Cancer Rehabilitation:

1
Cancer Rehabilitation

• Evaluation, Prevention and
• Management of Disability

Stephen F. Levinson, M.D., Ph.D. levinson_at_ece.roch
ester.edu
2
The Impact of Cancer on Function

• Local Effects
• Distant Systemic Effects
• Effects Related to Cancer Treatment
• Chemotherapy Surgery
• Radiation Other Modalities

3
Common Rehabilitation Problems Seen in Cancer
Patients

• Myopathies
• Neuropathies Plexopathies
• Edema
• Pain

• Bony Metastases
• Spinal ColumnInvolvement
• Cognitive Impairment
• Bulbar Involvement
• Generalized Deconditioning

4
The Phases of Cancer Rehabilitation

• Pretreatment
• Treatment
• Survival
• Palliation

5
Pretreatment Evaluation The Social Environment

• Living Situation
• Family Support
• Valued Roles
• Vocational Background
• Education
• Responsibilities
• Hobbies

6
Pretreatment Evaluation Types of Functional
Impairment

• Mobility
• Communication
• Cognition
• Bowel/Bladder Control
• Personal Hygiene Skin Care

• Deconditioning
• Nutrition
• Feeding
• Swallowing

7
Pretreatment Evaluation Prediction Prevention
of Disability

• Chemotherapy
• Neurotoxins
• Vincristine Cis- Carboplatinum
• Suramin Taxol
• Nutritional Impairment
• B12 Folate Deficiency

8
Pretreatment Evaluation Prediction Prevention
of Disability

• Radiation
• Fibrosis Skin Oral Dysfunction
• Neuropathy/Plexopathy
• Presurgical Considerations
• Limb Salvage vs. Amputation
• Level of Amputation
• Other Treatments

9
Rehabilitation During Treatment Immobility

• Effects of Immobility
• Prevention of Related Problems
• Contractures Decubiti
• Muscle Atrophy Deconditioning
• Metabolic Abnormalities
• Role of Exercise Mobilization

10
Rehabilitation During Treatment Myopathy

• Tumor Infiltration
• Paraneoplastic
• Carcinomatous Myopathy Neuromyopathy
• Radiation
• Steroids Other Chemotherapy
• The Role of Exercise
• Adaptive Equipment etc.

11
Rehabilitation During Treatment Bone Destruction

• Direct Invasion
• Metastatic
• Breast Lung Renal
• Colon Pelvic
• Radiation
• Radiation Kills Tumor and Bone

12
When is a Bone Unstable?
1.3 cm
13
Rehabilitation During Treatment Bone Destruction

• Evaluation
• X-Ray Bone Scan CT
• Management
• Pain Stability
• Unweighting Bracing
• Assistive Devices
• Surgical Considerations

14
Rehabilitation During TreatmentSpinal Column
Involvement

• Issues of Stability
• Evaluation
• 3 Column Model
• Types of Bracing
• Body Jacket Halo SOMI
• Surgical Management

15
Rehabilitation During TreatmentSpinal Column
Involvement

• Spinal Cord Compression
• Early Detection
• Pain - Especially at Night
• MRI CT Myelogram
• Treatment Strategies
• Radiation Surgery
• Pain Management

16
Rehabilitation During TreatmentSpinal Column
Involvement

• Management of Functional Impairment
• Mobility
• Self-Care
• Sphincter Disturbances
• Hyperreflexia (Dysreflexia)

17
Rehabilitation During TreatmentNeuropathy
Plexitis

• Causes
• Neurotoxic Chemotherapy
• Direct Invasion Radiation
• Compression Paraneoplastic
• Management
• Pain Control Bracing
• Adaptive Devices Other

18
Rehabilitation During TreatmentPain Management

• Non-opiate Analgesics
• Opiate Analgesics
• Long-acting Forms Breakthrough
• Patient Controlled Analgesia
• Complications Constipation
• Sedation Respiratory Depression

19
Rehabilitation During TreatmentPain Management

• Analgesic Adjuvants
• Antihistamines Stimulants
• Tricyclics Neuroleptics
• Physical Modalities
• Blocks Electrical Stimulation
• Heat Modalities
• Relative Contraindication to Therapeutic Heat

20
Rehabilitation During TreatmentOrthotics
Prosthetics

• Splinting to Maintain Position
• Orthotics to Restore Function
• AFO to lock the knee during stance phase
• Prosthetics to Replace Function/Appearance
• Breast Prosthesis Vocal Prosthesis
• Prosthetic Limb

21
Rehabilitation During TreatmentExtremity Sarcomas

• Limb Salvage Options
• Levels of Amputation
• Lower Extremity
• Partial Foot BKA
• AKA Hip Disartic.
• Hemipelvectomy

22
Rehabilitation During TreatmentExtremity Sarcomas

• Levels of Amputation
• Upper Extremity
• Partial Hand Below Elbow
• Above Elbow Shoulder Disartic.
• Forequarter
• Post-op Management
• ROM Compression Early Fitting (IPOP)

