- Email: [email protected]
Cardiovascular, pulmonary, and cancer rehabilitation. 3. Cancer rehabilitation
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Cardiovascular, Pulmonary, Cancer Rehabilitation Michael J. Brennan, Rehabilitation
and Cancer Rehabilitation.
3.
MD
Center of Fairjield
Robert W. DePompolo,
County, Bridgeport,
CT 06610
MD
Mayo Clinic, Rochester, MN 55905
Fae H. Garden, MD Baylor
College of Medicine,
Houston,
TX 77030
ABSTRACT. Brennan MJ, DePompolo RW, Garden FH: Cardiovascular, pulmonary, and cancer rehabilitation. 3. Cancer rehabilitation. Arch Phys Med Rehabil77:S52-S-58, 1996. l This self-directed learning module highlights several important rehabilitation aspects in the care of persons with cancer. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the organization of a cancer rehabilitation team, unique rehabilitation issues presented by specific common tumors, and the impact of common complications on successful rehabilitation outcomes. 0 1996 by the American Academy of Physical Medicine and Rehabilitation 3.1 Objective. -Support the integration of rehabilitation services into a comprehensive cancer treatment program.
Both the incidence of cancer and survival after a diagnosis of cancer are increasing. More than 8 million persons in the United States are currently living with a history of a cancer diagnosis. Treatment patterns for cancer tend to be more aggressive and are more likely to make use of multimodal therapy. The potential for these treatments to cause disabilities is high. Unfortunately, there is a lack of hard data concerning the rate of common treatment-related complications and of the disability directly related to cancer or cancer treatments. However, it can be reasonably concluded that the cancer survivor’s need for rehabilitation services is growing and will continue to grow. Although many hospitals have invested space and personnel to develop specialty cancer programs, few rehabilitation units are designated specifically for the care of the cancer patient. Rehabilitation personnel may lack the skills needed to work with disabled cancer patients and their families. Alternatives to the traditional inpatient unit include outpatient therapy services for patients whose conditions have stabilized. Home health therapy services can provide a convenient cost-effective method for providing therapy services at home. When independent living with home care services is no longer appropriate, an extended-care facility such as a skilled nursing facility or nursing home may be considered. Inpatient hospice programs are available in some areas. Hospice or palliative care programs can sometimes provide family training as well as outpatient therapy, nursing, and social services. Many of the members of a cancer rehabilitation team can be identified among the existing personnel at a cancer treatment center. The members of a multidisciplinary cancer rehabilitation team vary according to program size, type of institution, and range of disabilities encountered. The physician, who usually serves as the team leader, is responsible for bridging rehabilitation efforts and medical issues. In addition, the physician must keep the team properly focused Arch
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on the major care issues, maintain team morale, represent the team appropriately within the rest of the medical center, and ensure that the team responds in a timely manner to requests for services. An oncology nurse, physical and occupational therapist, social worker, psychologist, pharmacist, speech pathologist, dietitian, recreational therapist, and chaplain are typical members of a cancer rehabilitation team. Although each member brings a unique background and training to the team, to work effectively the team must accept and actually encourage overlap of tasks, responsibilities, and roles (1, pp. 413-32; 2, pp. 2539-41). 3.2 Objective.-Summarize the nutritional needs of a 60year-old man undergoing chemotherapy for multiple myeloma.
Nutritional needs of cancer patients take into account preexisting individual nutritional parameters, clinical status, tumor type and size, and treatment plan. Calorie intake should be between 115% and 130% of resting energy expenditure. Tumor types vary in their metabolic activity, and weight loss will vary depending on the site and extent of cancer involvement. Recommended protein intake ranges from 1.5g/kg per day to 2Sg/kg per day. Surgery, radiation, and chemotherapy will further increase a person’s protein needs. Loss of appetite can result from tumor growth and tumorinduced discomfort. Radiation therapy to the head and neck can alter saliva production and taste sensation. If the oral mucosa is affected, sensitivity to the temperature and texture of food results. Swallowing may be difficult, and consequently enteral tube feeding may be necessary to minimize weight loss. Acute enteral complications of radiation therapy to the stomach and small bowel include nausea, vomiting, cramps, and intermittent diarrhea. Long-term complications include partial or complete intestinal obstruction, intestinal perforation, malabsorption, and enteric fistula. The extent of side effects from chemotherapy vary and depend on the type and combination of agents given, the duration of treatment, and individual tolerance. Nausea,
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vomiting, and anorexia are common initial side effects after the administration of cancer chemotherapeutic agents. Additional side effects include stomatitis, mucosal ulceration, glossitis, and pharyngitis. Standard antiemetic agents include metoclopramide, a substituted benzodiazepine that binds to dopamine receptors. Haloperidol, prochlorperazine, dexamethasone, and cannabinoids are also effective in some patients. Advances in the control of chemotherapy-induced emesis include use of a ents that exert their activity by blocking serotonin (5hydr xytryptamine) receptors. An example of a medication in tB is category is ondansetron hydrochloride (Zofran), which clan be administered by the oral or intravenous route. Antimetabolite, chemotherapeutic agents interfere with DNA, RNA, or protein synthesis by blocking the use of essential vitamins, purines, and pyrimidines. The rapidly reproducing cells o , the bone marrow and gastrointestinal tract are especially vuhrerable to the effects of this treatment. Numerous nutritional deficiencies can result. Serum levels of vitamins are nondiagnostic, and nutritional deficiencies are best identified by outward manifestations and by the patient’s response to therapeutic vitamin replacement trials. During the couise of cancer treatments, patients may associate particular foods or flavors with nausea and vomiting. A learned food aversion can develop. Although the exact mechanism is unknown, it has been described as a variant of classic conditioning. The conditioned stimulus is the food or taste, and the unconditioned stimulus is the illness. Usual foods consumed i the hours before the start of chemotherapy can cause a rearned food aversion. Meats, vegetables, and caffeinated beverages are the types of foods most likely to result in such a response. Routine use of total parenteral nutrition in patie ts receiving chemotherapy is not advised except in case of nsevere malnourishment. Supplemental nutritional support i patients who have an adequately functioning gastrointestin 1 1 tract can include gastrostomy or jejunostomy feedings (l,~ pp. 393-404; 2, pp. 2554-56, 2559).
d
3.3 Objective.-qompare the acute and chronic complications of chemotherapy and radiation therapy which could inte$erie with your rehabilitation efforts for a debilitated 70-year-old patient with systemic cancer. Most chemothe apeutic agents produce a cytotoxic effect in a wide variety, r of normal tissues. Severe bone marrow depression can result in leukopenia and lymphocytopenia with an increased1 risk of infection. Thrombocytopenia can lead to hemorrhag . Platelet counts as low as between 20,000 and 50,000/mm3 ay necessitate withdrawal of the patient from active phys cal therapy services. Resistive exercises may result in incr ased blood pressure and increase the risk for hemorrhage. ausea, alopecia, and impaired wound healing are also signi:, cant side effects of chemotherapy. Neuropsychological effects of chemotherapy are most often seen with high-dose therapy and usually resolve within 48 to 72 hours. Prolonged ‘cognitive and behavioral deficits can be present weeks af r treatment has been discontinued. The acute reaction to rain irradiation consists of somnolence, headache, nausea,1and worsening of preexisting focal symptoms. Pretreatmem with dexamethasone, 24 to 72 hours before radiotherapy 10 the brain, is often ordered.
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Late effects of radiation therapy include myelopathy, plexopathy, encephalopathy, and cerebral necrosis. Differential diagnosis between the late effects of radiation and disease recurrence is often difficult. Children, in particular, sustain measurable late neuropsychological effects from wholebrain radiation therapy. These effects may be dose related and may be enhanced by the use of chemotherapy. The peripheral nervous system can also be involved with plexopathies from late tissue fibrosis seen after radiation therapy. Other organ systems, such as endocrine, renal, immune, cardiovascular, gastrointestinal, pulmonary, and musculoskeletal, can sustain late effects of chemotherapy and radiation therapy. In general, chemotherapy-related neuropathies tend to be distal and symmetrical. The chemotherapeutic agents vincristine and cisplatin have been shown to cause autonomic neuropathies. Vincristine causes a distal axonal degeneration that resembles other toxic neuropathies. Patients experience sensory complaints of numbness and paresthesias. Some patients have severe neuropathic pain. Recovery is usually complete, although many months may pass before resolution of symptoms (1, pp. 229-41, 405- 11; 2, pp. 2548, 2564-66; 3, pp. 840-58; 4). 3.4 Objective. approach small cell chest wall
-Formulate a comprehensive rehabilitation to a B&year-old man with a 2-year history of lung cancer who presents with progressive pain.
