5th Lecture Cancer Rehabilitation PDF

Neurological cancer Rehabilitation Prof. Mahmoud Hamada Associate Prof of Physical Therapy PhD of Physical Therapy Cairo University  What is a brain tumor? A collection of abnormal cells that grows in the brain or central spine canal One abnormal cell becomes tw...

Neurological cancer Rehabilitation Prof. Mahmoud Hamada Associate Prof of Physical Therapy PhD of Physical Therapy Cairo University  What is a brain tumor? A collection of abnormal cells that grows in the brain or central spine canal One abnormal cell becomes two, two becomes four, four becomes eight, until there is a lump of abnormal cells  Epidemiology Incidence: 8-25/ 100.000 2nd reason of the death Among the published inpatient brain tumor rehabilitation studies, about 30% of admissions are Glioblastoma, 25% are metastases (primary tumors mostly in lung and breast), and about 20% are meningiomas.  Etiology Genetical predisposition Hereditary factors Viral infections: Epstein-Barr virus - primary brain lymphoma Environmental factors: pesticides, chemicals, RAT Common signs and symptoms of a brain tumor Unusual headaches. Seizure(s) Memory, personality, or behavior changes Inability to process incoming information correctly Visual changes: blurred vision, double vision Change in motor control  Two broad categories of brain tumors Primary Brain Tumors. – begin in the brain, tend to stay in the brain – incidence = nearly 79,000 diagnosed annually – 4,800 are children in U.S – Prevalence = nearly 700,000 people – “benign versus malignant” and everything between Metastatic Brain Tumors. – begin as a cancer elsewhere which spreads to the brain – always malignant Primary and Metastatic Tumor grading International grading system by WHO – Grade I – least malignant, slow growth – Grade II – slow growing, but can spread, some recurrence – Grade III – faster growing, “malignant,” often recurrence – Grade IV – fastest, most aggressive Tumor may contain several “grades” of cells at once  Most common primary brain tumors Meningioma Gliomas – Low Grade Astrocytoma – Malignant Astrocytoma – Glioblastoma – Oligodendroglioma Medulloblastoma  Effects on the family change of traditional roles single parenting in a two parent household loss of relationships as they existed caregiving/caretaking/safety responsibilities fear of seizures fear of personality/behavior changes fear of the unknown fear of the future “care of the caregiver” takes second or third place  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 1. Surgery: Nearly all patients presenting for restorative and supportive rehabilitation will have already undergone surgery. For both primary and metastatic tumors, advances in surgical management have contributed to improved survival, provided tissue for pathology and treatment planning, and improved quality of life by decreasing symptoms associated with elevated intracranial pressure. But patient selection for surgery is not necessarily as clear. The ideal candidates are probably patients with surgically accessible lesions, better functional status, younger age, and well- controlled primary tumor.  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 2. Chemotherapy: Chemotherapy is not generally used for benign or metastatic brain tumors and has only recently become common in primary malignant tumors. This limitation stems from the need for Chemotherapy to interrupt rapid cell division, whereas many brain tumors are slow-growing by nature and few agents can cross the blood–brain barrier to access the tumor. Nausea and vomiting is a side effect of CT that substantially affects rehabilitation. Antiemetic and antinausea medications (Compazine, ondansetron) can be used prior to CT. Thrombocytopenia from CT can cause bleeding from the nose, gums, urinary tract, or gastrointestinal tract. Neutropenia is also common after CT,and counts below 1,500/mL of blood may be associated with an increased the risk of infections.  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 3. Radiation Therapy: Radiation therapy uses high-energy light beams (x-rays) or charged particles (proton beams) to damage critical biological molecules in tumor cells. The treatment is usually provided on an outpatient basis with each workday for a period of several weeks. Significant neurologic injury can be seen with therapeutic irradiation, with the symptoms depending on the location and dosage. RT is associated with local alopecia and skin erythema, fatigue, nausea and vomiting, loss of appetite, and alteration of taste. RT-induced fatigue may be persistent for several months. The most noticeable long-term side effect is a gradual decline of cognitive function and memory. Corticosteroids can help alleviate these symptoms, prompting some to advocate standing low-dose steroids while undergoing RT.  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 4. Deep Vein Thrombosis: In general, patients with cancer are predisposed to thromboembolism, and this holds true for persons with brain tumors. The incidence of symptomatic postoperative deep vein thrombosis (DVT) or pulmonary embolism in patients with high- grade gliomas ranges from 3%–60%, depending on the type of prophylaxis used. The risk of DVT is increased during the perioperative period for those with leg weakness, age greater than 60 years old, large tumor size, and during the use of CT. Using venous Doppler ultrasound as a screening tool reported an incidence of 21.2%, well above the rates seen in stroke.  