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July 8th Comprehensive Cancer Rehab. Chris Wilson PT, DPT, GCS PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in Practice July 2013. Types of Cancer. Types of cancers. Cancers are named by their origin: carcinomas sarcomas lymphomas leukemias. Sarcomas.

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july 8th comprehensive cancer rehab

July 8th Comprehensive Cancer Rehab

Chris Wilson PT, DPT, GCS

PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in Practice

July 2013

types of cancers
Types of cancers

Cancers are named by their origin:

  • carcinomas
  • sarcomas
  • lymphomas
  • leukemias

Sarcomas are cancers that arise from cells of connective tissue, bone, muscle etc.

  • osteosarcoma
  • myosarcoma
  • liposarcoma
  • synovial sarcoma

Lymphomas are cancers that arise from cells of the lymph nodes, lymph system and the body’s immune system

  • Hodgkin's Disease
  • Non-Hodgkin's lymphoma

Leukemias are cancers that arise from cells of the bone marrow and blood stream.

  • Acute lymphocytic leukemia
  • Chronic myelocytic leukemia
  • Most common type of cancer
  • Carcinomas arise from the cell linings of body surfaces
  • Usually involve organs
types of carcinoma
Types of carcinoma
  • lung
  • breast
  • colon
  • prostate
lung cancer
Lung Cancer
  • Second most commonly diagnosed cancer in men and women
  • Leading cause of death in men and women
  • Stage 1 – 4
  • Usually diagnosed in more advanced stages
  • Difficult to screen for
  • Frequently metastasizes to the brain
prostate cancer
Prostate Cancer
  • Most commonly diagnosed cancer in men
  • Second leading cause of cancer deaths
prostate cancer grading
Prostate Cancer Grading
  • A pathologist looks for cell abnormalities and "grades" the tissue sample from 1 to 5.
  • The sum of 2 Gleason grades is the Gleason score.
  • These scores help determine the chances of the cancer spreading
  • They range from 2, less aggressive, to 10, a very aggressive cancer.
  • Gleason scores helps guide the type of treatment.

Colon Cancer

  • Third most common cancer
  • Third leading cause of cancer deaths
  • Very effective screening
  • Screening can lead to prevention
overview of historical physical therapy for cancer
Overview of “Historical” Physical Therapy for Cancer
  • Patient complains of pain, dysfunction, disability
  • Doctor identifies a need for physical therapy
  • Patient is scheduled for physical therapy services
  • Receives a bout of care and is commonly discharged without follow up by P.T.
  • Very little to no communication between therapists or physicians as a patient transitions from setting to setting
  • Physical therapists often outside “routine” cancer management model
philosophy of rehab
Philosophy of Rehab



Sustained Wellness

“Empower patients to maintain their own health and commitment to healing, through an individualized exercise and wellness program” = PRISM


prevention phases
Prevention Phases
  • Why Rehabilitation?
    • PT/OT treats impairment, such as mm weakness, fatigue, restricted joint motion and poor cardiac respiratory fitness. Impartment could lead to disability and limitations.
    • PT/OT aim to decrease or prevent disabilities and promotes safe activity, at home, work, or recreational activities
    • PT/OT promotes participation and re-integration to society, by treating impartments and disabilities
prevention and wellness of the oncology patient
Prevention and Wellness of the Oncology Patient
  • Primary prevention – Prevention of a disease in a potentially susceptible population – impacting the active pathology stage
  • Secondary prevention – Decreasing the duration and severity through intervention – impacting the impairment and functional limitation phase
  • Tertiary prevention – Decreasing the degree of disability in those with irreversible disorders – impacts disability
screening and consultation
Screening and Consultation
  • Patients scheduled for free consultation/screening
  • Wilson Resource Cancer Center (Troy)  Started June 2011
    • Breast
    • Breast cancer surveillance program pre/post surgery
    • GU
    • Lymphedema treatment when appropriate
    • All other cancer diagnoses
  • Rose Cancer Center (Royal Oak)  Started September 2012
    • Breast
    • GU
    • All other cancer diagnoses
  • Grosse Pointe  Started July 2012
    • All types
exercise and wellness
Exercise and Wellness
  • Cancer Survivorship – Exercise & Wellness Program  Similar to Cardiac Rehab- Phase III
  • SOLA or community fitness
  • Home Exercise Program
  • Referrals as needed for other services
    • Cancer Resource Centers
    • Local Support Groups – Org/Regional services
    • Integrative Medicine
    • American Cancer Society
paradigm shift of healthcare models
Paradigm Shift of Healthcare Models
  • Patient Centered Medical Home
    • Increased access, quality, decreased cost
  • Accountable Care Organizations
    • Creating facility/physician based organization to better coordinate management of disease
    • Shared profit and risk for savings and clinical and patient outcomes
  • Managed Care Systems
    • Focus on Use Management and Controlling Visits
  • Integrated Medical Records
  • Payment models shifting toward less visits
    • copays or private pay
oncology rehabilitation 7
Oncology Rehabilitation7

