ONCOLOGY REHABILITATION IN THE ACUTE CARE SETTING

LORI BORIGHT, PT, DPT, CES

ACUTE CARE ONCOLOGY REHAB ST JOHN PROVIDENCE HEALTH SYSTEM

• Multidisciplinary– ONC REHAB Training and certification – System PTs and OTs – All levels of care

• Ambulation based cardiovascular training program for our hospital based Oncology Nursing Units

• Modeled after RMCRI– Phase 1 (During Treatment)

• Primary aim is to attenuate cancer related weakness and fatigue (CRF)

CANCER RELATED FATIGUE (CRF)• Multifactorial Etiology

– Disease process– Treatments

• Oncology patients demonstrate improvements in strength and cardiovascular status in response to goal specific exercise

• Optimal to begin program as cancer treatment commences and continue throughout

• UNCO– Acute and long-term cardio protective effects of

exercise preconditioning

PLAN OF CARE

• Newly diagnosed cancer patients should receive information regarding cancer related weakness and fatigue

– Signs and symptom recognition as well as management options across the continuum

– Lymphedema risk reduction practices if appropriate – Role of exercise interventions– Precautions and contraindications

• Referral to the oncology rehab program upon hospital admission

TARGET POPULATION

Patients who benefit include:• Patients admitted for inpatient chemotherapy

and or radiation treatment

• Oncology patients admitted due to a secondary diagnosis

– Cardiopulmonary » CHF » Decreased O2 Saturation

– Vascular » Blood Clot » Anemia

– Weakness/Debility

BENEFITS OF PARTICIPATION

• Program participants demonstrate Increased– Functional mobility– Functional independence– Cardiovascular endurance– Extremity and core strength– Standing balance– Knowledge of disease and

treatment process– Psychosocial wellbeing

INITIAL SESSION

• Standard Strength, Endurance and Mobility Assessment with ONC Emphasis – Lab Values– Vitals obtained Pre, During, Post

• Introduction to ONC Rehab• Issue Folder/Ed Materials• Conduct 6 MWT• EX prescription • Prescribe Mobility Program (currently in place at

Macomb and SJH) if indicated• Explain follow up plan of care

INITIAL SESSION PIC/FOLDER

FOLLOW UP SESSIONS

• Frequency 3X per week• Session Time 25-30 minutes

– 10-15 cardio– 10-15 strength and balance etc.

• Mobility Program utilized where indicated as supplement to program

• 6MWT• Exercise Advancement

– Seated/Standing – Balance– CV Ex – Walking Program

FOLLOW UP SESSION/BALANCE ADVANCEMENT

FUNCTIONAL MEASURE6 MINUTE WALK TEST• Evidence Based Functional Outcome Measure with

Normative Data Available• Sub-maximal measure of aerobic capacity

– Prediction Formula for VO2Max– Peak VO2=0.03xdistance(m)+3.98

• Goal to educate therapists across the continuum to utilize a consistent outcome measure

6 MINUTE WALK

FUNCTIONAL MEASUREPERCEIVED EXERTION INDEX

• Subjective measure of exercise intensity

• 1-10 scale similar to VAS for Pain

• Patients advised to NOT Exceed 4 ("a little tired") for “Phase 1” training in Acute Care Setting

12

“Not Tired at All”

34

“A Little Tired”

56

“Tired”

78

“Really Tired”

910

“So Tired, I Cannot Go Anymore”

PERCEIVED EXERTION INDEX

EQUIPMENT/CART/CONTENTS

MEASURING WHEEL

ASSISTIVE DEVICES

LBE/PEDDLER

THERABAND ETC.

VHI SOFTWARE

OT INVOLVEMENT

• Education– Energy Conservation

• Lymphedema Support

• Adaptive Equipment to assist with ADLs

EDUCATION MATERIALS

• Folder

• Program overview

• Treatment side effects

• Benefits of exercise– Target HR, Exercise Prescription

• Perceived Exertion Index

• Home Exercise Program

• Map of SJPHS OP Therapy Locations

• Community Resources

SJPHS PROGRAM DEVELOPMENT PLANS

• Secure ONC Staff Representation at each site• Continue staff education

– Train additional staff for program support– Professional Staff Education– Grand Rounds– 2nd System wide Oncology Symposium

– Anticipated for rehab staff Fall 2015

• Develop Standard Operating Procedures– Unify acute care processes across all hospital programs

• Grow program to include other hospital nursing units– IPR

• Improve transition to OP sites for seamless continuum of care

REFERENCES

• American Thoracic Society (2003). Guidelines for the Six-Minute Walk Test. American Journal of Respiratory and Critical Care Medicine. 166:1. 111-117.

• Hydock, David S., Lien, Chia-Ying, Jensen, Carol M., Hayward, Reid. Exerceise Preconditioning Provides Long-Term Protection Against Early Chronic Doxorubicin, Integrative Cancer Therapies 7 March 2011 10:47.

• Rocky Mountain Cancer Rehabilitation Institute, Workshop Manual, 2014.

REFERENCES

• Ross, Robert M., Murthy, Jayasimha N., Wollak, Istvan D., Jackson, Andrew S. The Six Minute Walk Test Accurately Estimates Mean Peak Oxygen Uptake. BMC Pulmonary Medicine 2010, 10:31.

• Wonders, Karen Hydock, David S., Schneider, Carol M., Hayward Reid. Acute Exercise Protects Against Doxorubicin Cardiotoxicity. Integrative Cancer Therapies 2008 7:147.

• RMCRI/UNCO http://www.unco.edu/rmcri/Recent_publications.html