Recurrent or progressive pain in any patient treated for cancer is always an ominous sign. Post-thoracotomy pain that persists or reappears months after surgery suggests recurrent disease. However, not all postoperative pain syndromes are associated with recurrent cancer. For example, there is phantom breast pain of unknown etiology and postmastectomy pain syndrome thought to be due to intercostobrachial nerve injury. Pain that progresses despite the use of antineoplastic therapy or pain that becomes rapidly more severe should always be regarded as representing disease progression until proven otherwise. Many cancer centers make use of an interdisciplinary pain management team. The primary approach to the management of patients with cancer pain is the appropriate use of opiate medication. Frequent reassessment is required to optimize treatment of cancer-related pain. Analgesic needs typically escalate as the disease progresses or as tolerance develops to opiates. In contrast, if the disease or its side effects are better controlled, the need for opiates may diminish dramatically. Certain cancer pain syndromes are amenable to physiatric techniques, including transcutaneous electrical nerve stimulation (TENS), exercise techniques, the use of orthotics, and other modalities. Anesthetic intervention such as nerve blocks and the epidural or intrathecal administration of anesthetics and/or opiates, as well as neurosurgical ablative and neurostimulatory procedures, may all be indicated in the treatment of cancer pain. Cordotomy, the destruction of a unilateral spinal thalamic track, is indicated only for severe unilateral leg pain in patients with life expectancies of less than 6 months. In patients with advanced disease, there is Arch
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often a need for multiple routes of administration of opiates in order to obtain adequate analgesia (5, pp. 351-3; 6). A number of other medications and adjuvant agents can be employed for treatment of cancer-related pain. The reader is referred to the Study Guide on Cancer Pain, Pelvic Pain, and Age-Related Considerations.’ 3.5 Objective. -Provide a rehabilitation prescription for a patient who has shoulder pain after radical neck resection for cancer of the larynx. Cancer of the head and neck may result in impaired function of the upper extremities, speech, and swallowing. Transection of nerves integral to the stabilizing muscles of the neck and shoulder, particularly the spinal accessory nerve and branches of the cervical plexus, may occur in both modified and radical neck dissections. This can result in limitation in shoulder range of motion (ROM), as well as in shoulder instability. Patients typically describe pain and soreness over the anterior portion of the shoulder and also pain in the lateral aspect of the neck and occasionally into the anterior chest. In addition to musculoskeletal pain, discomfort can arise from contracture of the soft tissue of the shoulder, anterior chest wall, neck, and upper back. Physical therapy to maintain joint range and muscle strength may decrease the pain. In addition, the use of appropriate modalities should be considered such as superficial heat, ice, and TENS. However, skin over irradiated areas is more sensitive to thermal modalities and skin irritants, and team members should be cautious when applying these modalities. The patient should have a thorough evaluation of his or her activities of daily living, swallowing abilities, and communication functions. Swallowing and language deficits can occur in patients who have undergone resection of portions of the tongue, pharynx, hypopharynx, and larynx. Radiotherapy is typically given in addition to surgical management of head and neck cancers, and the consequences include osteonecrosis, mucositis, and radiation burns to the neck and jaw, which can also result in impaired function.“.’ 3.6 Objective.-Design the rehabilitation program for a woman 2 days after surgery for breast cancer. Breast cancer will affect 1 in 9 women in the United States. Current primary management includes either modified radical mastectomy or lumpectomy with associated axillary node dissection and radiotherapy. Stage I disease has a 90% survival rate 5 years after treatment when either of these approaches is used. Adjuvant chemotherapy and antiestrogen therapy may be used in this population as well. Immediate postoperative mobilization of the affected arm has been recommended to avoid limitation in ROM of the shoulder. Gentle passive and active-assisted ROM exercises can be instituted at the earliest possible time. Full active and active-assisted ROM exercises should be started after the surgical drains have been removed. Full ROM of the shoulder is often needed in order to obtain necessary positioning for postoperative radiation therapy. The most common long-term complication of breast cancer management is lymphedema, which occurs in 6% to 62% of patients after radical mastectomy. (See Objective 3.14 for Arch
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further cations 5% of 261-5;
discussion of lympedema.) Other long-term compliinclude brachial plexopathy, which occurs in up to patients treated with adjuvant radiotherapy (1, pp. 5, pp. 339-41, 351-2, 354-5; 10).
3.7 Objective.-Compare the long-term outcomes of children treated for brain tumor and for leukemia. Although cancer deaths among children have declined markedly over the last several decades, malignancy remains the second leading cause of death in children in the United States. Acute lymphoblastic leukemia, primary brain tumors, and Hodgkin’s disease are the three most common malignancies found in children (1, pp. 243-50). The 5-year survival rate of children with leukemia is 70% after treatment with radiation therapy and chemotherapy. Long-term complications from whole-brain radiation therapy used for prophylactic treatment of children with acute lymphoblastic leukemia include depressed cognitive function even with doses as low as 1,SOOcGy.’ ’ Brain tumors in children, of which medulloblastoma is the most common, tend to occur in the infratentorial region and the posterior fossa. Focal neurological deficits result from the effects of both the primary tumors and the localized treatment of such tumors. Secondary malignancy in patients treated for cancer is a recognized long-term complication. Children treated for malignancies and Hodgkin’s disease are at greatest risk. An incidence of 17% by age 20 has been found, which is 20 times greater than that of the general population. The most common secondary tumors are osteosarcomas, soft tissue sarcomas, leukemias, and tumors of the brain, thyroid, and breast.12 3.8 Objective. -Critically analyze the use of limb-sparing procedures for a I3-year-old patient with osteogenic sarcoma of the distal end of the femur. Sarcomas account for 7% of all pediatric malignancies. Previously, amputation was the only treatment option; now, limb salvage procedures are the most common surgical treatment. In these procedures, endoprosthetics are used to replace bone involved with tumor. The knee joint is most often replaced, because of the higher frequency of primary bone tumors of the proximal tibia and distal femur. Survival rates are comparable to those for patients undergoing limb salvage and traditional amputation. Long-term complications occurring with limb salvage procedures include loosening of the endoprosthesis, peripheral nerve damage, and poor wound healing leading to a high rate of surgical revision.13 Amputations are complicated by difficult prosthetic fittings as a result of the unusual shapes and sizes of residual limbs (1, pp. 297-3 19). Lower extremity limb salvage procedures are associated with less energy consumption with ambulation when compared to above-knee amputations.14 Another surgical option is the Van Nes rotationplasty, in which bone tumor is removed about the knee. The lower leg is brought up and rotated while the neurovascular bundle is maintained, and the ankle is substituted as a functional knee. Patients benefit from the preserved proprioception around the surgically created knee which results in improved function and decreased energy consumption. A modified belowknee prosthesis is prescribed. Complications seen in the Van
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Nes rotationplasty are similar to those encountered in limb salvage procedures. Limb salvage procedures have also been used in adults as well as in children with metastases at a single location, particularly at the hip or pelvis. For further information the reader is referred to Objective 2.3 in the Limb Deficiency section of this Study Guide. 3.9 Objective. --Distinguish between primary and metastatic brain Itumors in a 60-year-old patient who presents with a single frontal lobe lesion. Primary and n@astatic brain tumors cause significant dysfunction. The incidence of primary and metastatic brain tumors has been increasing over the last several years. Brain metastasis has a frequency 25 times greater than that of primary brain t ors. Eighty percent of brain metastases are found in the+ cerebral hemispheres, 10% to 15% in the cerebellum, and b % to 3% in the brain stem. Fifty percent of metastases are single. The most common primary intracranial tumors are meningiomas, whereas~ the most common primary brain tumors are gliomas. The functional sequelae of most intracranial tumors are due to local injury, vascular compromise, and edema. Motor and sensory deficits, visual field disturbance, and cognitive i pairment can develop as a result of brain tumors, dependi g on the location of the lesion. Treatment for both primary nd metastatic tumors may include surgical resection, whole brain or localized radiotherapy, and intrathecal chemot erapy. High doses of corticosteroids may also be used in I t ese patients, and neurological impairment may increase with weaning from these medications. The neurological deficits encountered are treated by traditional rehabilitation intervention.‘5.‘6 3.10 Objective. -Evaluate the common causes of sexual dysfunction~in a 40-year-old woman with cervical cancer. Cancer and cancer treatments can produce significant disruption of sexuaI function. For many persons undergoing cancer treatment,lsex is the least of their concerns, but others remain apprehensive about how their illness will affect their sexuality or sex&l relationship. Sexual problems of cancer patients typical1 have an acute onset, appearing immediately after treatm1 nt or during recovery. These may include decreased sexual desire, erectile failure, and orgasmic dysfunction. The ef dects of the disease and the side effects of treatment must be differentiated from depression. Partners can contribute to ,sexual dysfunction by fostering dependent roles or reacting In a negative way to the patient’s physical disfigurement. Ec onomic stress caused by the treatment can lead to marital pipblems that are expressed by avoidance of sexual contact. Some patients need to receive the physician’s “permission” to lengage in sexual activity during the course of their cancer treatment. Women who have undergone treatment for cancer may negative impact on their sexual rerejection can lead to the avoidance Gynecological surgery can result in a Patients will need to be counseled