Comprehensive Oncology Rehabilitation

Began in 1922

Program Success

Management Plan

Advanced certifications

Informed stakeholders

management administrative structure
Management & Administrative Structure

Comprehensive Oncology Rehab Team Members

Professional Communications

Timing of Access to Patients

Protocol Guidelines

Advanced Training of Personnel

Professional resources, settings, equipment

Reimbursement, funding, costs to patients


advanced education requirements
Advanced Education Requirements

Oncology and Rehabilitation

Cancer Pathology & Staging

Cancer Treatments

Evolution of side effects

Timing of education & interventions

Prevention activities

Intensity of interventions- education, manual therapy and exercise (flexibility, strengthening, aerobic)

Current Research

Rehab throughout the continuum of care

education of stakeholders
Education of Stakeholders


Nurse Navigators



Social workers, nutritionists, chaplains, OT, SLP, radiation therapists


Universities & Residency Programs


advanced education opportunities
Advanced Education Opportunities

APTA Oncology Section


Upcoming Certification Examinations

Oakland University

Graduate Certificate in Oncology Rehabilitation

Annual Oncology Symposium

Deb Doherty and Jackie Drouin

documenting progress and justifying future care
Documenting progress and justifying future care
  • An important part of therapy is using functional tools to document and validate progression or regression of care
  • We use established, evidence-based, researched outcome measures called functional tools to document the patient’s progress or current status
functional outcome measures
  • Berg Balance Training
  • 10 Meter Walk Test
  • Modified Borg Test
  • 5 Times Sit to Stand Test
    • FACT – G
    • FACT – B
    • Etc…
  • Functional Reach Test
  • Modified Reach Test
  • Cognitive Assessment
  • Bicep Test
  • Fear Avoidance Behavioral Questionnaire
  • SF-36
pt functional outcome measures


  • Provide direction in terms of strength and areas of deficits or weakness
  • Used a predictability tool
  • Provide risk factor information
pt functional outcome measures1

Berg Balance Assessment

  • Determine falls for older adults
  • Scored from 0-56
    • High Fall Risk – 36 or lower
    • Medium Fall Risk – 37 - 45
    • Low Fall Risk – 45 or greater
  • Helps with determining discharge disposition and predictive validity for future falls
10 meter walk test
10 Meter Walk Test
  • Gait speed assessment
    • Gait speed is predictive of disability, fall risk, and future need for ECF/Nursing Home
    • Therapist uses a stopwatch to quantify duration for a patient to ambulate 10 meters.
    • The more slowly a person ambulates the higher risk of falls, injury, and need for assistance at home
    • Predictive of future morbidity and mortality
5 times sit to stand
5 Times Sit to Stand
  • Measures functional lower limb muscle strength
  • Quantifying functional change of transitional movements
  • Therapist asks pt to stand up and sit down 5 times as quickly as they can
  • Time the patient how long to complete test
rate of perceived exertion scale
Rate of Perceived Exertion Scale
  • Rating of how tired a person is on a 1-10
  • Therapy grades the patient on this scale to determine intensity of treatment
functional outcome measures1


  • Orientation
  • Alertness/Attention Span
  • Communication
  • Safety Awareness
  • Motivation


  • Ability to follow commands
  • Memory
  • Insight regarding deficits
functional outcome measures2


Allen Leather Lacing Test

  • Screening test
  • Provides estimate of cognitive functioning, information processing and ability to learn
  • Assists with goal setting, treatment planning and determining discharge location
functional outcome measures3


  • Completed in standing
  • Single-task dynamic test that defines functional reach as “the maximal distance one can reach forward beyond arm’s length while maintaining a fixed base of support in a standing position”
functional outcome measures4


  • Dynamic test that measures a person’s margin of stability during a functional task
  • Predicts risk for falling in the next 6 months
functional outcome measures5


  • Adapted for patients that are unable to stand
  • Completed in sitting
functional outcome measures6


  • Test of upper body strength and endurance
  • 30 seconds of repeated biceps curls
  • Therapists count how many repetitions the patient can perform in 30 seconds
nutrition and physical activity 5
Nutrition and Physical Activity5
  • American Cancer Society:
  • ~1/3 of the cancer deaths in US each year due to
    • poor nutrition
    • physical inactivity
    • excess weight
  • “Maintaining a healthy body weight, being physically active on a regular basis, and eating a healthy diet are as important as not using tobacco products in reducing cancer risk.”
exercise and wellness program overview
Exercise and Wellness Program Overview

Exercise and Wellness Program Goal:

Empower patients to maintain their own health and commitment to healing, through an individualized exercise and wellness program.

exercise and wellness program overview1
Exercise and Wellness ProgramOverview

Coordinate providers and services through continuum of care

Hospital-Based Cancer Resource Center

Acute Care

Ambulatory Care

programs for the medically compromised patient in an inpatient setting

Programs for the Medically Compromised Patient in an Inpatient Setting

Need therapists who are dedicated to oncology floor as their primary practice area

Establish a personal relationship and trust with physicians, nurses, patients, multidisciplinary team