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 5. Wound Healing and Infection: Steroids and RT both delay healing and contribute to wound infections, particularly at the craniotomy site. CT also delays wound healing by decreasing proliferation of fibroblasts and contraction of wounds, causing neutropenia, and interfering with protein synthesis. The most frequent causative agent is staphylococcal organisms. Signs and symptoms of infection include redness and drainage from the wound, foul odor from the wound, fever, or elevated white blood cell count. Prophylactic antibiotics are prescribed for only a short time during and after the perioperative period. Cephalosporins and fluoroquinolones are reasonable choices to treat skin infections. Treatment may also include surgical irrigation and debridement  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 6. Nutrition and Swallowing: For a variety of reasons, anorexia is common among brain tumors and usually worsens as the tumor grows and spreads. Postoperative pain and fatigue contribute to loss of appetite. Cachexia is a severe wasting syndrome that causes weakness and a loss of weight, fat, and muscle. Nutritionists advocate avoiding carbonated drinks and gas- producing foods such as beans and peas to avoid a feeling of fullness. High-protein and high-calorie foods such as eggs, cheese, milk, poultry, and fish have been shown to help wounds heal. Eating foods with fiber and adequate water intake should help with maintaining regular bowel movements.  BRAIN TUMOR TREATMENT REHABILITATION IMPLICATIONS 7. Pain Management: Several different parts of the body may be sources of pain experienced by patients with neurologic deficits by brain tumors. Thalamic pain and other central pain syndromes may be difficult to treat, but centrally acting neuropathic pain medications such as gabapentin, pregabalin, carbamazepine, may be helpful. Pain with motion of the hemiparetic shoulder may be secondary to muscle imbalance or an inferior subluxation. Shoulder support is achieved with a lap tray or weight-bearing activities with activities of daily living (ADLs) and mobility. This will approximate the joint, decrease shoulder pain, and incorporate the affected extremity into the task. Physical and occupational therapy interventions, such as application of modalities, range of motion, and strengthening exercises, may improve shoulder function. Narcotic pain medications should be used at the lowest possible effective dose. Physical Therapy  Special considerations need to be observed when a patient is being seen shortly after surgery. Postoperatively, a patient may experience increased intracranial pressure, which precludes positions that inhibit proper cerebrospinal fluid movement. Avoiding activities that result in a Valsalva maneuver also helps in preventing an increase in intracranial pressure. A patient who is experiencing increased intracranial pressure may exhibit signs such as a decreased level of consciousness, speech or visual problems, headaches, seizures, vomiting, or respiratory changes. 1. The preventative phase of rehabilitation emphasizes early intervention and education to prevent or slow down further development of the tumor and its effects. 2. The restorative phase of rehabilitation, patients are expected to return to their prior level of function or to functional independence. Goals are directed toward restoration of function and productivity in the workplace. 3. The supportive phase of rehabilitation is self-care activities such as dressing, grooming, bathing, eating, and toileting. 4. Palliative rehabilitation, according to Dietz, is indicated for patients in the terminal stage who have rapidly progressing tumors where function continues to decline. The primary goal of this phase is to help the patient remain comfortable and preserve independence as long as possible. An additional goal is to involve the family in assisting the patient.  As with all comprehensive rehabilitation plans, treatment and assessment of the older patients with neuro-oncological diagnoses needs to be formulated according to the individual. There are a variety of factors to be considered including, tumor type, tumor aggressiveness, tumor location, tumor size, treatments and resulting side-effects, prognosis, as well as, baseline functional level, co-morbidities, family and social support, hobbies and activity level, and home environment. All of these will result in different clinical symptoms, impairments, and/or therapy needs. Common impairments which may respond to therapy intervention include fatigue, impaired aerobic capacity, impaired strength, impaired balance and coordination, spasticity, visual-perceptual impairment, impaired safety awareness and judgment, and pain.  1. Strength Weakness related to paralysis is most prominent post-brain surgery. Strength may return over a period of weeks or months. In general, the earlier the return of strength, the greater the recovery. Muscles that are still completely paralyzed 4–8 weeks post- operatively generally remain so. As previously discussed, patients may also experience myelopathy related to radiation or myopathy, related to use of corticosteroids, as well as overall deconditioning for a variety of reasons. The elderly and patients on high dosages of corticosteroids over a period of time are more susceptible to developing steroid myopathy. Notable examination findings for the patient with steroid myopathy include weakness in the neck flexors, and the muscles of the shoulder and pelvic girdle. Withdrawal of steroids and physical therapy are the only therapeutic options for steroid myopathy. This weakness is potentially reversible if steroids are completely withdrawn, however, if steroids must be continued, then the smallest possible dose should be considered.  