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about the use of artificial lubrication and change from customary sexual positions. Women should be educated about the possible need for vaginal dilators to prevent stenosis as well as to prepare for the possibility of bleeding with intercourse. Side effects of chemotherapy and radiation therapy can produce additional psychological impairments to resuming sexual relationships. The American Cancer Society (l-SOO-ACS-2345) has local units all over the country which can provide volunteer visitor programs to assist with a patient’s physical and psychological needs. Some of these volunteers can serve as models of successful adjustment following cancer surgery and therapy. Sexual problems in men may occur after cancer treatment. Surgical treatment of prostate cancer can cause damage to vascular and nerve structures, resulting in impotence, retrograde ejaculation, or infertility. Orchiectomy has obvious hormonal and reproductive implications. Preoperative discussion of reproductive concerns should include consideration of sperm banking if permanent sterilization is anticipated. Pelvic or abdominal irradiation can produce fatigue, diarrhea, and erectile dysfunction. Irradiation to the urethra can cause painful ejaculation. Sexual rehabilitation may include the use of erectile assistive devices and surgical reconstruction of the phallus. The decision to use an implanted penile prosthesis must be made by both the patient and his sexual partner. Operations that require stoma construction can result in problems for both male and female sexuality. The creation of an artificial opening for body excretions can have a profound negative effect on sexual self-image. The timing of a return to sexual activity after stoma construction is essential. Sexual relations should not be resumed until the patient is significantly recovered in terms of both acute surgical healing and physical endurance. Alternatives to traditional sexual intercourse positions should be discussed. The patient should be reminded to empty the stoma appliance before engaging in sex in order to avoid leaks or odors. It may be preferable for the patient or his or her partner to cover the stoma apparatus so that it is not directly visible during sexual intercourse (1, pp. 251-66; 17). 3.11 Objective. -Formulate a rehabilitation program for a deconditioned 80-year-old patient with small cell carcinoma of the lung who is complaining of falls. Impaired balance in a patient with a history of carcinoma, especially a lung tumor, signals the possibility of metastatic disease to the nervous system. Twenty-five percent of pulmonary carcinomas metastasize to the brain. Motor deficits typically correspond to areas of local destruction, edema, and vascular compromise. Lung cancer, as well as other carcinomas, particularly those of the ovary, have been associated with paraneoplastic syndromes.” The Lambert-Eaton myasthenic syndrome is perhaps the best known of the paraneoplastic syndromes. Electrodiagnostic techniques to identify this syndrome are discussed in the neuromuscular sections of the Study Guide on electromyography. Other paraneoplastic syndromes that affect both the central and the peripheral nervous systems have been described. Treatment directed at the malignancy may reverse the effects caused by the paraneoplastic syndrome. However, reversal does not Arch
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necessarily occur, and long-term effects can result. Peripheral neuropathy from chemotherapy administered as an antineoplastic agent may also result in poor balance. Finally, epidural disease causing cord dysfunction can impair balance as well as strength, both of which impairments may cause falls. The spinal cord can also be injured by the administration of radiotherapy.‘5”9’20 3.12 Objective. -Evaluate the existing treatment for malignant hypercalcemia.
options
Although hypercalcemia is a frequent complication of some tumors, such as lung and breast cancer, it can also be seen in a variety of other malignancies. Hypercalcemia is a common life-threatening metabolic abnormality in patients with cancer, and therefore it is important to be able to recognize its clinical presentation. The early symptoms can include nausea, anorexia, lethargy, fatigue, hypertension, and polyuria. Unfortunately, these symptoms are nonspecific and the picture can be confused by other medical issues, especially since hypercalcemia is often seen at an advanced stage of the malignancy (3, pp. 816-21; 21; 22). Although reduction of the tumor burden is considered the only effective long-term treatment for hypercalcemia, this measure can often be only slowly instituted, and it may not be possible at all. If the patient is symptomatic from the hypercalcemia, or if serum calcium levels are 13mg/dL or greater, other treatment options need to be initiated. Vigorous hydration is often the initial treatment, as it can facilitate the excretion of calcium. Furosemide is now recommended for use only when fluid overload is a problem or diuresis is not adequate. Other treatment options for persistent hypercalcemia include intravenous mithramycin, subcutaneous calcitonin, intravenous biphosphonates, oral phosphorus, corticosteroids, and continuous intravenous infusion of gallium nitrate (3, pp. 819-21; 23). Because many patients with marked hypercalcemia do not respond adequately to hydration alone, and because aggressive hydration can itself have significant consequences, these other treatment options often are needed for adequate therapy. The decision to treat hypercalcemia can be difficult if the underlying cancer prognosis is poor, because the hypercalcemia treatment itself can have significant side effects. However, there may be short-term improvement of symptoms even in the face of poor cancer prognosis which justifies intervention. Both the recognition of the existence of this complication and an understanding of its response to treatment are important as cancer rehabilitation goals are set and therapy resources are committed. 3.13 Objective. -Describe your rehabilitation approach to a 60-year-old patient with prostatic cancer who presents with neck pain and acute arm and leg weakness. Metastatic spinal cord compression in patients with systemic cancer is a common complication, especially with carcinomas of the breast, lung, prostate, and kidney, as well as in myeloma, sarcoma, and lymphoma (1, pp. 345-6). Other possible causes of spinal cord dysfunction in patients with cancer are treatment related and include radiation myelitis and radiation fibrosis (2, pp. 2538-69). The thoracic spine is by far the most common level of metastatic spinal cord Arch
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compression, followed by lumbar and cervical levels. Although many rehabilitation issues of acute spinal cord injury apply here, there are some unique and important differences. As in acute spinal cord injury, spine stability is an early and critical issue (2, pp. 2538-69; 24). Management may require the use of rigid spinal orthosis, cord decompression, radiation therapy, chemotherapy, or surgical stabilization (1, pp. 345-61; 2; 24; 25; 26). Unlike the situation with traumatic spinal instability, management must be tempered by prognosis. Treatment to achieve optimal spine stability has to be considered in the light of the life expectancy of the patient, the need for pain control, and the issues of quality of life. These decisions require input not only from the spine surgeon but also from the other pertinent care team members and, of course, the patient. Functional outcome from cord compression has been reviewed by several authors. Tumor radiosensitivity, the presence or absence of neurological findings, and the tumor type have consistently been found to be reasonable prognostic indicators (1, pp. 345-61; 24; 27). The customary concerns in spinal cord injury rehabilitation are compounded by the effect of the cancer and its treatment on other organ systems. This can include unique cardiovascular, pulmonary, gastrointestinal, genitourinary, bone, hematopoietic, immune, dermatological, and endocrine problems, as well outlined by Schlicht and Smelz (1, pp. 345-61). For example, spine metastasis is likely to coexist with lytic lesions to the long bones of the arms and legs, and this circumstance will make transfer training difficult at best. Awareness of these common comorbidities and complications will increase our ability to set reasonable rehabilitation goals. Finally, it should be noted that the most common complaint at the onset of metastatic spinal cord compression is pain and that pain often occurs before the onset of weakness or sensory loss. Therefore, spine pain in patients with known cancer should be worked up aggressively. Spinal cord compression due to metastasis is a medical emergency, as favorable outcome is possibly dependent on the speed of diagnosis and treatment. The best noninvasive imaging studies presently available for diagnosis are magnetic resonance and computed tomography. 3.14 Objective.-Formulate a plan for the management of upper extremity lymphedema in a woman 1 year after Eumpectomy, axillary lymph node dissection, and radiotherapy for breast cancer. Upper extremity lymphedema associated with breast cancer is well documented as a common complication, but its reported incidence varies (1, pp. 267-77; 28; 29; 30). Also, although lymphedema can be either an early or a late complication, it may represent tumor recurrence. That possibility should be considered, especially if the involved limb is painful. Lymphedema may be due to several factors, including surgical technique, infection, axillary radiation, and venous obstruction (1, p. 268). Similarly, the pathophysiology has been described as a cascade of events, including the structural integrity of the lymphatic system and the physiological
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impact of protein-rich liquid in the tissue (1, pp. 26777; 31). The approach to treatment is controversial, there being proponents of nonintervention, nonsurgical intervention, and surgical treatment. Most authors, however, support a conservative approach, including prevention and some form of massage, exercis , and compression. Prevention should start with the selecti n of a surgical technique that least affects lymph drainage $ hile effectively treating the cancer. Prevention should also mclude appropriate postoperative care such as elevation, R exercises, and compressive wraps (1, p. 271; 32). Most T mportant is patient education about home care principles a d possible complications. Nonsurgical i terventions for the treatment of postmastectomy lymphede 4 a have been outlined by several authors (1, pp. 267-77; 31; ~33). The program might include frequent arm measureme ts to note changes, a review of elevation principles, camp essive wraps, muscle sets of the involved, elevated arm ag inst the compressive wraps, and decongestive massage. Ir+addition, z mechanical compression is often added for more srgnificant edema problems. Two basic types of devices are u$ed: single chamber and multiple chamber. The single-chamber devices are typically set at 40 to 60mm Hg pressure and ~cycled on and off for 45 minutes per treatment or longer. The multiple-chamber devices allow sequential distal-to-pro imal pumping to essentially “milk” the arm. There rem 4 ns some debate over the optimal device and the use schedule.~Once the lymphedema has been controlled, gradated compre sive garments often are needed to prevent its recurrence. T isese garments are sold both as standard fit and custom fit. They can be limited to just a distal sleeve or extend proximally to the axillary area, in which case a shoulder flap is often required to hold the garment in place. Detachable or nondetachable gloves and gauntlets can be added. The extent of the garment depends on the location of the edema. Custom fitting is often required to properly control significant edema. More recently: special massage techniques have been introduced that att 4 mpt to directly stimulate the activity of the lymphatic system.” These techniques are usually coupled with compressive wrapping. However, mechanical compression devices should be avoided. The role of surgical treatment for lymphedema management remains cohtroversial at this time (1, pp. 267-77; 31; 34; 35). In addition to the physical issues, lymphedema causes psychosocial concerns that have an impact on treatment success or failure. 3.15 Objective. -Construct a rehabilitation program for an 80-year-014 man with hip pain who has a history of renal cell qarcinoma.