Non-direct care time just as valued as direct treatment time

common reasons for admission to hospital
Common reasons for admission to hospital
  • Initial diagnosis and workup
    • Variable receptiveness to P.T. but “plant the seed”
  • Chemotherapy treatments
    • “well visit”
  • Related sequelae
    • ex. UTI, sepsis, confusion, dehydration, nausea, diarrhea, vomiting, weakness, falls
  • Unrelated medical issue
    • still placed on oncology floor
  • Decline in status or worsening of cancer
    • re-evaluate patient needs or functional status
exercise and wellness program physical therapy screening
Exercise and Wellness Program Physical Therapy Screening

Standing request from nurse manager and oncology chief/champion for PT Screen

Essentially direct access for referral to PT services

Order often a formality but obtained

Medical executive order reauthorized annually

Avoids traditional model of a patient not often getting a PT treatment till day 3-4

Direct communication between nurse and PT for any possible patient needs with immediate assessment and treatment


Exercise and Wellness Program Physical Therapy Screening

Rounding therapist gets patient list from unit clerk

Inpatient Rounding Process Flow

Is pt on PT schedule?

Patient Hospice?



Initiate Screen

Check Nurse Progress Notes for

- ambulation in halls

- exercising

- safety





Provide Occupational Therapy Screening for education/ADL training for benefit of caregiver

Contra-indications to PT?

Safety concerns?







Recommend evaluation for physical therapy

Provide an exercise prescription / recommendation for therapy



-mentor exercise program

-outpatient therapy

multidisciplinary rounds
Multidisciplinary Rounds



Staff nurse

Nurse manager



Social Work

Nurse Navigator from Cancer Center

Pastoral Care


Care management/discharge planner


everyone must talk about their insights on the case

Approximately 6 patients discussed

1 Hour total

Twice a week

Patients chosen by Nurse Manager due to complexity, medical issues, social issues, length of stay concerns

oncology daily huddles
Oncology Daily Huddles
  • Brief meeting at 11:00 -11:22 AM on days when there are not Multi Disciplinary Rounds
    • All nurses, nurse manager, PT/OT, care manager, hospice nurses, etc.
    • Other members of MultiD team welcome
  • 1 minute per patient
  • Nurse clarifies any daily needs or concerns that need to be addressed
  • PT outlines any issues with safety, compliance, handoff, discharge needs
bone metastases and tumors
Bone Metastases and Tumors

Breast, prostate, renal, thyroid, and lung carcinomas commonly metastasize to bone5

Osteolytic bone mets more commonly cause long bone fx than osteoblastic8

Bisphosphonates are commonly prescribed to inhibit osteoclast mediated bone-resorption8

Orthopedic evaluation and radiographic studies

Prophylactic internal fixation favorable outcomes vs after pathologic fx

If unable, radiotherapy and NWB may be prescribed

Bone mets should prompt conversation with primary oncologist

bone metastases tumors and pt
Bone Metastases/Tumors and PT

In any cases of cancer, PTs should be vigilant for bone metastases9

Conservative management of WB and resistive forces/manual therapy until risk of fracture of bone mets established

PTs can and should prompt for radiographs if concern for mets or unexplained pain

Risk Factors for Imminent Fracture:9,10


Especially with movement

Anatomical site

translational forces

WB bones

Size of metastasis

When 50% of cortex destroyed, fx rate ~80%9

Cortical lesions >2.5–3.0 cm

Unresponsive to radiation

bone metastases tumor guidelines 11
Bone Metastases/Tumor Guidelines11

>50% cortex involved

No exercises

touch down or non-weight bearing

use crutches, walker

active ROM exercise (no twisting)

25–50% cortex involved

No stretching

partial weight bearing

light aerobic activity

avoid lifting/straining activity  

0–25% cortex involved

Full weight bearing

“Bone metastases in the shaft of the humerus of a bronchial carcinoma with cortical destruction in both planes.”
  • Chestradiology.net
Destruction of the right vertebral arch and the transverse processes of L3 as well as a large paravertebral soft tissue tumor.
Diffuse skeletal metastases.
  • Rib metastases on the right side.
  • Left-sided pseudolesions at the costo-chondral transition, which are caused by microfractures in Osteoporosis.
blood levels and exercise 6
Blood levels and exercise6

Platelets and thrombocytopenia

Normal 140,000-400,000

50-140k low intensity exs and aerobic exs

30-50k recommend AROM and walking unless at high fall risk

< 25k therapy and mobility contraindicated

Neutropenia – increased infection risk

patient should wear mask outside of room

PT/PTA should wear mask in room


♀ normal – 12-16 mg/dl

♂ normal – 14-17mg/dl

8-10mg/dl – exs intolerance

<7-8 mg/dl – bedrest unless very close monitoring

brain metastases 11
Brain Metastases11

~8%–10% occurrence of brain mets in adults with CA11

Majority of brain mets from:

lung CA (40%–50%)

breast CA (15%–25%)

melanoma (5%–20%)

Historical standard of care:


whole brain radiation therapy

Common symptoms of brain mets:



