mobility

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MotionBreast Prostate Urogenital/Abdominal Head and Neck

Shoulder girdlemobility

Lower extremity mobility

Trunk mobility Shoulder mobility

Neck mobility

Jaw mobility

Strength• EDGE Systematic Reviews for breast,

prostate, and colorectal cancer

• Hand-held dynamometry

• Hand grip dynamometry

BREAST CANCER COMMON IMPAIRMENTS

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Lymphedema• Approximately 30% of women with

breast cancer will develop lymphedema

• Risk factors ––Axillary lymph node dissection (ALND)

–Greater number of lymph nodes removed

–Axillary radiation

–BMI >28

Stages of Lymphedema• Stage 0 – Latent

• Stage I – reversible; elevation and compression

• Stage II – irreversible – 500 ml absolute difference?

– 5% difference?

• Stage III - elephantitis

Foeldi 2010

Complete Decongestive Therapy (CDT)

• Manual lymph drainage (MLD)• Compression bandaging using short-stretch, not

long-stretch (ACE wraps) bandages, followed by custom compression garments (after decongestion)

• Skin care• Decongestive exercises

for the bandaged extremities

• Patient education in self-management techniques

Klose 2010

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Limb Volume

Stout Gergich et al, Ca, 2008

Levenhagen et al, PTJ, 2017

Lymphatic Cording

• More common in lower BMI

• Treatment–Stretching

–Soft tissue mobilization

–Break adhesions

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Breast Reconstruction• Implants

–Soft tissue mobilization–Scar mobility–Arm mobility–To be done during fill periods

• Tissue Flaps–Scar mobility–Strengthening of donor site/region–Arm mobility

PROSTATE CANCER COMMON IMPAIRMENTS

Lower Extremity Lymphedema

• Stage 1 = 27%

• Stage 2 = 9%

BUT

There are fewer pelvic lymph node dissections done than ALND.

Rasmusson et al, 2013

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Generalized Weakness

• Long-term impact of ADT therapy–Sarcopenia–Muscle wasting–Decreased physical performance–Osteoporosis

• Treatment–Exercise–Importance of aerobic and strengthening

components

Storer et al, 2012; Hanson et al, 2013

COMMON CANCER TREATMENT MORBIDITIES

Cancer-related Fatigue

A persistent sense of physical, emotional and/or cognitive tiredness or exhaustion that is not related to activity and

which interferes with daily activities…

…not relieved by rest.

NCCN 2018; Servaes et al, 2002; Cella et al, 2001

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Cancer-related Fatigue

Incidence: –Chemotherapy – 72%

–Radiation therapy – 90%

–Post-treatment survival – 66%

Prevalence – 98%

Cella 1998, Alexander 2009, Karthikeyan 2012

Causes of Cancer-related Fatigue

• Central v. peripheral phenomenon:–Muscle activation – not different than controls

–Baseline (prior to treatment) levels of fatigue have highest correlation with diagnosis post

• Factors implicated:• Pain• Sleep disturbance• Anemia• Medication side effects• Pro-inflammatory cytokines• Psychological distress

Jacobsen 2004; Kisiel-Sajewicz2012; Schultz 2011

Recommend Screening Measures by the EDGE Task Force

Screening by interprofessional practitioner

One‐Item Fatigue Scale

Screening by rehabilitation practitioner

Brief Fatigue Inventory

Fisher 2018

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Recommend Assessment Measures by the EDGE Task Force

Rehabilitation Practitioner Assessment

Multidimensional Fatigue Symptom Inventory

Fisher 2018

CRF Treatment

• Exercise intervention based on the patient’s specific cancer diagnosis

• Gait training and functional mobility

• Energy conservation, equipment recommendation and stress reduction techniques

• Education to the patient and caregivers on the nature of cancer related fatigue

Treatment Evidence –Aerobic Exercise

Summary of Evidence

• Safe ‐ active treatment, post treatment and during the palliative stage of care (NCCN, 2014).