Certain tumor$ have a high propensity for metastasizing to bone, the mo$t common being renal cell, thyroid, lung, breast, and prostate cancers. The vertebral column is the most frequently ~involved site. Bone metastases are rarely solitary; more th n one bony lesion is found in 90% of cases. Solitary metasta es usually are confined to the spine, the pelvis, or the rib 3 . The proximal femur is the most common long bone site involved. Metastatic disease rarely occurs
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below the elbow and below the knee. Bone tumors, regardless of size, impair the ability of the bone to bear weight and withstand normal torsional forces. Therefore, all metastases should be treated both symptomatically and prophylactically to avoid further functional compromise. Treatment is typically radiotherapy, but surgical resection of the lesion is indicated in some cases. Weight-bearing status depends on the severity of the lesion and the potential risk for pathological fracture. It is suggested that there is a significantly increased risk of fracture in long bones when painful lesions are greater than 2Scm in diameter, they occupy 50% or more of bony cortical diameter, they affect more than 50% of the medullary cross-sectional area, or they involve the cortical surface.jh Adequate analgesia for bone-related pain is often achieved with the use of nonsteroidal anti-inflammatory drugs. Pain management in these patients may include appropriate immobilization (1, pp. 363-92; 37; 38). References *1. *2.
*3.
*4. *5. 6. *I.
8. 9.
10.
11.
*12.
13.
14.
*15. 16. 17. 18.
19.
Garden FH, Grabois M, editors. Cancer rehabilitation. Phys Med Rehabil: State of the Art Rev. 1994;8(2). Gerber LH, Levinson S, Hicks J, Gallelli P, Whitehurst J, Scheib D, Sonies BC. Evaluation and management of disability: rehabilitation aspects of cancer. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993;2538-69. Groenwald SL, Frogge MH, Goodman M, Yarbro CH, editors. Cancer nursing: principles and practice. 3rd ed. Boston: Jones & Bartlett, 1993. Dropcho EJ: Central nervous system injury by therapeutic irradiation. Neurol Clin 1991;9:969-88. Elliott K, Foley KM. Neurologic pain syndromes in patients with cancer. Neural Clin 1989;7:333-60. Brennan MJ. Role of physiatry. In: Arbit E, editor. The management of cancer-related pain. New York: Futura, 1993; 179-93. Williams FH, Maly BJ. Pain rehabilitation. 3. Cancer pain, pelvic pain, and age-related considerations. Arch Phys Med Rehabil 1994;75:S-15-6. Kaplan E, Gumport SL. Cancer rehabilitation. In: Goodgold J, editor. Rehabilitation medicine. St. Louis: Mosby 1988;285-97. Krauss DH, Shaw JP. Management of head and neck cancer pain. In: Arbit E, editor. The management of cancer-related pain. New York: Futura, 1993;41 l-23. Markowski J, Wilcox JP, Helm PA. Lymphedema incidence after specific postmastectomy therapy. Arch Phys Med Rehabil 1981; 62:449-52. Janlovic M, Brouwers P, Valsecchi MG, Veldhuizen AV, Huisman J, Kingma A, et al. Association of 1,800 cGy cranial irradiation with intellectual function in children with acute lymphoblastic leukemia. Lancet 1994;344:224-7. Tucker MA. Adverse effects of treatment: secondary cancers. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993; 2410- 1. Rougraff BT, Simon MA, Kneisl JS, Greenberg DV, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur: a long-term oncological functional, and quality-oflife study. J Bone Joint Surg 1994;76-A:649-56. Otis JC, Lane JM, Kroll MA. Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above-the-knee amputation. J Bone Joint Surg 1985;67-A:606-I 1. Patchell RA: Brain metastases. Neural Clin 1991;9:817-24. Posner JB, Chemik NL. Intracranial metastases from systemic cancer. Adv Neural 1978; 19:579-92. Glasgow M, Haltin V, Althausen AF. Sexual response and cancer. CA Cancer J Clin, American Cancer Society, 1987;36:322-33. Bunn PA, Ridgway EC. Paraneoplastic syndromes. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993; 2043-4. Delattre JY, Posner JB. Neurological complications of chemotherapy
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20.
21.
22.
23.
24. 25. 26.
*27.
28.
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and radiation therapy. In: Aminoff MJ, editor. Neurology and general medicine: the neurological aspects of medical disorders, New York: Churchill Livingstone, 1989;365-87. Hovestadt A, Van Woerkom TCM, Vecht CJ. The frequency of neurological disease in a cancer hospital. (Letter) Eur J Cancer 1990;26:7656. Vassilopoulou-Sellin R, Newman BM, Taylor SH, Guinee VF. Incidence of hypercalcemia in patients with malignancy referred to a comprehensive cancer center. Cancer 1993; 7 I : 1309-12. Ralston SH, Gallacher SJ, Pate1 U, Campbell J, Boyle IT. Cancerassociated hypercalcemia: morbidity and mortality: clinical experience in 126 treated patients. Ann Intern Med 1990; I 12:499-504. Warrell RP. Oncologic emergencies: metabolic emergencies. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993;2128-34. O’Connor MI, Currier BL. Metastatic disease of the spine. Orthopedics 1992; 15:61 I-20. Galasko CSB. Spinal instability secondary to metastatic cancer. J Bone Joint Surg 1991;73-B:104-8. Shimizu K, Shikata J, Lida H, Iwasaki R, Yoshikawa J, Yamamuro T. Posterior decompression and stabilization for multiple metastatic tumors of the spine. Spine 1992; 17:1400-4. Kim RY, Spencer SA, Meredith RF, Weppelmann B, Lee JY, Smith JW, et al. Extradural spinal cord compression: analysis of factors determining functional prognosis-prospective study. Radiology 1990; 176:279-82. Hoe AL, Iven D, Royle CT, Taylor I. Incidence of arm swelling following axillary clearance for breast cancer. Br J Surg 1992;79:261-2.
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29. Ryttov N, Holm NV, Qvist N, Blichert-Toft M. Influence of adjuvant irradiation on the development of late arm lymphedema and impaired shoulder mobility after mastectomy for carcinoma of the breast. Acta Oncol 1988; 27:667-70. 30. Kissin MW, Querci della Rovere G, Easton D, Westbury G. Risk of lymphoedema following the treatment of breast cancer. Br J Surg 1986;73:580-4. 3 I. Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg 1989;22:505-15. 32. Whitman M, McDaniel RW. Preventing lymphedema: an unwelcome sequel to breast cancer. Nursing93 1993; 23( 12):36-9. 33. Stillwell GK. Treatment of postmastectomy lymphedema. Mod Treatment 1969; 6:396-4 12. 34. Miller TA. Surgical approach to lymphedema of the arm after mastectomy. Am J Surg 1984; 148:152-6. 35. Savage RC. The surgical management of lymphedema. Surg Gynecol Obstet 1985; 160:283-90. *36. Mandi A, Szepesi K, Mdrocz I. Surgical treatment of pathologic fractures from metastatic tumors of long bones. Orthopedics 1991; 14:439. 37. Boland P, Billings J, Healy JH. The management of pathological fractures. J Back Musculoskel Rehabil 1993;3:27-34. 38. McDonnell ME, Shea BD. Role of physical therapy in patients with metastatic disease to the bone. J Back Musculoskel Rehabil 1993;3:78-84. *Key
References.