Paralysis or focal weakness

Altered mental status


PT can expect some recovery of function if radiation, chemo, steroids effective

“Brain metastases should be included in differential diagnosis of any cancer patient in whom new neurologic symptoms or signs develop”

emotional and psychological issues
Emotional and Psychological Issues
  • Monitor oncology staff and therapists for emotional overload – watch for burnout
  • Mourning process and encourage sharing with colleagues, Social Work, Pastoral Care, friends
  • Family dynamics in times of stress
  • At times, near the end stage of life, PT often fixated on as “the last hope” or when PT not tolerated, as the final catalyst to transition to hospice/palliative care
lessons learned during implementation
Lessons Learned during Implementation
  • Attempted a group exercise session with inpatients with cancer
    • Limited participation, isolation issues, patients preferred to exercise with PT alone during IP stay
    • May revisit when Oncology Unit expands beyond 22 beds
  • Dedicate staff and time to huddles, rounds
  • Constant connection, communication and follow up between IP and OP and SAR/Homecare
  • Able to obtain dedicated exercise room in Oncology Unit renovation due to new programs implemented
hospice and palliative care
Hospice and Palliative Care
  • APTA HoD RC 17-11 – Unanimous and introduced by Michigan
  • The APTA endorses the inclusion of the following concepts in hospice and palliative care:
    • Continuity of care and the active, compassionate role of PTs and PTAs
    • Rights of all individuals to have appropriate and adequate access to PT, regardless of medical prognosis or setting
    • An interdisciplinary approach, including timely and appropriate PT/PTA involvement, especially during transitions of care or during a physical or medical change in status
    • Education of PT/PTAs and students in the concepts related to treating an individual while in hospice and palliative care
    • Appropriate and comparable coverage and payment for physical therapy services
  • Task force to develop a plan to achieve these goals
pts role in hospice and palliative care
PTs Role in Hospice and Palliative Care

Common misunderstandings about PTs role in Hospice/Palliative Care

“Aggressive PT” and “No PT” are not the only options

Focus to avoid interruption in rehabilitation care

Even more sensitive to patient wishes/comfort

Shift focus to:

quality of life

anticipatory future disability and equipment needs

“bucket list” assistance

Prevention of pressure ulcers, contractures, immobility pain

Family/caregiver education and support/consultation



Fatigue is considered one of the most common side effects of cancer.

cancer related fatigue crf
Cancer-related fatigue (CRF)
  • A distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion
  • Related to cancer or cancer treatment
  • Not proportional to recent activity
  • Interferes with usual functioning

- NCCN 2011

causes of fatigue
Causes of Fatigue
  • Etiology unknown
  • Anemia (hemoglobin < 12g/dL)
  • Pain
  • Emotional distress
  • Sleep disruption
  • Altered nutrition
  • Altered activity
  • Medical issues (thyroid, heart, infections)
fatigue facts
Fatigue Facts
  • Fatigue is the most common side effect of cancer treatment.
  • Fatigue is the most distressing side effect
  • MDs and RNs tend not to focus on fatigue
  • Patients tend to under report their fatigue

- ACS 2011

fatigue facts1
Fatigue Facts
  • Cancer Related Fatigue is not relieved by rest
  • Reported in 70-100% of persons undergoing CA Rx
  • 30 – 50% of patients report fatigue lasting months to years after concluding treatment.
fatigue facts2
Fatigue Facts
  • CRF is grossly under-treated
fatigue facts3
Fatigue Facts
  • CRF has a cognitive and physical aspects
fatigue facts4
Fatigue Facts

Encourage your patients to make their physicians and nurses aware of their fatigue level!

origin of fatigue
Origin of Fatigue
  • From cancer treatment
  • From the cancer itself
what is expected surgery
What is expected? - Surgery
  • Some mild fatigue relieved with rest lasting 2-3 weeks post op
what is expected c hemo
What is expected? - Chemo
  • “Roller coaster fatigue”
  • Mild to severe fatigue
  • Increases with dosage
  • Unpredictable
  • Should begin to ease 4 weeks after conclusion, but may take 3-12 months to resolve.
what is expected radiation
What is expected? - Radiation
  • Linear fatigue
  • Usually begins at about 4 weeks
  • Increases linearly as dose increases
  • May peak 1 week after last dose
  • Should begin to ease 4 weeks after conclusion, but may take 3-12 months to resolve.
what is not ok
What is not ok
  • Increased shortness of breath with minimal exertion
  • Uncontrolled pain
  • Inability to control side effects from treatments (such as nausea, vomiting, diarrhea, or loss of appetite)
  • Uncontrollable anxiety or nervousness
  • Ongoing depression
fatigue rating scale
Fatigue Rating Scale

0 = no fatigue

1-3= mild fatigue

4-6= moderate fatigue

7-10= severe fatigue

treatment of fatigue
Treatment of Fatigue

“ Try to be as active as possible as you go through treatment. Some patients, especially those who have extensive disease, should be referred to a physical therapist or to an expert in physical medicine to help decide on a specific exercise program.”