Understand patient’s specific cancer diagnosis and status to avoid harm (McNeely, 2006).

• ACSM recommends consideration of pretreatment exercise levels and current health status

in relation to treatment (Schmitz, 2010).

• Avoid overtraining during active treatment as it can be hard on the immune system.

(Schmitz, 2010).

Initial Phase of Exercise:

• 3‐5x per week at twenty minute intervals

(McNeely, 2006).

• Start with frequency, then increase

duration and lastly increase intensity as

tolerated (McNeely, 2006)

Secondary Phase of Exercise:

• Include a warm up, exercise phase and cool

down phase

• The exercise phase can last from 20‐60

minutes (McNeely, 2006)

General Guidelines:

The American College of Sports Medicine base recommendation for cancer survivors is 150

minutes of exercise per week of moderate intensity or 75 minutes of vigorous intensity (Schmitz,

2010).

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Treatment Evidence -Strengthening

Summary of Evidence:

• Strengthening is an integral component of the exercise program for cancer survivors.

• Patients with cancer can experience muscular atrophy from sarcopenia, steroid use,

inactivity and the disease process itself (McNeeley, 2006).

• The extent of the exercise strengthening prescription depends on the patient’s

tolerance for strength training.

• A very weak patient may have to perform less number of exercises, less resistance

and a higher amount of repetitions to build strength tolerance.

Dosage Guidelines:

• ACSM recommends strength training 2‐3x per week with a focus on major muscle

groups and a recovery rest of 48 hours between sessions (Schmitz,2010).

• It is recommended that patients perform a minimum of one set for 8‐12 repetitions

and they should have 8‐10 resistance exercises in their program (McNeeley,2006).

Treatment Evidence - FlexibilitySummary of Evidence:

• Surgery, inactivity and radiation treatment can lead to muscle and joint restrictions.

• Flexibility programs should be created based on the specific needs of the patient.

For instance breast cancer survivors may have decreased mobility through the

shoulder and upper chest region due to surgery and radiation.

• Deep breathing for relaxation can be incorporated during the flexibility aspect of

the program.

• Cancer can be anxiety producing and deep breathing can assist patients in

alleviating some of this stress.

• The cool down or flexibility portion of the exercise program is an excellent time for

patients to utilize breathing techniques combined with stretching.

Dosage Guidelines:

• Total stretch time of two minutes per exercise

• This can be broken down into smaller increments four – five intervals of 30 second

stretches (McNeely, 2006).

Treatment Evidence –Balance/Gait

• The cancer disease process and its treatment can lead to balance and gait dysfunction. • Cancers of the central nervous system can lead to issues of gait instability. • Chemotherapeutic agents used to treat cancer may lead to chemotherapy induced

peripheral neuropathy, this may affect up to 38% of cancer survivors (Pignatoro,2010). • The cytotoxic agents of chemotherapy may cause temporary or permanent damage to

the autonomic, peripheral motor and sensory nerves. • This is manifested as a loss of sensation in a stocking/ glove distribution, distal motor

weakness and/or autonomic signs such as dry mouth and orthostatic hypotension (Pignatoro,2010).

• Therapists should carefully evaluate patients for assistive devices needed to improve gait stability. Functional mobility and safe ambulation are indispensable features in assisting cancer survivors to maintaining a high quality of life.