The American College of Sports Medicine (ACSM) recommends that exercise programs for patients with cancer diagnosis meet the goal of maintaining cardiovascular endurance, muscular strength, and function. Benefits include: decreased nausea, decreased fatigue, increased endurance, and improved quality of life. Guidelines recommend weekly aerobic activity of 150 minutes of moderate intensity exercise or 75 minutes of vigorous-intensity exercise or an equivalent combination. As well as two to three weekly sessions of strength training for major muscle groups and stretching of major muscle groups on days which other exercises are performed. The National Comprehensive Cancer Network (NCCN) recommends 30 minutes per day, 5 days per week as a goal for exercise for patients with cancer.. It is important to begin slowly and progress incrementally. Alternative forms of exercise such as yoga or Tai Chi should be considered. Pools should be avoided if the patient is actively receiving radiation therapy due to risk of bacterial infection or skin irritation.  2. Fatigue Fatigue is one of the most commonly complained of symptoms in patients with cancer diagnosis. It can also be one of the most difficult to treat. Regular exercise is one of the few treatments that has proved effective in addressing this issue in patients with cancer. Other techniques to address fatigue include energy conservation techniques, and psychosocial interventions. Energy conservation techniques include: delegating tasks, prioritizing activities, scheduling activities during the day according to peak energy levels, limiting naps to 20–30 minutes, and avoiding multi-tasking. The Brief Fatigue Inventory (BFI) is an 11-point Likert scale with 9 items and has been shown to be a reliable instrument when evaluating fatigue in patients with cancer.  3. Balance Difficulties in balance can be multi-factorial. It can be directly due to injuries related to the tumor itself, or as a complication from the medical therapies or a combination of both. The vestibular system may be affected directly dependent on tumor location, or indirectly through mass effect or edema. The musculoskeletal system may affect balance in patients with brain and spinal cord tumor through deficits in strength, decreased proprioception, and peripheral neuropathy. Visual deficits may also interfere with balance.  3. Balance Head/neck and trunk control exercises Bed mobility and transfer practice Upper and lower limb strengthening exercises Sensory stimulation Soft tissue mobilisation, stretches and massage Balance work in sitting or standing Gait re-education and stairs practice  4. Pain Patients with spinal cord tumor may experience both somatic and neuropathic pain. Pain can be related to bony metastases, spinal cord compression, or compression by the tumor on nerve roots. Pain caused by compression of the spinal cord is often worse in the recumbent position due to increase pressure. Neuropathic pain may respond to electrical stimulation. Use of heat or electrical stimulation should not be used over areas of acute trauma, tumor site, areas with impaired sensation, or with persons who are unable to provide feedback regarding pain due to cognitive or communication impairments. The patient may also benefit from review of neutral posture and ideal body mechanics in relation to their specific area of injury.  4. Pain Pain related to spasticity may be alleviated with regular stretching and range of motion exercises. Patients with decreased mobility and sensation related to spinal tumor with bowel and bladder incontinence are at even greater risk of developing pressure ulcers due to the catabolic state of the body related to cancer. Therefore, training patients in techniques to intermittently relieve pressure and perform skin checks is of great importance. Another common complaint of pain for patients with primary brain tumor is headache. Using techniques such as guided imagery, biofeedback, and breathing techniques may be beneficial to reduce pain and anxiety.Advise patients to consult with their oncologists first before they take aspirin and NSAID, which inactivate platelet functions, for their pain.  5. Vision It is common for patients with brain tumor to have visual problems due to compression to the optic nerves or visual processing areas of the brain caused either directly by the tumor or indirectly by pressure resulting from midline shift or edema. Patients may have visual field cuts, issues processing visual information, blurred or double vision. Often this is treated medically with steroids but Patients and family can be educated in compensation techniques including scanning, reducing environmental hazards in home by removing throw rugs, obstacles, and using brightly colored tape to mark the edges of steps if depth perception is an issue. Patient may benefit from referral to a neuro-ophthalmologist in addition to an occupational therapist who specializes in vision rehabilitation. Also consider that older patients may already have underlying visual issues including glaucoma or cataracts.  6. Cognition Observe the patient in a number of settings and activities, e.g. in a quiet versus busy room. Attention may vary by position change (lying, sitting). Determine which components of attention (e.g. concentration, focused or distracted attention, alternating or divided attention) are impaired or intact. For memory, consider if the patient is functioning in a structured versus unstructured environment. Try eliciting clarification from the patient, observe his awareness to his environment and his ability to utilize feedback. Finally, use a functional baseline measure by selecting a relevant functional task as the basis of your evaluation and assessment.Patients with cognitive impairments may benefit from maintaining a regular routine and using tools such a journals and calendars to serve as reminders and document events. Best Wishes Prof.Mahmoud Hamada