-NCCN 2005

nccn crf recommendations
NCCN CRF recommendations
  • Fatigue should be screened, assessed, and managed according to clinical practice guidelines.
  • All patients should be screened for fatigue at their initial visit, at regular intervals during and following cancer treatment, and as clinically indicated.
  • Fatigue should be recognized, evaluated, monitored, documented, and treated promptly for all age groups, at all stages of disease, prior to, during and following treatment.
  • Patients and families should be informed that management of fatigue is an integral part of total health care.
  • Health care professionals experienced in fatigue evaluation and management should be available for consultation in a timely manner.
  • Implementation of guidelines for fatigue management is best accomplished by interdisciplinary teams who are able to tailor interventions to the needs of the individual patient.
  • Cancer-related fatigue should be included in clinical health outcome studies.
  • Rehabilitation should begin with the cancer diagnosis.
nccn guidelines
NCCN Guidelines
  • Consider initiation of exercise program of both endurance and resistance exercise
  • Consider referral to rehabilitation: physical therapy, occupational therapy

NCCN 2011

cancer related fatigue what to do
Cancer Related FatigueWhat to do?

Exercise 6 days a week

Lower your expectations for the day

Pace yourself use energy conservation principles

Pay attention to energy swings and schedule tasks during the most energetic part of the day

Take mini breaks with or without a nap

Alternate high and low physical activities

Eat a healthy diet

Reduce stress and anxiety

Go to bed 20-30 minutes earlier than your usual time to “unwind”

treatment of crf
Treatment of CRF
  • Treat contributing factors
    • Treatment of medical issues
    • Nutritional support
    • Distress management
    • Sleep support
what the research says
What the research says
  • The only evidence based treatment for cancer related fatigue is:


what the research says1
What the research says
  • Exercise is safe during chemo and radiation.
  • Exercise is helpful to exercise during radiation and chemotherapy.
  • Exercise should be encouraged
  • Exercise is under-utilized
  • Exercise is safe with advanced disease.
  • Exercise is recommended with palliative care and end of life
what the research says2
What the research says
  • Exercise is helpful in persons with cachexia
    • Cancer cachexia describes a syndrome of progressive weight loss, anorexia, and persistent erosion of host body cell mass in response to a malignant growth.
    • Although often associated with preterminal patients bearing disseminated disease, cachexia may be present in the early stages of tumor growth before any signs or symptoms of malignancy.
    • A decline in food intake relative to energy expenditure (which may be increased, normal, or decreased) is the fundamental physiologic derangement leading to cancer-associated weight loss.
    • In addition, abnormalities of host carbohydrate, protein, and fat metabolism lead to continued mobilization and ineffective repletion of host tissue, despite adequate nutritional support.
two ways to fight fatigue
Two ways to Fight Fatigue


To fight anemia and increase red blood cells

Consult your physician


Increases red blood cells

Increase endorphins

Improve overall conditioning

Consult a PT/OT

sleeping vs napping
Sleeping vs. Napping
  • “Normal” uninterrupted nighttime sleep is crucial.
    • If “normal” sleep is being achieved and the patient is exercising, napping as needed is ok.
    • If not, napping should be discouraged.
    • Medication for improved sleep is recommended if needed.
exercise cautions
Exercise Cautions
  • Bone metastases
  • Thrombocytopenia
  • Anemia
  • Fever or active infection
  • Limitations secondary to metastases or other disease
  • www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/
  • www.pfizerpro.com/.../docs/NCCNFatigueGuidelines.pdf
exercise benefits

Exercise Benefits

Exercise is one factor within your control that can make a difference in your life.

benefits of exercise
Benefits of Exercise
  • Enhances immune system
  • Reduces stress, anxiety and depression
  • Stimulates production of endorphins
  • Improves heart and lung function
  • Enhances muscle strength and endurance
  • Increases flexibility
  • Improves sleep
  • Eases some side effects of treatment
  • Maintain steady weight
  • Lowers cholesterol levels
  • Strengthens bones
  • Control blood sugar
  • Improves leans body mass
  • Lessens fatigue
  • Reduces “Chemo Brain”
  • Decreases constipation
  • Improves quality of life
exercise precautions
Exercise Precautions

Avoid exercise if you:

Have any type of infection

Feel dizzy or unstable

Have a fever

Had Chemotherapy with 24 hours

Have low blood counts

cardiovascular conditioning
Cardiovascular Conditioning

A form of exercise important to all cancer patients but especially those on Chemotherapy drugs that have cardiotoxic side effects.

Improves physical and mental functioning

Prevent recurrence and extend survival

Consult physician about any precautions

Learn to take and track your heart rate

30 minutes 5 days a week

heart rate
Heart Rate

Maximum Heart Rate = (MHR)

MMR = 220 – your age

Target HR (lower limit) = 0.6 x MHR

Target HR (upper limit) = 0.8 x MHR

strength training
Strength Training

A gradual, progressive strength training program may actually minimize the risk for lymphedema by helping dilate or widen remaining lymphatic channels

Prevents deconditioning from cancer related treatments

Start slowly but 6 days a week

Alternate arm, leg and core exercise doing each group 2 times per week

Low to moderate load for 8-10 reps.

benefits to strength training
Benefits to Strength Training

Muscles burn calories twice as efficiently as fat and therefore help to maintain or lose weight

Improve posture

Build stronger bones

Increase lean body mass

Improve balance and coordination

Use less effort to perform work and home activities

flexibility and stretching
Flexibility and Stretching

Muscles and fascia can tighten up after surgery, radiation and chemotherapy

Tight muscles and fascia can cause significant musculoskeletal problems to joints