Dosage Guidelines:

No exact dosage guidelines

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Cancer-related Pain

An unpleasant sensory and emotionalexperience associated with actual or

potential tissue damage

Intl Assoc for the Study of Pain

Pain

• Pain, in addition to fatigue, is the most common complaint in cancer survivors

• High prevalence of pain–Related to lower quality of life and function

• Pain may occur at any point during course of treatment

Cancer Pain

Multifactorial• Post-surgical

• Radiation

• Chemotherapy

• Other treatments

• Pre-existing

Cancer Related• Breast: 40-89%

• Genitourinary: 58-90%

• Head & Neck: 67-91%

• Pancreatic: 72-85%

• Prostate: 56-94%

• Uterine: 30-90%

• After curative treatment: 39%

• During anticancer treatment: 55%

• Advanced, metastatic, or terminal cancer: 66%

Everdingen 2016

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Recommended Pain Measures by EDGE Task Force

Pain Intensity

Visual Analog Scale

Numeric Rating Scale

Pain Quality

McGill Pain Questionnaire – Short Form

Chemotherapy Induced Peripheral Neuropathy

• Chemotherapeutic agents impact peripheral nerves

• CIPN is not preventable• Prevalence – First month after chemo: ~62% – 3 months after chemo: ~60%– > 6 months: ~30%

• Balance deficits and falls are common

Argyriou 2006, Baldwin 2012, Ghoresishi 2012

Assessment

CIPN

Functional Assessment of Cancer Therapy/GynecologicOncology Group‐Neurotoxicity (FACT‐GOG‐Ntx)

Balance

Fullerton Advanced Balance Scale (FAB)

Timed Up and Go (TUG)

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Functional Mobility Impairment

• Balance–Timed Up and Go

–Fullerton Advanced Balance Scale

• Walk Tests–6 MWT

• Mobility (general)–Short Performance Physical Battery

Recommended Prostate Cancer Functional Outcome Measures by

the EDGE Task Force

• 2-Minute Walk Test (2-MWT) • 6-Minute Walk Test (6-MWT) • 10-Meter Timed Walk (10-MTW) • Timed Up and Go (TUG) • 5 times sit to stand (5xSTS) • Short Performance Physical Battery (SPPB) • Physical Performance Battery for Patients with

Cancer (PPB)

Fisher 2015, Davies 2016

AM-PAC• Focuses on activity limitations

based on ICF

• Computer Adaptive TestingBasic Mobility Daily Activity Applied Cognitive

Bending/Standing/Carrying

Grooming/hygiene Communication

Ambulation Feeding and meal prep Print Information

Transfers Personal Care New learning and applying knowledge

Wheelchair skills

http://am‐pac.com/

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AM-PAC• Paper-pencil and Computerized Adaptive

Test

• Inpatient Short Form – 6 items/domain (6 clicks)

AM-PAC

PROSPECTIVE SURVEILLANCE MODEL

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Oncology Team• Radiologist• Pathologist• Breast surgeon• Medical oncologist (hemotologist-oncologist)• Radiation oncologist• Breast Care Coordinator• Cancer rehabilitation specialist• Dietician• Psychological support• Plastic Surgeon• Genetic counselor• Research coordinator

Pre‐Operative Rehab

Assessment

Early

Post‐Operative Rehab

Ongoing Surveillance

and Continued Interval Rehab

Referral to/Initiation of Rehabilitation

Cancer Treatment Cancer Survivorship

Adapted from Stout et al, 2012

Pre-Operative Rehabilitation Assessment

• Purpose: – Gather baseline measurements for future comparison – Identify impairments which may interfere with effective medical

treatment

• Pre-operative visit can be in conjunction with physician office pre-surgical visit or with nurse care manager visit

• Provides important opportunities for prehabilitation

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Pre-Operative Rehabilitation Assessment

• Subjective– Patient history and

understanding of disease process• Opportunities for patient

education– Establish baseline levels

of• HRQOL• Self-reported upper

extremity function• Presence of pain• Presence of fatigue

• Objective Measurements– Range of motion – Strength– Muscular endurance– Posture and flexibility – Limb volume (involved

and uninvolved)– Gait speed– Balance

Pre-Operative Rehabilitation Assessment• Assessment and Plan

– Provide patient with education• Lymphedema risk reduction

• What to expect following surgical treatment

– Address impairments with program tailored to patient

PrehabilitationPreventive rehabilitation with intent to mitigate subsequent disability

Dietz, 1980

“…process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.’’

