File #4

1. Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer File #4 Breast Cancer Rehabilitation

2. Breast Cancer Rehabilitation • The physical therapy profession is the ideal medical profession to deal with all aspects of establishing and following a safe and realistic mobility and strengthening plan of treatment for the breast cancer patient. This professional has the ability to decipher all medical information presented by the physician and diagnostic studies presented concerning the status of the breast cancer patient.

3. Educate public of early detection • Educate the patient, family, physician and other health care providers of the need for rehabilitation for the patient diagnosed with breast cancer. • Follow a safe and functional rehabilitation program with realistic goals for each individual • Help improve Quality of Life • Promote care to decrease side effects • Improve patient’s outlook on recovery • Breast Cancer: FYI Resources suggests, “Consider at least one session with a physical therapist if you have any kind of breast cancer related surgery”. Role of the physical therapist when treating breast cancer patients:

4. America Cancer Society, Surveillance Research, 2005 Estimated Breast Cancer In situ and Invasive for Age Groups AGE In Situ Invasive < 40 1,600 9,510 40 and older 56,890 201,730 Under 50 13,760 45,780 50 and older 44,730 165,460 Under 65 37,040 123,070 65 and older 21,450 88,170 ALL AGES 58,490 211,240 (American Cancer Society, 2005)

5. THE REFERRAL FOR PHYSICAL THERAPY

6. General Practitioner Internist Surgeon Plastic Surgeon Oncologist Radiation Oncologist Radiologist Psychiatrist Pathologist Nurse Social Worker Psychologist Nutritionist Chaplain Family Member Friend Patient Physical Therapist Who is going to make the therapy referral? Many choices and potential referral sources.

7. “Despite potential benefits, referrals of cancer patients for rehabilitation are often made needlessly late or not at all”.Physician Text: CANCER MEDICINE************************************************* • Physical therapist may need to solicit the benefits of cancer rehabilitation to physicians, other cancer team members and patients. (Ragnarsson, 2003)

8. Could breast cancer rehabilitation be your Niche?

9. Niche: • A place, employment, status or activity for which a person or thing is best fitted. • A specialized market (Webster’s Universal Encyclopedic Dictionary, 2002)

10. What is your niche? • Oncology • Orthopedics • Athletics • Temporomandibular Dysfunction's • Urinary Incontinence • Pediatrics • Soft tissue work • Relaxation Programs • Administration

11. Determining your Niche

12. Make your own niche Cancer Center • S Search • U Understand • C Confidence • C Challenge • E Excitement • S Support • S Succeed Rehabilitation

13. Health Care ReformICD-9-CM Codes

14. HEALTH CARE REFORM Wellness reduces Illness Wellness decreases expense

15. Key Issues ofHealth Care Reform Access to Care Quality of Care Prevention Standard Benefits Package Cost Containment Education and Research National Boards State Autonomy Workers’ Compensation (APTA, 1994)

16. Helpful breast cancer ICD 9-CM codes • Fatigue – limiting ADL’s……………………….780.7 • Nausea – limiting ADL’s.……………………...787.0 • Generalized pain limiting function…………780.9 • Weakness limiting ADL’s……………………...780.7 • Muscular wasting, disuse atrophy…………728.2 • Difficulty walking………………………………..719.7 • Lymphedema…………………………………....457.1 • Breast Pain……………………………..…………611.71 • Adhesive Capsulitis……………………..……..726.0 (McCormack, 2002)

17. For all of the expensive medical interventions, insurance companies should realize the benefit of physical therapy, to promote wellness and decrease sickness during and after treatment programs for breast cancer. • Mammogram • Biopsy • Pathology • Lumpectomy • Radiation • Modified Radical Mastectomy • Reconstruction • Chemotherapy • Rehabilitation • Insurance reimbursement for program services is usually very good. • All coding should be assigned to a patients’ functional diagnosis rather • than the oncology diagnosis. The diagnosis should be based on whatever • functional activities are limited and what is creating the limitation. • (McCormack, 2002)

18. Psychology and Support Issues

19. ARE YOU THE THERAPIST TO TREAT THE PATIENT DIAGNOSED WITH BREAST CANCER • The progress of your program will depend greatly upon your ability to motivate your patient.