23
Rehabilitation During TreatmentHead Neck Tumors

• Effects of Surgery
• Loss of Head Support
• Impaired Swallowing
• Loss of Speech
• Glossectomy
• Laryngectomy

• Effects of Radiation
• Fibrosis
• Loss of Salivation
• Altered Taste
• Dental Decay
• Prophylactic Extraction

24
Rehabilitation During TreatmentHead Neck Tumors

• Management
• Exercises Orthotics
• Artificial Saliva Seasonings
• Esophageal Speech
• Vocal Prostheses (TEF)

25
Rehabilitation During TreatmentBreast Cancer

• Treatment Options
• Lumpectomy vs. Modified Radical Mastectomy
• Axillary Node Dissection
• Radiation Therapy
• Complications Issues
• Shoulder Contracture Fibrosis
• Disfigurement Lymphedema

26
Rehabilitation During TreatmentBreast Cancer

• Management
• Early Mobilization
• Delayed Healing vs. Loss of Motion
• Breast Prosthesis
• Reconstructive Surgery

27
Rehabilitation During After Treatment The
Swollen Extremity

• Causes
• DVT
• Cellulitis
• Lymphedema
• Direct Invasion Surgical
• Radiation Other
• Lymphatic/Venous Obstruction by Tumor

28
Rehabilitation During After Treatment The
Swollen Extremity

• Evaluation
• Venous Doppler / Venogram
• Lymphangiogram
• Proximal Imaging (CT/MRI)

29
Rehabilitation During After TreatmentLymphedema

• Management
• Elevation
• Compressive Garments Pumps
• Manual Lymph Drainage,Massage and Other
  Treatments
• Caution Risk of Mobilizing Tumor Cells

30
Rehabilitation of the Cancer SurvivorTransition
from Patient to Survivor

• Residual Effects of Acute Care
• Residual Effects of Disease
• Residual Effects of Treatment
• Nutritional Deficits
• Loss of Physical Capacity

31
Rehabilitation of the Cancer SurvivorTransition
from Patient to Survivor

• Psychosocial Issues
• Impaired Body Image
• Fear of Recurrence
• Denial of Recurrence
• The Survivor vs. the World

32
Rehabilitation of the Cancer SurvivorTransition
from Patient to Survivor

• Community Reintegration
• Vocational Issues
• Counseling Retraining
• Return to School
• Work Adaptations
• Job Discrimination

33
Rehabilitation of the Cancer SurvivorTransition
from Patient to Survivor

• Community Reintegration
• Sexuality Reproduction
• Impaired Sexual Function Infertility
• Teratogenesis Pregnancy
• Issues in Children

34
Rehabilitation of the Cancer SurvivorLate
Complications Neurologic

• Neuropathies Plexopathies
• Radiation-Induced
• Residual Chemotherapy
• Tumor Recurrence

35
Rehabilitation of the Cancer SurvivorLate
Complications Neurologic

• Myelopathies
• Radiation Myelitis
• Spinal Metastases
• Cognitive Dysfunction
• Whole Brain Irradiation
• Intrathecal Chemotherapy
• Brain Metastases

36
Rehabilitation of the Cancer SurvivorLate
Complications Neurologic

• Paraneoplastic Disorders
• Unrelated to Disease Activity
• Motor Control
• Myasthenic Syndrome
• Chronic Pain
• Radiation Neuritis Fibrosis
• Recurrence

37
Rehabilitation of the Cancer SurvivorLate
Complications Musculoskeletal

• Skin Soft Tissue Fibrosis
• Effects of Radiation
• Loss of Elasticity, Vascularity Moisture
• Tissue Thickening Edema Contracture
• Management
• Moisturizing Creams Stretching Exercises
• Splinting Orthotics Surgical Interventions

38
Rehabilitation of the Cancer Survivor Evaluation
of Suspected Recurrence

• Suspicious Findings
• Pain Swelling
• New Neurologic Findings
• Evaluation
• History Physical Exam
• Screening Studies
• Bone Scan Plain X-Rays Labs

39
Rehabilitation of the Cancer SurvivorEvaluation
of Suspected Recurrence

• Evaluation
• Specific Studies
• MRI CT EMG
• Lymphangiogram
• Arteriogram
• Surgery

40
Rehabilitation of the Cancer SurvivorLong-Term
Needs

• Community Support Services
• Support Groups
• Local National Organizations

41
National Cancer Institute (NCI)9000 Rockville
Pike31 Center Dr. - MSC 2580Bethesda, MD
20892-2580Phone (800) 4-CANCER (800-422-6237
)Web http//cis.nci.nih.gov/
42
National Coalition for Cancer Survivorship1010
Wayne Avenue, Suite 770Silver Spring, MD
20910-5600Phone (877) NCSS-YES
(877-622-7937)Fax [phone]E-mail info_at_c
anceradvocacy.orgWeb www.canceradvocacy.org