Silver et al, 2013

Evidence for Need for Prehabilitation• Effectiveness on long term outcomes

– Lung cancer: improved pre-operative pulmonary function status and mitigated declines post-operatively Mojovic et al, 2014

– Colorectal cancer: improved 6MWT compared to control Carli et al, 2010

– Orthopedic population: Post operative ROM and self-reported function improved compared to control Gilbey et al, 2003

• Effectiveness on readmission for cancer patients– Rates typically 16% - 25% (1 month) and 53% - 66% (1 year) Rochefort

and Tomlinson, 2012

– Those readmitted have higher risk for death Lum et al, 2012; Greenblatt et al, 2010

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Prehabilitation in Breast Cancer

• Shoulder motion – Necessary motion for external beam radiation position

• Cardiovascular status– Importance of cardiovascular fitness secondary to cardiotoxic

chemotherapies and left-sided radiation

• Strength– To combat forced inactivity

• Balance– Assess for preexisting deficits which may be heightened in CIPN

• Posture– Mitigate potential changes with radiation

Early Post-operative Rehabilitation• First follow-up visit recommended within a month post-

operatively – Generally outpatient facility– Can be home based if patient is homebound

• Subsequent visits at 3, 6, 9 and 12 months for reassessment– Trigger via a screen in follow-up visits with physician– Regularly scheduled at the first post-op visit

• Purpose:– Identify new impairments that need to be addressed following

surgical treatment

• Compare current measurements with baseline measurements

Early Post-operative Rehabilitation

• Subjective– Gather information based on pathological reports of

cancer• These findings will dictate follow-up medical treatment

– Gather measurements related to:• Level of pain• Level of fatigue

– Generally expect a decline in HRQOL and self-reported upper extremity function in this time period

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• Objective – repeat measures for– Range of motion – educate on precautions if drains remain or if

precautions based on reconstruction are in place– Strength – typically impacted due to surgical process and pain– Muscular endurance – typically impacted due to surgical

process and pain– Posture and flexibility – typically guarding due to surgical

process and pain– Limb volume – compare to baseline and contralateral; ensure

threshold of 3% is not met– Gait speed– Balance – may be of concern due to chemotherapy induced

peripheral neuropathies


• Assessment and Plan–Provide patient with education

• ROM restrictions• Lifting restrictions• Lymphedema skin care

–Address impairments with home program tailored to patient• Postural education• Potential need for self-manual lymph drainage and

prescription of compression sleeve


• Phase extends through approximately 6 months

• Impairments may be later effects dependent upon treatment–Chemotherapy induced peripheral neuropathy–Chemotherapy induced cognitive impairment– Increased levels of fatigue–Changes in mobility

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Ongoing Surveillance and Interval Rehabilitation

• Survivorship continuum beyond the first year• Referral to physical therapy based on previous

history or emergence of new/late effects• Referral made by

– Patient– Nurse care manager– Physician

• Screening– NCI Distress Thermometer– Physical problems sub-section

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• Subjective–HRQOL – FACT-B+4,

SF-36 (EDGE Recommended)

–Arm function – DASH–Chief complaint

and/or patient concerns

–Update medical treatment history

• Objective reassessment of – Motion, strength, muscular

endurance

– Limb volume – ongoing monitoring if pre-clinical; treatment if ≥5% change

– Posture and flexibility –radiation fibrosis may develop

– Gait speed

– Balance


• Assessment and Plan–Treatment based on findings –Dosing frequency different for different problems

• Lymphedema treatment – frequently in the short term until stabilized; order compression garment and ensure compliance

• Strength and muscular endurance – address impairments, prescribe home program, refer to health facility for long term exercise and cardiovascular endurance

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Prospective Surveillance Implementation

• Build into the cancer care continuum at medical centers

• Work closely with referral sources• Attend tumor board meetings• Be on the oncology committee• Educate oncology physicians and rehabilitation

directors– Role of physical therapists, beyond lymphedema surveillance

• Understand the unique opportunities and delivery of care in your system

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• Nurse to measure limb volume bilaterally at follow-up visits

• Use of circumferential tape and truncated cone

• 10% difference prompted referral

CASE STUDIES

CASE A• 55-year-old post- menopausal African

American woman who works as a nursing administrator for a home healthcare company.