Cardiovascular, Pulmonary, Cancer Rehabilitation Michael J. Brennan, Rehabilitation
and Cancer Rehabilitation.
3.
MD
Center of Fairjield
Robert W. DePompolo,
County, Bridgeport,
CT 06610
MD
Mayo Clinic, Rochester, MN 55905
Fae H. Garden, MD Baylor
College of Medicine,
Houston,
TX 77030
ABSTRACT. Brennan MJ, DePompolo RW, Garden FH: Cardiovascular, pulmonary, and cancer rehabilitation. 3. Cancer rehabilitation. Arch Phys Med Rehabil77:S52-S-58, 1996. l This self-directed learning module highlights several important rehabilitation aspects in the care of persons with cancer. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the organization of a cancer rehabilitation team, unique rehabilitation issues presented by specific common tumors, and the impact of common complications on successful rehabilitation outcomes. 0 1996 by the American Academy of Physical Medicine and Rehabilitation 3.1 Objective. -Support the integration of rehabilitation services into a comprehensive cancer treatment program.
Both the incidence of cancer and survival after a diagnosis of cancer are increasing. More than 8 million persons in the United States are currently living with a history of a cancer diagnosis. Treatment patterns for cancer tend to be more aggressive and are more likely to make use of multimodal therapy. The potential for these treatments to cause disabilities is high. Unfortunately, there is a lack of hard data concerning the rate of common treatment-related complications and of the disability directly related to cancer or cancer treatments. However, it can be reasonably concluded that the cancer survivor’s need for rehabilitation services is growing and will continue to grow. Although many hospitals have invested space and personnel to develop specialty cancer programs, few rehabilitation units are designated specifically for the care of the cancer patient. Rehabilitation personnel may lack the skills needed to work with disabled cancer patients and their families. Alternatives to the traditional inpatient unit include outpatient therapy services for patients whose conditions have stabilized. Home health therapy services can provide a convenient cost-effective method for providing therapy services at home. When independent living with home care services is no longer appropriate, an extended-care facility such as a skilled nursing facility or nursing home may be considered. Inpatient hospice programs are available in some areas. Hospice or palliative care programs can sometimes provide family training as well as outpatient therapy, nursing, and social services. Many of the members of a cancer rehabilitation team can be identified among the existing personnel at a cancer treatment center. The members of a multidisciplinary cancer rehabilitation team vary according to program size, type of institution, and range of disabilities encountered. The physician, who usually serves as the team leader, is responsible for bridging rehabilitation efforts and medical issues. In addition, the physician must keep the team properly focused Arch
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on the major care issues, maintain team morale, represent the team appropriately within the rest of the medical center, and ensure that the team responds in a timely manner to requests for services. An oncology nurse, physical and occupational therapist, social worker, psychologist, pharmacist, speech pathologist, dietitian, recreational therapist, and chaplain are typical members of a cancer rehabilitation team. Although each member brings a unique background and training to the team, to work effectively the team must accept and actually encourage overlap of tasks, responsibilities, and roles (1, pp. 413-32; 2, pp. 2539-41). 3.2 Objective.-Summarize the nutritional needs of a 60year-old man undergoing chemotherapy for multiple myeloma.
Nutritional needs of cancer patients take into account preexisting individual nutritional parameters, clinical status, tumor type and size, and treatment plan. Calorie intake should be between 115% and 130% of resting energy expenditure. Tumor types vary in their metabolic activity, and weight loss will vary depending on the site and extent of cancer involvement. Recommended protein intake ranges from 1.5g/kg per day to 2Sg/kg per day. Surgery, radiation, and chemotherapy will further increase a person’s protein needs. Loss of appetite can result from tumor growth and tumorinduced discomfort. Radiation therapy to the head and neck can alter saliva production and taste sensation. If the oral mucosa is affected, sensitivity to the temperature and texture of food results. Swallowing may be difficult, and consequently enteral tube feeding may be necessary to minimize weight loss. Acute enteral complications of radiation therapy to the stomach and small bowel include nausea, vomiting, cramps, and intermittent diarrhea. Long-term complications include partial or complete intestinal obstruction, intestinal perforation, malabsorption, and enteric fistula. The extent of side effects from chemotherapy vary and depend on the type and combination of agents given, the duration of treatment, and individual tolerance. Nausea,
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vomiting, and anorexia are common initial side effects after the administration of cancer chemotherapeutic agents. Additional side effects include stomatitis, mucosal ulceration, glossitis, and pharyngitis. Standard antiemetic agents include metoclopramide, a substituted benzodiazepine that binds to dopamine receptors. Haloperidol, prochlorperazine, dexamethasone, and cannabinoids are also effective in some patients. Advances in the control of chemotherapy-induced emesis include use of a ents that exert their activity by blocking serotonin (5hydr xytryptamine) receptors. An example of a medication in tB is category is ondansetron hydrochloride (Zofran), which clan be administered by the oral or intravenous route. Antimetabolite, chemotherapeutic agents interfere with DNA, RNA, or protein synthesis by blocking the use of essential vitamins, purines, and pyrimidines. The rapidly reproducing cells o , the bone marrow and gastrointestinal tract are especially vuhrerable to the effects of this treatment. Numerous nutritional deficiencies can result. Serum levels of vitamins are nondiagnostic, and nutritional deficiencies are best identified by outward manifestations and by the patient’s response to therapeutic vitamin replacement trials. During the couise of cancer treatments, patients may associate particular foods or flavors with nausea and vomiting. A learned food aversion can develop. Although the exact mechanism is unknown, it has been described as a variant of classic conditioning. The conditioned stimulus is the food or taste, and the unconditioned stimulus is the illness. Usual foods consumed i the hours before the start of chemotherapy can cause a rearned food aversion. Meats, vegetables, and caffeinated beverages are the types of foods most likely to result in such a response. Routine use of total parenteral nutrition in patie ts receiving chemotherapy is not advised except in case of nsevere malnourishment. Supplemental nutritional support i patients who have an adequately functioning gastrointestin 1 1 tract can include gastrostomy or jejunostomy feedings (l,~ pp. 393-404; 2, pp. 2554-56, 2559).
d
3.3 Objective.-qompare the acute and chronic complications of chemotherapy and radiation therapy which could inte$erie with your rehabilitation efforts for a debilitated 70-year-old patient with systemic cancer. Most chemothe apeutic agents produce a cytotoxic effect in a wide variety, r of normal tissues. Severe bone marrow depression can result in leukopenia and lymphocytopenia with an increased1 risk of infection. Thrombocytopenia can lead to hemorrhag . Platelet counts as low as between 20,000 and 50,000/mm3 ay necessitate withdrawal of the patient from active phys cal therapy services. Resistive exercises may result in incr ased blood pressure and increase the risk for hemorrhage. ausea, alopecia, and impaired wound healing are also signi:, cant side effects of chemotherapy. Neuropsychological effects of chemotherapy are most often seen with high-dose therapy and usually resolve within 48 to 72 hours. Prolonged ‘cognitive and behavioral deficits can be present weeks af r treatment has been discontinued. The acute reaction to rain irradiation consists of somnolence, headache, nausea,1and worsening of preexisting focal symptoms. Pretreatmem with dexamethasone, 24 to 72 hours before radiotherapy 10 the brain, is often ordered.
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Late effects of radiation therapy include myelopathy, plexopathy, encephalopathy, and cerebral necrosis. Differential diagnosis between the late effects of radiation and disease recurrence is often difficult. Children, in particular, sustain measurable late neuropsychological effects from wholebrain radiation therapy. These effects may be dose related and may be enhanced by the use of chemotherapy. The peripheral nervous system can also be involved with plexopathies from late tissue fibrosis seen after radiation therapy. Other organ systems, such as endocrine, renal, immune, cardiovascular, gastrointestinal, pulmonary, and musculoskeletal, can sustain late effects of chemotherapy and radiation therapy. In general, chemotherapy-related neuropathies tend to be distal and symmetrical. The chemotherapeutic agents vincristine and cisplatin have been shown to cause autonomic neuropathies. Vincristine causes a distal axonal degeneration that resembles other toxic neuropathies. Patients experience sensory complaints of numbness and paresthesias. Some patients have severe neuropathic pain. Recovery is usually complete, although many months may pass before resolution of symptoms (1, pp. 229-41, 405- 11; 2, pp. 2548, 2564-66; 3, pp. 840-58; 4). 3.4 Objective. approach small cell chest wall
-Formulate a comprehensive rehabilitation to a B&year-old man with a 2-year history of lung cancer who presents with progressive pain.