20. COPING DISCS In each dish place the name of a family member that you could live without…….Pretty tough! Just an idea of how cancer patients and families may think.

21. Illness • Changes • Next holiday could be last • Medical environment and caregivers • Self Image • Relations coping with illness • Future • If in remission.....When will it return? Your patient is coping with:

22. Common fears of cancer patients: The 5 D’s • Death • Disfigurement • Disability • Dependence • Disruption of Relationships (Source unknown)

23. Criteria for Depression • Persistent low mood (4 weeks) • Inability to enjoy oneself • Repeated or early waking • Impaired concentration • Guilt, self blame or burden • Irritability and anger for no reason • Loss of interest • Agitation • Suicidal

24. How patients and families may cope • Laughter can keep you from feeling bad. • Notice those that might be worse off. • Fight with those around. • Important to have knowledge of illness. • Refuse to believe that it can happen. • Turn to others for support. • Stay busy to decrease time to worry. • Go over problems in mind. • Avoid illness as topic of conversation. • New faith in this experience. (Snyder, 1992)

25. WIGS that guarantee the hair will look so much like the original hair that the patient is the only one to know it is a wig. • NATURAL: • 1-800-272-2424 • HAT DESIGNS for hair loss......... 1-215-247-8777 SELF ESTEEM

26. 49%...Experienced prolonged depression • 74%...Found unknown inner strength • 69%...Frustrated • 43%...Sad with experience • 39%...Associated care with love • 46%...Felt appreciated • 30%...Felt taken for granted • Caregiving and Cancer, should be reviewed to promote this challenge at: • http:/www.utmb.edu/insights/Outreach/Caregiving_and_Cancer ppt CAREGIVERS (Survey of 225 Families)

27. American Cancer Society (ACS) 1-800-ACS-2345 • National Cancer Institute (NCI) 1-800-4-CANCER • Equal Employment Commission 1-800-872-3362 • State Dept. of Vocational Rehab. • National Lymphedema Network 1-800-541-3259 • Job Accommodation 1-800-526-7234 • National Coalition for Cancer Survivorship 1-301-650-8868 Support Guide

28. AMERICANS WITH DISABILITIES ACT Legal Protection For Cancer Patients Against Employment Discrimination

29. Dealing with Pain

30. PAIN Be prepared to deal with patients reporting pain and inform their physicians of the benefits of exercise.

31. Agency for Health Care Policy and Research Guidelines for Cancer Pain • Promotes communication between the patient and the health care provider dealing with pain. • The American Cancer Society estimates that 70% to 90% of cancer patients will experience pain during some phase of their disease or treatment. PAIN (www.mskcc.org, 1999)

32. PAIN • Document location and description of pain. • Rate worse pain, using a 1-10 scale. • Time pain is increased and decreased. • What increases and decreases pain. • This documentation will allow you to objectively assess changes in pain. (Hassler, 1994)

33. Why cancer pain? • Biological mechanism • Bone destruction • Obstruction • Infiltration or Compression • Infiltration or Distention • Inflammation, Infection and • necrosis of tissue. (Otto, 2004)

34. Pain Medications • Soft tissue Nonsteroidal Anti-inflammatory (NSAI) • Bone NSAI (Prednisolone) • Compression of nerves (Dexamethasone) • Muscle spasm (Diazepan or Baclofen) • Fungal tumor Antibiotics • Cellulitis Systemic

35. Evaluation • Physical and Neurological Exam • Differential Diagnosis • Pain history and pattern • Present and past medication • X-Rays, MRI, CT, EMG, lab results • Nutrition history and interventions • Functional evaluation • Realistic Goals • Plan management (Ca / pain / psych) • Focus on patient and family Management of Cancer Pain (Otto, 2004)

36. Pain Management A vicious cycle • Which modalities are best suited for the patient diagnosed with cancer? • List Modalities • List considerations • List safety

