CONSERVATIVE PHYSICAL THERAPEUTIC TREATMENT OPTIONS

FOR CANCER PATIENTS

Presenter: Douglas Herron PT, MPT, CLT

Physical Therapist and Certified Lymphedema Specialist,

Saint Mary’s Regional Medical Center

Life-saving cancer treatments can have adverse side effects on the anatomy and physiology of a patient’s body and tissue.

Cancer treatments such as:Surgical Intervention

mastectomies

lumpectomies

other indicated general and/or plastic surgical intervention

Chemotherapy

Radiation

Other medical therapies as required

Adverse anatomical and physiological effects can include:

• Cancer related fatigue / malaise

• Weakness

• Diminished balance

• Chemotherapy related neuropathy

• Chemotherapy cognition deficits

• Soft tissue changes• Scarring• Increased soft tissue turgor• Adhesions

• Axillary web syndrome / cording / myofascial adherence and tightening

• ROM limitations

• Nerve entrapments

• Radiation necrosis / qualitative soft tissue change

• Lymphedema / Seromas / Wounds

• Complications related to function and performance of activities of daily life

• Paresthesia

Other adverse side effects can include:• Altered body image

• Hair loss

• Depression

• Anxiety

• Pain

• Decreased energy levels

• Decreased coordination

• Prosthesis considerations such as breast prosthesis or wigs etc.

• Sexual dysfunction

• Decreased general functions

• Decreased ability to perform job

• Decreased ability to perform activities of daily living

• Changing roles and dynamics of family and relationships

• Financial stressors

• A myriad of many other individual or family stressors

• Feelings of isolation

• Loss

As a physical therapist and a certified lymphedema therapist, I work commonly with patients before, during, and following a variety of cancer treatments but most especially for breast cancer treatments.

• During my assessment, I look for anomalies in:

• Strength• Joint ROM and accessory motion• Soft tissue flexibility • Sensation• Balance • Abnormal movement patterns /

coordination or neurological engram loss• Myofascial restrictions

• Functional deficits• Activities of daily life limitations• Soft tissue anomalies• Axillary web syndrome and cording• Nerve entrapments• Scar tissue immobility / restrictions• Limb volume discrepancies comparing

involved and uninvolved sides.• Patient demographics to assess for

resources or support.

Typical findings include anomalies or deficits with at least some of

the afore mentioned areas

Physical Therapeutic intervention is helpful and restorative with many aspects of a patient’s identifiable limitations. We develop individualized goals with respect to a particular patient’s needs.

An individualized treatment plan is created to address the areas of greatest concern for a person’s health and well-being.

Physical Therapeutic Intervention

• Though therapeutic intervention is helpful for many deficits, I’d like to address just a few of the major impairments that I commonly identify and treat.

• Lymphedema• Orthopedic considerations

• ROM (joint and soft tissue)• Myofascial restrictions / nerve

entrapments• Scar tissue etc.

• Cancer related fatigue

Combating cancer related fatigue through skilled therapeutic intervention & exercise

The many benefits of properly administered exercise

• Exercise actually will reduce fatigue, anxiety and pain over time

• Also reduces risk of cardiovascular disease, Type 2 Diabetes, Metabolic Syndrome and some cancers

• Improves bone and muscle health, increases balance, flexibility, and mental health and function.

• Improves mood and increases ability to successfully perform activities of daily living

• Potentially can increase longevity and/or quality of life

• Assists a person in reaching a proper BMI

Cancer Related Fatigue and Exercise cont...

• Can regulate hormone levels • Helps prevent obesity• Improves immune system function• Reduces inflammation• Fights arteriosclerosis and

atherosclerosis• Improves gastrointestinal function• Strengthens muscles (number one

indicator of independence into older years)

• Increased ventilation coordination

Other benefits of Exercise ...

• Increases bone density• Can reduce compression fracture risk

to spine and other areas.

• Enhances mood (increased endorphin and enkephalin activity)

• Increases energy

• Can improve posture

• Improves coordination

• Can assist with blood pressure over time

• Assists with lymph and venous return and peristaltic action of gut.

• Angiogenesis

• Increased ability for respiration because of enhanced capillary system

• Bolsters immune system

• Fights depression / assists with self-esteem

• Assists with blood cholesterol levels and triglycerides.

Click to edit Master title style• Click to edit Master text styles

• Second level• Third level

• Fourth level• Fifth level

Cancer Related Fatigue and Exercise cont...

• Obesity has been linked to increased risks of 13 different cancers

• Exercise has been shown to reduce the risk of developing breast cancer in women by 12%

• Body fat and weight gain before or around the time of diagnosis can increase the risk of recurrence and death in Prostate Cancer

Cancer Related Fatigue and Exercise cont...

• Exercise has been shown to reduce the risk of developing colon cancer by 30-40%

• Recent evidence shows that obesity is linked to the risk of cancer progression

• Studies have shown that exercise can reduce the risk of cancer recurrence by up to 40%-60%

Cancer Related Fatigue and Exercise cont...

• 72-95% have cancer related fatigue CRF – continues after cancer treatments and should be managed from the beginning

• Budgeting energy• Planning, delegating movement, adapt

to new rhythm of life • Target heart rate and energy level

(Karvonen formula vs Borg scale)• Break it up throughout day if needed• Strength training (increases metabolic

rate) helps improve function, movement and prevents fatigue

Cancer Related Fatigue and Exercise cont...

• The American College of Sports Medicine recommends the following for adults:• 150 minutes of moderate-intensity

exercise per week

• What is exercise?• Cardiovascular• Strength• Flexibility• Balance

• How can this be broken up?• 3/3 on Borg scale (moderate

breathlessness and exertion as tolerated)• Goal of 30 minutes but breaks count as

part of 30. Energy levels fluctuate sometimes widely during and after cancer treatments.