Recurrent or progressive pain in any patient treated for cancer is always an ominous sign. Post-thoracotomy pain that persists or reappears months after surgery suggests recurrent disease. However, not all postoperative pain syndromes are associated with recurrent cancer. For example, there is phantom breast pain of unknown etiology and postmastectomy pain syndrome thought to be due to intercostobrachial nerve injury. Pain that progresses despite the use of antineoplastic therapy or pain that becomes rapidly more severe should always be regarded as representing disease progression until proven otherwise. Many cancer centers make use of an interdisciplinary pain management team. The primary approach to the management of patients with cancer pain is the appropriate use of opiate medication. Frequent reassessment is required to optimize treatment of cancer-related pain. Analgesic needs typically escalate as the disease progresses or as tolerance develops to opiates. In contrast, if the disease or its side effects are better controlled, the need for opiates may diminish dramatically. Certain cancer pain syndromes are amenable to physiatric techniques, including transcutaneous electrical nerve stimulation (TENS), exercise techniques, the use of orthotics, and other modalities. Anesthetic intervention such as nerve blocks and the epidural or intrathecal administration of anesthetics and/or opiates, as well as neurosurgical ablative and neurostimulatory procedures, may all be indicated in the treatment of cancer pain. Cordotomy, the destruction of a unilateral spinal thalamic track, is indicated only for severe unilateral leg pain in patients with life expectancies of less than 6 months. In patients with advanced disease, there is Arch
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often a need for multiple routes of administration of opiates in order to obtain adequate analgesia (5, pp. 351-3; 6). A number of other medications and adjuvant agents can be employed for treatment of cancer-related pain. The reader is referred to the Study Guide on Cancer Pain, Pelvic Pain, and Age-Related Considerations.’ 3.5 Objective. -Provide a rehabilitation prescription for a patient who has shoulder pain after radical neck resection for cancer of the larynx. Cancer of the head and neck may result in impaired function of the upper extremities, speech, and swallowing. Transection of nerves integral to the stabilizing muscles of the neck and shoulder, particularly the spinal accessory nerve and branches of the cervical plexus, may occur in both modified and radical neck dissections. This can result in limitation in shoulder range of motion (ROM), as well as in shoulder instability. Patients typically describe pain and soreness over the anterior portion of the shoulder and also pain in the lateral aspect of the neck and occasionally into the anterior chest. In addition to musculoskeletal pain, discomfort can arise from contracture of the soft tissue of the shoulder, anterior chest wall, neck, and upper back. Physical therapy to maintain joint range and muscle strength may decrease the pain. In addition, the use of appropriate modalities should be considered such as superficial heat, ice, and TENS. However, skin over irradiated areas is more sensitive to thermal modalities and skin irritants, and team members should be cautious when applying these modalities. The patient should have a thorough evaluation of his or her activities of daily living, swallowing abilities, and communication functions. Swallowing and language deficits can occur in patients who have undergone resection of portions of the tongue, pharynx, hypopharynx, and larynx. Radiotherapy is typically given in addition to surgical management of head and neck cancers, and the consequences include osteonecrosis, mucositis, and radiation burns to the neck and jaw, which can also result in impaired function.“.’ 3.6 Objective.-Design the rehabilitation program for a woman 2 days after surgery for breast cancer. Breast cancer will affect 1 in 9 women in the United States. Current primary management includes either modified radical mastectomy or lumpectomy with associated axillary node dissection and radiotherapy. Stage I disease has a 90% survival rate 5 years after treatment when either of these approaches is used. Adjuvant chemotherapy and antiestrogen therapy may be used in this population as well. Immediate postoperative mobilization of the affected arm has been recommended to avoid limitation in ROM of the shoulder. Gentle passive and active-assisted ROM exercises can be instituted at the earliest possible time. Full active and active-assisted ROM exercises should be started after the surgical drains have been removed. Full ROM of the shoulder is often needed in order to obtain necessary positioning for postoperative radiation therapy. The most common long-term complication of breast cancer management is lymphedema, which occurs in 6% to 62% of patients after radical mastectomy. (See Objective 3.14 for Arch
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further cations 5% of 261-5;
discussion of lympedema.) Other long-term compliinclude brachial plexopathy, which occurs in up to patients treated with adjuvant radiotherapy (1, pp. 5, pp. 339-41, 351-2, 354-5; 10).
3.7 Objective.-Compare the long-term outcomes of children treated for brain tumor and for leukemia. Although cancer deaths among children have declined markedly over the last several decades, malignancy remains the second leading cause of death in children in the United States. Acute lymphoblastic leukemia, primary brain tumors, and Hodgkin’s disease are the three most common malignancies found in children (1, pp. 243-50). The 5-year survival rate of children with leukemia is 70% after treatment with radiation therapy and chemotherapy. Long-term complications from whole-brain radiation therapy used for prophylactic treatment of children with acute lymphoblastic leukemia include depressed cognitive function even with doses as low as 1,SOOcGy.’ ’ Brain tumors in children, of which medulloblastoma is the most common, tend to occur in the infratentorial region and the posterior fossa. Focal neurological deficits result from the effects of both the primary tumors and the localized treatment of such tumors. Secondary malignancy in patients treated for cancer is a recognized long-term complication. Children treated for malignancies and Hodgkin’s disease are at greatest risk. An incidence of 17% by age 20 has been found, which is 20 times greater than that of the general population. The most common secondary tumors are osteosarcomas, soft tissue sarcomas, leukemias, and tumors of the brain, thyroid, and breast.12 3.8 Objective. -Critically analyze the use of limb-sparing procedures for a I3-year-old patient with osteogenic sarcoma of the distal end of the femur. Sarcomas account for 7% of all pediatric malignancies. Previously, amputation was the only treatment option; now, limb salvage procedures are the most common surgical treatment. In these procedures, endoprosthetics are used to replace bone involved with tumor. The knee joint is most often replaced, because of the higher frequency of primary bone tumors of the proximal tibia and distal femur. Survival rates are comparable to those for patients undergoing limb salvage and traditional amputation. Long-term complications occurring with limb salvage procedures include loosening of the endoprosthesis, peripheral nerve damage, and poor wound healing leading to a high rate of surgical revision.13 Amputations are complicated by difficult prosthetic fittings as a result of the unusual shapes and sizes of residual limbs (1, pp. 297-3 19). Lower extremity limb salvage procedures are associated with less energy consumption with ambulation when compared to above-knee amputations.14 Another surgical option is the Van Nes rotationplasty, in which bone tumor is removed about the knee. The lower leg is brought up and rotated while the neurovascular bundle is maintained, and the ankle is substituted as a functional knee. Patients benefit from the preserved proprioception around the surgically created knee which results in improved function and decreased energy consumption. A modified belowknee prosthesis is prescribed. Complications seen in the Van
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Nes rotationplasty are similar to those encountered in limb salvage procedures. Limb salvage procedures have also been used in adults as well as in children with metastases at a single location, particularly at the hip or pelvis. For further information the reader is referred to Objective 2.3 in the Limb Deficiency section of this Study Guide. 3.9 Objective. --Distinguish between primary and metastatic brain Itumors in a 60-year-old patient who presents with a single frontal lobe lesion. Primary and n@astatic brain tumors cause significant dysfunction. The incidence of primary and metastatic brain tumors has been increasing over the last several years. Brain metastasis has a frequency 25 times greater than that of primary brain t ors. Eighty percent of brain metastases are found in the+ cerebral hemispheres, 10% to 15% in the cerebellum, and b % to 3% in the brain stem. Fifty percent of metastases are single. The most common primary intracranial tumors are meningiomas, whereas~ the most common primary brain tumors are gliomas. The functional sequelae of most intracranial tumors are due to local injury, vascular compromise, and edema. Motor and sensory deficits, visual field disturbance, and cognitive i pairment can develop as a result of brain tumors, dependi g on the location of the lesion. Treatment for both primary nd metastatic tumors may include surgical resection, whole brain or localized radiotherapy, and intrathecal chemot erapy. High doses of corticosteroids may also be used in I t ese patients, and neurological impairment may increase with weaning from these medications. The neurological deficits encountered are treated by traditional rehabilitation intervention.‘5.‘6 3.10 Objective. -Evaluate the common causes of sexual dysfunction~in a 40-year-old woman with cervical cancer. Cancer and cancer treatments can produce significant disruption of sexuaI function. For many persons undergoing cancer treatment,lsex is the least of their concerns, but others remain apprehensive about how their illness will affect their sexuality or sex&l relationship. Sexual problems of cancer patients typical1 have an acute onset, appearing immediately after treatm1 nt or during recovery. These may include decreased sexual desire, erectile failure, and orgasmic dysfunction. The ef dects of the disease and the side effects of treatment must be differentiated from depression. Partners can contribute to ,sexual dysfunction by fostering dependent roles or reacting In a negative way to the patient’s physical disfigurement. Ec onomic stress caused by the treatment can lead to marital pipblems that are expressed by avoidance of sexual contact. Some patients need to receive the physician’s “permission” to lengage in sexual activity during the course of their cancer treatment. Women who have undergone treatment for cancer may negative impact on their sexual rerejection can lead to the avoidance Gynecological surgery can result in a Patients will need to be counseled