Stretching improves joint motions, decreases pain and increases circulation

rules for stretching
Rules for Stretching

Needs to be done in all positions…sitting, standing, hands and knees, side lying and lying on belly and back

Long term effects of stretching needs to be done daily for long term

Should be completed after cardiovascular and before strengthening

Consult PT/OT for optimal exercise for your condition

  • cancer.org(American Cancer Society)
  • nci.gov (National Cancer Institute)
  • nccn.org (National Comprehensive Cancer network)
  • breastcancer.org
  • seer.cancer.gov(National Cancer Institute)
exercise education
Exercise Education
  • Weight loss / management is a critical part of the long term treatment success for our patient.
  • Being too thin and too heavy is unhealthy
    • Open discussion
    • Describe why it is hard on the body
    • Make a realistic plan for the patient
exercise education1
Exercise Education
  • Give the patient a visual understanding of why they need to build cardiopulmonary and muscular strength
    • “You are an athlete in training”
    • “fill your pantry”
    • “Manage you battery”
exercise guidelines
Exercise Guidelines
  • Make sure the mode is enjoyable
  • The mode needs to be doable / accessible
  • Make sure the patient is successful immediately
exercise guidelines1
Exercise Guidelines
  • Start aerobic exercise on first visit
  • Take advantage of post – operative or in-between treatment timeframes
exercise guidelines2
Exercise Guidelines
  • Should involve both aerobic and strength exercise
  • “longer” exercise is better than “faster” exercise
  • Should incorporate UE, LE and Core
  • Any amount of exercise is helpful
exercise guidelines3
Exercise Guidelines
  • Minimalist program:
      • Walk 5 minutes, twice a day
      • Wall pushups
      • Sit to stand
exercise guidelines4
Exercise Guidelines
  • Goal is an average of 1 to 5 hours per week of combined aerobic and strength exercise

Direct correlation with the number of lymph nodes removed and if you are to receive radiation.

lymphedema triggers
Lymphedema Triggers
  • results in swelling or accumulation of fluid in one or more limb or extremity
  • caused by the break down of the body's ability to remove and filter intercellular fluids
  • condition effects both men and women
  • may be a side effect of treatment for cancer
  • surgical removal of lymph nodes, mastectomy/lumpectomy , radiation, trauma and hereditary factors can cause lymphedema.
primary lymphedema
Primary Lymphedema
  • Hypoplasia- one does not have enough lymph vessels or the vessels are too narrow to carry an adequate load of fluid
  • Hyperplasia - the vessels are too wide and the valves are unable to work properly preventing effective removal of fluid.
  • Aplasia - absence of single lymph vessels or capillaries
  • Fibrosis - nodes become hardened and malfunction
secondary lymphedema
Secondary Lymphedema
  • lymph nodes or lymph vessels damaged or removed
  • may be the result of surgical removal of nodes
  • radiation therapy
  • traumatic damage to large lymph vessels or nodes following an accident
  • infections, bacteria or fungi
malignant lymphedema
Malignant Lymphedema
  • when a tumor/cancer is the cause of lymphedema
lymphedema usual signs and symptoms
Lymphedema –Usual signs and symptoms
  • Onset might be slow or rapid
  • Progressive swelling
  • In many cases starts distally
    • Squaring of toes
    • Stammer’s sign positive
    • Loss of anatomical contours
  • Asymmetric swelling if bilateral
  • Cellulitis is very common
  • Discomfort, heaviness, achiness
  • Skin changes in later stages
diagnosis of lymphedema
Diagnosis of Lymphedema
  • Case history and clinical examination are very important to determine diagnosis
  • Diagnostic investigations are not generally necessary
  • Other tests to rule out other causes of edema
    • Heart, kidney, liver, thyroid,
  • Diagnostic investigation to exclude malignancy, prepare for surgical treatment, determine vascular status
differential diagnosis
Differential Diagnosis
  • Lipedema
  • Lipolymphedema
  • Post-thrombotic syndrome/DVT
  • Chronic Venous Insufficiency
  • Ruptured Baker's Cyst
  • Malignancy
  • Reflex Sympathetic Dystrophy
  • Congestive Heart Failure
  • Fluid Retention Syndromes
  • Immobility/dependency
  • Hepatic/renal disorders
stages of lymphedema
Stages of Lymphedema

Latency Stage

  • No visible signs of lymphedema.
  • Lymph collectors are able to keep up.
  • This stage, if identified early, we may be able to prevent enlargement of a limb
stages of lymphedema1
Stages of Lymphedema

Stage I Reversible Lymphedema

    • Accumulation of protein rich edema fluid.
    • Develops after physical exertion or at the end of the day and disappears after a nights rest.
  • Clinical signs:
    • Soft pitting edema
    • Texture is smooth
stages of lymphedema2
Stages of Lymphedema

Stage II Spontaneously Irreversible Lymphedema

  • Protein rich fluid with connective and scar tissue.
  • Clinical signs:
    • Pitting is denser
    • Gooey consistency
    • Texture harder because there is more protein present
      • (fibrosis starts).
  • Can get skin conditions such as eczema and erysipelas, papillamatosis and lymph fistule.
stages of lymphedema3
Stages of Lymphedema