• What if I cannot meet these recommendations?• I allow a person’s body to be their guide.

Good days / Bad days / Perform as tolerated. Sustaining and maintaining and even building their best bio-mechanical machine. The body adapts to the stress placed upon it.

Orthopedic Considerations

Orthopedic Considerations

• Pain• Surgical pain• Neuropathic pain• Chronic pain - Pain management

• Weakness• Post op or pre op• Muscle guarding

• ROM deficits / soft tissue flexibility deficits

• Body image and functional changes

Orthopedic considerations continuedSymptoms to look for:

• Soft tissue restriction

• Scar tissue immobility or axillary web syndrome (also known as cording) affect many people within several days or weeks after lymph node surgery (although it can occur later).

• In this condition, taut cord-like scar tissue can extend from the underarm or breast and along the inner arm to the elbow or wrist, causing discomfort, pain, or limited range of motion.

Orthopedic considerations continued

Symptoms to look for:

• Scar tissue can also adhere to adjacent structures and cause immobility, discomfort or restriction in many areas.

• Conservative therapeutic intervention can help. As with lymphedema, it is important to see a physical therapist certified in lymphatic therapy who has expertise in treating these conditions.

Orthopedic considerations continuedTherapeutic Intervention

• Myofascial release

• Myofascial mobilization

• Scar tissue mobilization

• Soft tissue mobilization

• Stretching

• Neural flossing

• Cupping

Orthopedic considerations continued

Therapeutic Intervention

• Ultrasound (non-thermal)

• Proprioceptive neuromuscular facilitation (PNF)

• Temperature modalities

• Exercise in a plethora of forms

• Joint mobilizations

• Combination techniques

The Lymphatic System and Lymphedema

• The lymphatic system is part of the vascular system.

• The lymphatic system consists of initial lymph capillaries, pre-collectors, collectors, lymph nodes, lymphangions, ducts, trunks, and angles. Lymph structures are found throughout the body. Nodes are heavily represented in the cervical, axillary and inguinal areas.

• Lymphedema is a progressive mechanical insufficiency of the lymphatic system which causes an abnormal amount of protein and water to accumulate in the interstitial spaces.

Lymphedema can be classified as:

Primary Lymphedema or

Secondary Lymphedema

Primary Lymphedema

• Congenital 10-25% (<2years after birth) – as in Milroy’s disease (heritable chromosomal abnormalities)

• Lymphedema Precox 65-80% (>2 to 35yrs) – as in Meige’s disease (can be hypoplasia, hyperplasia, Aplasia, or lymph node fibrosis)

• Lymphedema Tarda 11% (>35yrs)

Secondary Lymphedema / Mechanical Insufficiency

Causes can include:• Surgery

• Radiation

• Infections

• Trauma

• CVI (chronic venous insufficiency)

• Can be complicated by a congenital lymphatic malformation or chemotherapy, obesity, lipedema etc.

• Malignancies / others

Secondary Lymphedema

Lymphedema continued

• Lymphedema is a form of swelling resulting from insufficiency, impairment or trauma to a part of the vascular system known as the lymphatics.

• The lymphatic system is responsible for the return of approximately 10-20% of fluid back to the heart.

• This impairment is unavoidable with some cancer treatments.

Lymph carrying capacity

vs.

Lymph load

Lymphedema continued

• More than 5 million Americans are living with this progressive yet manageable condition.

• Lymphedema tends to have a gradual onset and develop slowly, worsening over time.

• Symptoms may come as a sinusoidal wave - appearing for a time and then resolving - this can be misleading to the patient, as if everything is Okay when it’s really not.

Lymphedema stages

Lymphedema continued• Don’t wait. Risk reduction education and

appropriate treatment at each stage of progression is important.

• The more time passes, the more likely lymph fluid will build up in the tissue, causing damaging changes in the appearance and function of the limb and the skin. Waiting for treatment is likely to take more time and energy than if the patient had sought treatment at the first signs of trouble.

• Generally, lymphedema is most likely to happen within 5 years after cancer treatment, although the risk never entirely goes away. Lymphedema occurs at the affected quadrant.

Secondary Lymphedema / Mechanical Insufficiency

• Malignant Lymphedema –(malignant tumor obstruction)

• Malignant tumors• Causing pressure and blockage on

lymphatics from the outside

• Malignant lymphangiosis• Malignant cells block / clot the lymphatic

system (internally) – usually the collectors

• Angiosarcoma• (such as Stewart-Treves Syndrome-

reddish/blackish lumps that increase in size)

Therapuetic Lymphedema Treatment

Complete Decongestive Therapy (CDT)

• Manual lymphatic drainage (MLD)

• Compression Therapy• Short stretch multi-layered wrapping• Compression garments• Layering• Donning devices

• Skin care

• Exercise• Movement patterns for lymphangion

assist• Lower load, higher repetition to reduce

inflammation

• Intermittent pneumatic compression pumps as indicated

• Education• Risk reduction techniques

References

• Patlak, M., & Nass, S. J. (2012). THE ROLE OF OBESITY IN CANCER SURVIVAL AND RECURRENCE. The National Academic Press, 1-126. Retrieved February 20, 2015, from http://books.nap.edu/openbook.php?record_id=13348

• Physical Activity and Cancer. (2009, July 22). Retrieved May 26, 2016, from http://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/physical-activity-fact-sheet#q4

• Silver, J., MD. (2013, December). Cancer Rehabilitation: An Important Opportunity to Improve. Association of Cancer Executives: ACE Update, 1-3.