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about the use of artificial lubrication and change from customary sexual positions. Women should be educated about the possible need for vaginal dilators to prevent stenosis as well as to prepare for the possibility of bleeding with intercourse. Side effects of chemotherapy and radiation therapy can produce additional psychological impairments to resuming sexual relationships. The American Cancer Society (l-SOO-ACS-2345) has local units all over the country which can provide volunteer visitor programs to assist with a patient’s physical and psychological needs. Some of these volunteers can serve as models of successful adjustment following cancer surgery and therapy. Sexual problems in men may occur after cancer treatment. Surgical treatment of prostate cancer can cause damage to vascular and nerve structures, resulting in impotence, retrograde ejaculation, or infertility. Orchiectomy has obvious hormonal and reproductive implications. Preoperative discussion of reproductive concerns should include consideration of sperm banking if permanent sterilization is anticipated. Pelvic or abdominal irradiation can produce fatigue, diarrhea, and erectile dysfunction. Irradiation to the urethra can cause painful ejaculation. Sexual rehabilitation may include the use of erectile assistive devices and surgical reconstruction of the phallus. The decision to use an implanted penile prosthesis must be made by both the patient and his sexual partner. Operations that require stoma construction can result in problems for both male and female sexuality. The creation of an artificial opening for body excretions can have a profound negative effect on sexual self-image. The timing of a return to sexual activity after stoma construction is essential. Sexual relations should not be resumed until the patient is significantly recovered in terms of both acute surgical healing and physical endurance. Alternatives to traditional sexual intercourse positions should be discussed. The patient should be reminded to empty the stoma appliance before engaging in sex in order to avoid leaks or odors. It may be preferable for the patient or his or her partner to cover the stoma apparatus so that it is not directly visible during sexual intercourse (1, pp. 251-66; 17). 3.11 Objective. -Formulate a rehabilitation program for a deconditioned 80-year-old patient with small cell carcinoma of the lung who is complaining of falls. Impaired balance in a patient with a history of carcinoma, especially a lung tumor, signals the possibility of metastatic disease to the nervous system. Twenty-five percent of pulmonary carcinomas metastasize to the brain. Motor deficits typically correspond to areas of local destruction, edema, and vascular compromise. Lung cancer, as well as other carcinomas, particularly those of the ovary, have been associated with paraneoplastic syndromes.” The Lambert-Eaton myasthenic syndrome is perhaps the best known of the paraneoplastic syndromes. Electrodiagnostic techniques to identify this syndrome are discussed in the neuromuscular sections of the Study Guide on electromyography. Other paraneoplastic syndromes that affect both the central and the peripheral nervous systems have been described. Treatment directed at the malignancy may reverse the effects caused by the paraneoplastic syndrome. However, reversal does not Arch
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necessarily occur, and long-term effects can result. Peripheral neuropathy from chemotherapy administered as an antineoplastic agent may also result in poor balance. Finally, epidural disease causing cord dysfunction can impair balance as well as strength, both of which impairments may cause falls. The spinal cord can also be injured by the administration of radiotherapy.‘5”9’20 3.12 Objective. -Evaluate the existing treatment for malignant hypercalcemia.
options
Although hypercalcemia is a frequent complication of some tumors, such as lung and breast cancer, it can also be seen in a variety of other malignancies. Hypercalcemia is a common life-threatening metabolic abnormality in patients with cancer, and therefore it is important to be able to recognize its clinical presentation. The early symptoms can include nausea, anorexia, lethargy, fatigue, hypertension, and polyuria. Unfortunately, these symptoms are nonspecific and the picture can be confused by other medical issues, especially since hypercalcemia is often seen at an advanced stage of the malignancy (3, pp. 816-21; 21; 22). Although reduction of the tumor burden is considered the only effective long-term treatment for hypercalcemia, this measure can often be only slowly instituted, and it may not be possible at all. If the patient is symptomatic from the hypercalcemia, or if serum calcium levels are 13mg/dL or greater, other treatment options need to be initiated. Vigorous hydration is often the initial treatment, as it can facilitate the excretion of calcium. Furosemide is now recommended for use only when fluid overload is a problem or diuresis is not adequate. Other treatment options for persistent hypercalcemia include intravenous mithramycin, subcutaneous calcitonin, intravenous biphosphonates, oral phosphorus, corticosteroids, and continuous intravenous infusion of gallium nitrate (3, pp. 819-21; 23). Because many patients with marked hypercalcemia do not respond adequately to hydration alone, and because aggressive hydration can itself have significant consequences, these other treatment options often are needed for adequate therapy. The decision to treat hypercalcemia can be difficult if the underlying cancer prognosis is poor, because the hypercalcemia treatment itself can have significant side effects. However, there may be short-term improvement of symptoms even in the face of poor cancer prognosis which justifies intervention. Both the recognition of the existence of this complication and an understanding of its response to treatment are important as cancer rehabilitation goals are set and therapy resources are committed. 3.13 Objective. -Describe your rehabilitation approach to a 60-year-old patient with prostatic cancer who presents with neck pain and acute arm and leg weakness. Metastatic spinal cord compression in patients with systemic cancer is a common complication, especially with carcinomas of the breast, lung, prostate, and kidney, as well as in myeloma, sarcoma, and lymphoma (1, pp. 345-6). Other possible causes of spinal cord dysfunction in patients with cancer are treatment related and include radiation myelitis and radiation fibrosis (2, pp. 2538-69). The thoracic spine is by far the most common level of metastatic spinal cord Arch
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compression, followed by lumbar and cervical levels. Although many rehabilitation issues of acute spinal cord injury apply here, there are some unique and important differences. As in acute spinal cord injury, spine stability is an early and critical issue (2, pp. 2538-69; 24). Management may require the use of rigid spinal orthosis, cord decompression, radiation therapy, chemotherapy, or surgical stabilization (1, pp. 345-61; 2; 24; 25; 26). Unlike the situation with traumatic spinal instability, management must be tempered by prognosis. Treatment to achieve optimal spine stability has to be considered in the light of the life expectancy of the patient, the need for pain control, and the issues of quality of life. These decisions require input not only from the spine surgeon but also from the other pertinent care team members and, of course, the patient. Functional outcome from cord compression has been reviewed by several authors. Tumor radiosensitivity, the presence or absence of neurological findings, and the tumor type have consistently been found to be reasonable prognostic indicators (1, pp. 345-61; 24; 27). The customary concerns in spinal cord injury rehabilitation are compounded by the effect of the cancer and its treatment on other organ systems. This can include unique cardiovascular, pulmonary, gastrointestinal, genitourinary, bone, hematopoietic, immune, dermatological, and endocrine problems, as well outlined by Schlicht and Smelz (1, pp. 345-61). For example, spine metastasis is likely to coexist with lytic lesions to the long bones of the arms and legs, and this circumstance will make transfer training difficult at best. Awareness of these common comorbidities and complications will increase our ability to set reasonable rehabilitation goals. Finally, it should be noted that the most common complaint at the onset of metastatic spinal cord compression is pain and that pain often occurs before the onset of weakness or sensory loss. Therefore, spine pain in patients with known cancer should be worked up aggressively. Spinal cord compression due to metastasis is a medical emergency, as favorable outcome is possibly dependent on the speed of diagnosis and treatment. The best noninvasive imaging studies presently available for diagnosis are magnetic resonance and computed tomography. 3.14 Objective.-Formulate a plan for the management of upper extremity lymphedema in a woman 1 year after Eumpectomy, axillary lymph node dissection, and radiotherapy for breast cancer. Upper extremity lymphedema associated with breast cancer is well documented as a common complication, but its reported incidence varies (1, pp. 267-77; 28; 29; 30). Also, although lymphedema can be either an early or a late complication, it may represent tumor recurrence. That possibility should be considered, especially if the involved limb is painful. Lymphedema may be due to several factors, including surgical technique, infection, axillary radiation, and venous obstruction (1, p. 268). Similarly, the pathophysiology has been described as a cascade of events, including the structural integrity of the lymphatic system and the physiological
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impact of protein-rich liquid in the tissue (1, pp. 26777; 31). The approach to treatment is controversial, there being proponents of nonintervention, nonsurgical intervention, and surgical treatment. Most authors, however, support a conservative approach, including prevention and some form of massage, exercis , and compression. Prevention should start with the selecti n of a surgical technique that least affects lymph drainage $ hile effectively treating the cancer. Prevention should also mclude appropriate postoperative care such as elevation, R exercises, and compressive wraps (1, p. 271; 32). Most T mportant is patient education about home care principles a d possible complications. Nonsurgical i terventions for the treatment of postmastectomy lymphede 4 a have been outlined by several authors (1, pp. 267-77; 31; ~33). The program might include frequent arm measureme ts to note changes, a review of elevation principles, camp essive wraps, muscle sets of the involved, elevated arm ag inst the compressive wraps, and decongestive massage. Ir+addition, z mechanical compression is often added for more srgnificant edema problems. Two basic types of devices are u$ed: single chamber and multiple chamber. The single-chamber devices are typically set at 40 to 60mm Hg pressure and ~cycled on and off for 45 minutes per treatment or longer. The multiple-chamber devices allow sequential distal-to-pro imal pumping to essentially “milk” the arm. There rem 4 ns some debate over the optimal device and the use schedule.~Once the lymphedema has been controlled, gradated compre sive garments often are needed to prevent its recurrence. T isese garments are sold both as standard fit and custom fit. They can be limited to just a distal sleeve or extend proximally to the axillary area, in which case a shoulder flap is often required to hold the garment in place. Detachable or nondetachable gloves and gauntlets can be added. The extent of the garment depends on the location of the edema. Custom fitting is often required to properly control significant edema. More recently: special massage techniques have been introduced that att 4 mpt to directly stimulate the activity of the lymphatic system.” These techniques are usually coupled with compressive wrapping. However, mechanical compression devices should be avoided. The role of surgical treatment for lymphedema management remains cohtroversial at this time (1, pp. 267-77; 31; 34; 35). In addition to the physical issues, lymphedema causes psychosocial concerns that have an impact on treatment success or failure. 3.15 Objective. -Construct a rehabilitation program for an 80-year-014 man with hip pain who has a history of renal cell qarcinoma.