• She went to her PCP after feeling a lump in her right upper-outer quadrant on self-exam -referred for imaging.

• Normal way of diagnosing – annual mammogram screen

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CASE A

Imaging• She had a 2.5 cm mass on Mammography and

ultrasound Surgical history• Patient underwent a right breast lumpectomy with

sentinel lymph node evaluation• Positive Sentinel lymph nodes therefore axillary

lymph node dissectionPathology• Malignant cells were detected in 1 sentinel and 2

axillary nodes = total 3 of 14 LN+• Tumor classified as Stage 2B (T2N1M0)• Pathology work up ER/PR+ Her 2 neu+

CASE A

• Post surgery –Chemotherapy TAC chemotherapy with

docetaxel (Taxotere) doxorubicin (Adriamycin), and cyclophosphamide cycled every 21 days for 6 cycles.

• Patient received radiation therapy for 6 weeks, including ipsilateral breast and axillary nodes

Considerations• Referred to physical therapy at the following

times;– Pre-surgical– Post-surgery– Post chemotherapy– Pre or post radiation

• What concerns should the therapist have?• What education should the therapist provide?• What measures should the therapist

take/what is at high risk for impairment?• Which EDGE outcomes are recommended?

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CASE B

• 67-year-old male retired who likes to boat, hike and fish.

• Mild OA in his knees as well as mild COPD.

• He had issues with nocturia (frequent urination at night 3 times each night).

• Went to his physician for a check up.

• Elevated PSA 9 mg/mL

CASE B

• Prostate adenocarcinoma of Gleason grade 7

• Dissection pelvic lymph nodes

• Treated with brachytherapy and a short course of 12 months of ADT

• PSA decreased following

Considerations

• What impairments should the therapist screen for/are most likely?

• What education is necessary for the patient?

• Which tests should be used for baseline measurement?

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References Sander A, Elliot L, Newsome C, Roach J, Tasche L. Development and content

validation of a scale to measure fear of physical activity and exercise in the breast cancer population. Rehabilitation Oncology [serial online]. March 2011;29(1):17-22.Minton O, Berger A, Barsevick A, Cramp F, Goedendorp M, Mitchell SA, Stone PC.

Cancer-related fatigue and its impact on functioning. Cancer. 2013;119 Suppl 11:2124-30.Donovan KA, McGinty HL, Jacobsen PB. A systematic review of research using the

diagnostic criteria for cancer-related fatigue. Psychooncology. 2013;22(4):737-744. Fisher MI, Geyer Lacy H, Davies C, Doherty D. Oncology EDGE: A Systematic

Review of Measures for Cancer Related Fatigue. Rehabil Onc. 2018; 36(2), 93-105. DOI: 10.1097/01.REO.0000000000000124Murphy R, Wassersug R, Dechman G. The role of exercise in managing the adverse

effects of androgen deprivation therapy in men with prostate cancer. Phys Ther Rev. 2011;16(4):269-277. Springer BA, Levy E, McGarvey C, et al. Pre-operative assessment enables early

diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Research And Treatment. 2010;120(1):135-147.Harrington S, Padua D, Battaglini C, et al. Comparison of shoulder flexibility,

strength, and function between breast cancer survivors and healthy participants. Journal of cancer survivorship : research and practice. Jun 2011;5(2):167-174.

Thank You!

Mary I. Fisher, PT, PhD

[email protected]

Oncology Rehabilitation for Therapists · Certified Lymphedema Therapist [email protected]...

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