Stage III Lymphostatic Elephantiasis

  • Protein rich fluid
  • Connective and scar tissue
  • Hardening of dermal tissue and papillomas of the skin
    • (angiomas)
  • Clinical signs:
    • Extreme swelling of the limb
    • Extreme deepening of skin folds
    • Papillomas
    • leg looks like a column and arm looks like a log
    • Ulceration and lacerations are common
management of lymphedema
Management of Lymphedema
  • Risk reduction, education, precautions
  • Early diagnosis and treatment
  • Complex Decongestive therapy –CDT
    • Manual lymph drainage
    • Compression bandaging
    • Exercise
    • Skin and nail care
    • Instruction in self care
  • Compression pumps
  • Surgery
lymphedema mgt complete decongestive therapy
Lymphedema Mgt. (Complete Decongestive Therapy)

Manual Lymph Drainage

  • Purpose of this hands on technique is to facilitate peristalsis of the lymphangion
  • Increase in peristalsis will help pump the fluid through the lymph system at a faster rate
    • increase LTV
  • Reroutes the lymph flow around the blocked areas into more centrally located healthy lymph vessels which drain into the venous system.
lymphedema mgt cdt
Lymphedema Mgt(CDT)

Manual Lymph Drainage

  • The proximal area is treated first, clearing first the adjacent and unaffected lymphotomes, then the proximal sections of the affected lymphotomes
  • The direction of pressure depends on the areas of edema, and the direction should always be towards a cleared lymphotome
lymphedema mgt cdt1
Lymphedema Mgt. (CDT)

Manual Lymph Drainage

  • The technique and variations are repeated rhythmically at least 10 times either in the same location using stationary circles or in an expanding circle
  • useless to do any less because the interstitial mass of the tissue fluid needs some time before it responds
lymphedema mgt cdt2
Lymphedema Mgt.(CDT)

Manual Lymph Drainage

  • The pressure phase of a half circle lasts longer than the relaxation phase
  • As a rule there should be no reddening of the skin(this relative)
  • The technique should not elicit pain
lymphedema mgt cdt3
Lymphedema Mgt.(CDT)

Compression Bandaging

  • Reduces the ultrafiltration rate
  • Improves the efficiency of the muscle pump and joint pumps
  • Prevents the reaccumulation of evacuated lymph fluid
  • Breaks up fibrotic tissue(scar and connective tissue)
lymphedema mgt cdt4
Lymphedema Mgt.(CDT)

Patient Education

  • Patient/family instructed in
  • self MLD
  • self Bandaging,
  • skin care precautions
  • therapeutic exercises
  • goal of the program is for the patient/family to be in control of their lymphedema management
  • Increases interstitial pressure, reducing leakage of capillary and increase absorption of tissue fluid by venous and lymphatic vessels during ultrafiltration
  • Compression from foam pieces decreases fibrotic tissue
  • Decrease capacity of superficial veins and lymph vessels by decreasing the vessel lumen diameter, which decreases blood volume, improves flow rate and decreases reverse flow
  • Contraindications: Arterial occlusive disease , cutaneous infections and dermatitis.
compression bandaging
Compression Bandaging

High elasticity(long stretch)

  • Continuous compression with low resistance, i.e.Stockings and ACE wrap
  • can be extended 100-200%
  • contain high elastic components
  • develop high restoring force and hence develop high resting pressure
  • should only be worn with activity and not at rest.
compression bandaging1
Compression Bandaging

Low elasticity(short stretch)

  • Gives resistance and compression
  • will have 30-90% extension
  • restoring force is low as is their resting pressure
  • When muscles are active, low stretch bandages form a support since they create a high working pressure
  • can be worn at rest and with exercise
contraindications to cdt
Contraindications to CDT

Absolute Contraindications

  • Untreated malignant tumors tending toward metastases
  • Acute inflammations(bacterial or viral)
  • Thrombosis
  • Active TB
  • Allergic reaction
contraindications of cdt
Contraindications of CDT

Relative Contraindications

  • Chronic inflammation
  • Functional disturbances of thyroid (if treated okay to do treatment)
  • Bone marrow patients(must be cleared to be in the community without a mask, watch for fatigue)
contraindications to cdt1
Contraindications to CDT

Relative Contraindications

  • Bronchial asthma (do not treat during an acute episode)
  • Cardiac arrhythmia(check with physician)
  • Deep abdominal drainage is not performed during menses, on pregnant patients or inflammatory disorders of the abdomen
contraindications to cdt2
Contraindications to CDT

Contraindications to Bandaging

  • Arterial diseases
  • Cardiac edema
  • Acute infections
  • Malignant lymphedema (can do for palliative treatment)
  • Bandaging should never cause pain, numbness/tingling, discoloration of digits. Remove immediately if happens.
goals of cdt
Goals of CDT
  • Utilize remaining lymph vessels and other lymphatic pathways
  • Decongest swollen body parts(arm/trunk)
  • Eliminate fibrotic scar tissue
  • Avoid the reaccumulation of lymph fluid
  • Prevent/eliminate infectionsMaintain normal or near normal size of limb
  • Functional return to ADL's
skin care
Skin Care
  • Skin obtains nourishment from underlying blood supply
  • Swelling increases the distance between skin and blood supply
  • Increased risk for infection
skin care1
Skin Care
  • Daily “skin checks”
  • Caution when cutting nails
  • Use wooden cuticle tools
  • Avoid artificial nails
skin care lotion
Skin Care – Lotion
  • Important to keep skin hydrated
  • Decrease risk for skin breakdown and infection
  • PH level of lotion approximately 7.0 which is natural PH of skin
  • Gentle lotion – low in alcohol
    • Johnson & Johnson Baby Lotion
    • Curel
    • Eucerin
extreme hot or cold
Extreme Hot or Cold