Certain tumor$ have a high propensity for metastasizing to bone, the mo$t common being renal cell, thyroid, lung, breast, and prostate cancers. The vertebral column is the most frequently ~involved site. Bone metastases are rarely solitary; more th n one bony lesion is found in 90% of cases. Solitary metasta es usually are confined to the spine, the pelvis, or the rib 3 . The proximal femur is the most common long bone site involved. Metastatic disease rarely occurs
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below the elbow and below the knee. Bone tumors, regardless of size, impair the ability of the bone to bear weight and withstand normal torsional forces. Therefore, all metastases should be treated both symptomatically and prophylactically to avoid further functional compromise. Treatment is typically radiotherapy, but surgical resection of the lesion is indicated in some cases. Weight-bearing status depends on the severity of the lesion and the potential risk for pathological fracture. It is suggested that there is a significantly increased risk of fracture in long bones when painful lesions are greater than 2Scm in diameter, they occupy 50% or more of bony cortical diameter, they affect more than 50% of the medullary cross-sectional area, or they involve the cortical surface.jh Adequate analgesia for bone-related pain is often achieved with the use of nonsteroidal anti-inflammatory drugs. Pain management in these patients may include appropriate immobilization (1, pp. 363-92; 37; 38). References *1. *2.
*3.
*4. *5. 6. *I.
8. 9.
10.
11.
*12.
13.
14.
*15. 16. 17. 18.
19.
Garden FH, Grabois M, editors. Cancer rehabilitation. Phys Med Rehabil: State of the Art Rev. 1994;8(2). Gerber LH, Levinson S, Hicks J, Gallelli P, Whitehurst J, Scheib D, Sonies BC. Evaluation and management of disability: rehabilitation aspects of cancer. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993;2538-69. Groenwald SL, Frogge MH, Goodman M, Yarbro CH, editors. Cancer nursing: principles and practice. 3rd ed. Boston: Jones & Bartlett, 1993. Dropcho EJ: Central nervous system injury by therapeutic irradiation. Neurol Clin 1991;9:969-88. Elliott K, Foley KM. Neurologic pain syndromes in patients with cancer. Neural Clin 1989;7:333-60. Brennan MJ. Role of physiatry. In: Arbit E, editor. The management of cancer-related pain. New York: Futura, 1993; 179-93. Williams FH, Maly BJ. Pain rehabilitation. 3. Cancer pain, pelvic pain, and age-related considerations. Arch Phys Med Rehabil 1994;75:S-15-6. Kaplan E, Gumport SL. Cancer rehabilitation. In: Goodgold J, editor. Rehabilitation medicine. St. Louis: Mosby 1988;285-97. Krauss DH, Shaw JP. Management of head and neck cancer pain. In: Arbit E, editor. The management of cancer-related pain. New York: Futura, 1993;41 l-23. Markowski J, Wilcox JP, Helm PA. Lymphedema incidence after specific postmastectomy therapy. Arch Phys Med Rehabil 1981; 62:449-52. Janlovic M, Brouwers P, Valsecchi MG, Veldhuizen AV, Huisman J, Kingma A, et al. Association of 1,800 cGy cranial irradiation with intellectual function in children with acute lymphoblastic leukemia. Lancet 1994;344:224-7. Tucker MA. Adverse effects of treatment: secondary cancers. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993; 2410- 1. Rougraff BT, Simon MA, Kneisl JS, Greenberg DV, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur: a long-term oncological functional, and quality-oflife study. J Bone Joint Surg 1994;76-A:649-56. Otis JC, Lane JM, Kroll MA. Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above-the-knee amputation. J Bone Joint Surg 1985;67-A:606-I 1. Patchell RA: Brain metastases. Neural Clin 1991;9:817-24. Posner JB, Chemik NL. Intracranial metastases from systemic cancer. Adv Neural 1978; 19:579-92. Glasgow M, Haltin V, Althausen AF. Sexual response and cancer. CA Cancer J Clin, American Cancer Society, 1987;36:322-33. Bunn PA, Ridgway EC. Paraneoplastic syndromes. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993; 2043-4. Delattre JY, Posner JB. Neurological complications of chemotherapy
Arch
Phys Med Rehabil
Vol77,
March
1996
CANCER
S-58
20.
21.
22.
23.
24. 25. 26.
*27.
28.
Arch
REHABILITATION,
and radiation therapy. In: Aminoff MJ, editor. Neurology and general medicine: the neurological aspects of medical disorders, New York: Churchill Livingstone, 1989;365-87. Hovestadt A, Van Woerkom TCM, Vecht CJ. The frequency of neurological disease in a cancer hospital. (Letter) Eur J Cancer 1990;26:7656. Vassilopoulou-Sellin R, Newman BM, Taylor SH, Guinee VF. Incidence of hypercalcemia in patients with malignancy referred to a comprehensive cancer center. Cancer 1993; 7 I : 1309-12. Ralston SH, Gallacher SJ, Pate1 U, Campbell J, Boyle IT. Cancerassociated hypercalcemia: morbidity and mortality: clinical experience in 126 treated patients. Ann Intern Med 1990; I 12:499-504. Warrell RP. Oncologic emergencies: metabolic emergencies. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott, 1993;2128-34. O’Connor MI, Currier BL. Metastatic disease of the spine. Orthopedics 1992; 15:61 I-20. Galasko CSB. Spinal instability secondary to metastatic cancer. J Bone Joint Surg 1991;73-B:104-8. Shimizu K, Shikata J, Lida H, Iwasaki R, Yoshikawa J, Yamamuro T. Posterior decompression and stabilization for multiple metastatic tumors of the spine. Spine 1992; 17:1400-4. Kim RY, Spencer SA, Meredith RF, Weppelmann B, Lee JY, Smith JW, et al. Extradural spinal cord compression: analysis of factors determining functional prognosis-prospective study. Radiology 1990; 176:279-82. Hoe AL, Iven D, Royle CT, Taylor I. Incidence of arm swelling following axillary clearance for breast cancer. Br J Surg 1992;79:261-2.
Phys Med Rehabil
Vol77,
March
1996
Brennan
29. Ryttov N, Holm NV, Qvist N, Blichert-Toft M. Influence of adjuvant irradiation on the development of late arm lymphedema and impaired shoulder mobility after mastectomy for carcinoma of the breast. Acta Oncol 1988; 27:667-70. 30. Kissin MW, Querci della Rovere G, Easton D, Westbury G. Risk of lymphoedema following the treatment of breast cancer. Br J Surg 1986;73:580-4. 3 I. Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg 1989;22:505-15. 32. Whitman M, McDaniel RW. Preventing lymphedema: an unwelcome sequel to breast cancer. Nursing93 1993; 23( 12):36-9. 33. Stillwell GK. Treatment of postmastectomy lymphedema. Mod Treatment 1969; 6:396-4 12. 34. Miller TA. Surgical approach to lymphedema of the arm after mastectomy. Am J Surg 1984; 148:152-6. 35. Savage RC. The surgical management of lymphedema. Surg Gynecol Obstet 1985; 160:283-90. *36. Mandi A, Szepesi K, Mdrocz I. Surgical treatment of pathologic fractures from metastatic tumors of long bones. Orthopedics 1991; 14:439. 37. Boland P, Billings J, Healy JH. The management of pathological fractures. J Back Musculoskel Rehabil 1993;3:27-34. 38. McDonnell ME, Shea BD. Role of physical therapy in patients with metastatic disease to the bone. J Back Musculoskel Rehabil 1993;3:78-84. *Key
References.