37. Pain FatigueAnxiety Depression A Vicious Cycle

38. Cutaneous Stimulation • Heat • Cold • Massage, Pressure , and Vibration • Exercise • Repositioning • Immobilization • Counter stimulation • Transcutaneous Electrical Nerve Stimulation • Acupuncture Listed Physical Therapy Modalities (Pfalzer, 1992)

39. Time Out Test • As far as specialization, what is an advantage of being a physical therapist? • Wellness can decrease medical cost? T / F • A patient diagnosed with breast cancer, only thinks about their diagnosis? T / F • As a physical therapist, you might note signs of depression? T / F • What are considered the 5 fears of a cancer patient? • By supplying information concerning support organizations, you can help decrease patient stress? T/F • The pain cycle can lead to what other complications? ANSWERS You can pick your individual field of interest; True; False; True; Death, Disfigurement, disability, dependency and disruption of relationships; True; Fatigue, anxiety and/or depression.

40. LIVING A QUALITY LIFE THROUGH REHABILITATION

41. Mission Statement • Through emotional support, education, rehabilitation, and exercise we strive to empower the patient diagnosed with cancer to maintain and improve their quality of life. (Coleman Consulting, 1997)

42. Philosophy • Physical rehabilitation should be synonymous with cancer care. Loss of strength and function, as well as overall physical fitness must be restored in order to maintain quality of life. Our aim is to assist the patient diagnosed with cancer with education, exercise and support throughout the treatment and recovery periods. Promotion of wellness allows an individual the opportunity to meet future health challenges. (Coleman Consulting, 1997)

43. Rehabilitation Options • Prevention: Prevent functional loss in early stages of diagnosis. • Restorative: Reach maximal function when physical impairment or disability are present. • Supportive: Increase self care and mobility for the patient with progressive cancer and impairment. Teach energy saving methods. • Palliative: Comfort and function for those patients diagnosed with terminal conditions.

44. General Goals • Prevent Deconditioning • Maximal functional skills • Emotional Support to patient and family • Education of patient of condition • Treatment and Home Program • Assist in Pain and Symptom Control • Assist in Health Promotion

45. Specific Goals • Increase Strength and Endurance • Decrease nervousness, irritability & anxiety • Increase attention span and concentration • Improve Posture • Maintain or Improve ROM & flexibility • Promote independence (gait/transfer/ADLs) • Development of disease education, including treatment program.

46. Evaluation Tools

47. Evaluation Scales • Functional Independence Measure (FIM) • Karnofsky Performance Status Scale • Zubrod Performance Scale

48. FIM • 7 Complete Independence (Timely, Safely) NO ASSISTANCE • 6 Modified Independence (Device) • Modified Dependence HELPER • 5 Supervision • 4 Minimal Assist (Subject = 75%+) • 3 Moderate Assist (Subject = 50%+) • Complete Dependence • 2 Maximal Assist (Subject = 25%+) • 1 Total Assist (Subject = 0%+) • ADMIT / DISCHARGE / FOLLOW-UP • Self Care / Sphincter Control / Mobility / Locomotion / Communication / Social Cognition

49. Able to carry on normal activity, no special care needed. Unable to work, able to live at home and care for most personal needs, varying amount of assistance Unable to care for self, requires institution or hospital care for disease that may be rapidly progressing 100 Normal, no complaints, No evidence of disease 90 Able to carry on normal activityminor signs or symptoms of disease 80 Normal activity with effort, some signs or symptoms of disease 70 Cares for self, unable to carry on normal activity or to do work. 60 Requires occasional assistance of others, but able to care for most needs 50 Requires considerable assistance from others, frequent medical care 40 Disabled, requires special care 30 Severely disabled, death not certain 20 Very sick, hospital, need support 10 Moribund 0 Dead Karnofsky Specific: General: (Abraham, 2005)

50. Important information to obtain when evaluating the cancer patient • Medical Information • Primary diagnosis / Stage of disease / Surgery / Chemo / Radiation / Blood counts / Prognosis • Physical Exam • Mental status / Vital signs / Strength / ROM / Reflexes / Pain • Mobility State • Bed mobility / Balance / Transfers / Ambulation / Assistive devices • Psychological State Coping skills • Social State Family / Job / Recreation • Home Environment