  • Hot packs or ultrasound
  • Deep massage on affected limb
  • Saunas
  • Hot tubs
  • Sunburns
  • Hot showers
exercise and wellness program point of entry to the program
Exercise and Wellness Program Point of Entry to the Program

Ambulatory Patient Entry

Cancer Center / Oncology Nurse Navigators

Local Support Groups

Radiation Oncology Department

Multi-Disciplinary Clinics

Physicians / Physician Offices

Inpatient Unit Rounding (Acute Care PT Referral)

Patient Self Referral

exercise and wellness program follow up care
Exercise and Wellness Program Follow Up Care

Physical Therapistwill provide patient and physician with an evaluation, a specific exercise assessment and an exercise prescription

Patient will follow one of four programs:

1. Traditional Therapy (requires physician Rx)

2. Supervised Exercise & Wellness Program

3. Home Exercise

4. Individual Wellness

exercise and wellness program follow up care continued
Exercise and Wellness Program Follow Up Care (Continued)

Supervised Exercise & Wellness Program

Patients are able to implement their recommended exercise program in a Beaumont facility with skilled supervision

Located at the Beaumont Medical Center, Sterling Heights – Rehabilitation and Dialysis Center

Open exercise sessions

Tuesdays and Thursdays from 10am to 7pm (2-4pm by request)

Nominal fee for participation

Self pay at $7 per session

Shared gym space with Cardiac Rehabilitation Phase 3 and Pulmonary Rehabilitation


“To be complete, a healing system must be able to cover the entire field of human experiences – physically, mentally and spiritually.”~ Stanley Burroughs

  • Reyna Colombo – Director Rehab Services, Beaumont Troy
  • Jackie Drouin – Oakland University
  • Deb Doherty – Oakland University
  • Kris Thompson – Oakland University
  • Dr. John Maltese – Physical Medicine and Rehabilitation – Beaumont Health System
  • Dr. Adil Akhtar – Beaumont Oncology Services
  • Dr. Eric Brown – Beaumont Oncology Services
for further information
For Further Information

Beaumont Health System


Healthcare Advisory Board


Association of Community Cancer Centers


American Physical Therapy Association – Oncology Section


American College of Surgeons – Commission on Cancer


  • National Coalition of Cancer Survivorship. Defining Terms. Available at http://www.canceradvocacy.org/resources/take-charge/defining-terms.html Accessed February 20, 2012.
  • Association of Community Cancer Centers. Cancer Program Guidelines. Rockville, MD: Association of Community Cancer Centers; 2009.
  • American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient Centered-Care. Chicago, IL. American College of Surgeons: 2012.
  • Healthcare Advisory Board. Cancer survivorship. Available at http://www.advisory.com/Research/Oncology-Roundtable. Accessed February 20, 2012.
  • American Cancer Society. Cancer Facts and Figures 2012. Available at http://www.cancer.org/Research/CancerFactsFigures/index. Accessed January 12, 2012.
  • Malone DJ, Bishop Lindsay KL. Physical Therapy in Acute Care: A Clinician’s Guide. Thorofare, NJ. Slack Inc. 2006.
  • Stubblefield MD. Cancer Rehabilitation. Seminars in Oncology. 2011; 38: 386-393.
  • Michaelson MD, Smith MR. Bisphosphonates for Treatment and Prevention of Bone Metastases. J Clin Oncol 2005; 23: 8219-8224.

9. Mirels H. Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop. 1989; 249: 256-264.

10. Coleman RE. Management of Bone Metastases. The Oncologist. 2000; 5:463-470.

11. DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles & Practice of Oncology. 7th ed. Philadelphia, PA. Lippincott Williams and Wilkins. 2005.

12. Barnholtz-Sloan JS, Sloan AE, Davis FG et al. Incidence proportions of brain metastases in patients diagnosed (1973 to 2001) in the Metropolitan Detroit Cancer Surveillance System. J Clin Oncol 2004;22:2865–2872.

13. Stout NL, Pfalzer LA, Springer B, et al. Breast cancer–related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care. Phys Ther. 2012;92: 152-163.

  • Drouin JS, Wilson E, Battle E, Seidell JW et al. Changes in Energy Expenditure, Physical Activity and Hemoglobin Measures Associated with Fatigue Reports During Radiation Treatment for Breast Cancer: A Descriptive and Correlation Study. Rehabilitation Oncology. 2011: 29: 3-8.
  • Wilson CM, Ronan SL. Rehabilitation Postfacial Reanimation Surgery after Removal of Acoustic Neuroma: A Case Report. J Neurol Phys Ther. 2010; 34: 41-49