3/5/2018 CANCER ASSOCIATED FATIGUE & PAIN OBJECTIVES CHRONIC PAIN ACUTE PAIN PAIN SCALES

Transcription

1 OBJECTIVES CANCER ASSOCIATED FATIGUE & PAIN SCOT M. SAWYER, PT, DPT BOARD CERTIFIED ELECTROPHYSIOLOGY CLINICAL SPECIALIST Recognize the multi-factorial pain response cancer survivors may exhibit Understand how to recognize cancer related fatigue Identify appropriate outcome measures for assessing fall risk Discuss the role of physical therapy along the continuum of care for cancer survivors ACUTE PAIN CHRONIC PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage... Not every person with cancer will experience pain (procedures, surgical, pharmacological, radiation, etc.) Often severe and usually lasts < 3 months. Medications are often prescribed at this stage. Lasts beyond the point of injury to where tissue is likely healed (> 3months) Neuropathic, phantom, persistent Massage, acupuncture, meditation, yoga, distractive techniques PAIN THEORY: NEUROMATRIX. MELZACK, R. & KATZ, J. PAIN. COGN SCI VOLUME 4, JANUARY/FEBRUARY PAIN SCALES Chronic pain is not a warning to prevent disease, it is the disease itself, where neural mechanisms have gone awry. Neuromatrix theory of pain proposes that pain is a multidimensional experience produced by characteristic neuro-signature patterns of nerve impulses generated by a widely distributed neural network in the brain. Neuromatrix is our brain s neural network which includes an image of our body (homunculus) upon which impulses, genetics, psychological profile, gate theory, personal physiology, homeostatic regulation and past experiences combine for the unique and individual experience of pain. Brief Pain Inventory (Short Form) International Association for the Study of Pain handout (IASP) MD Anderson Symptom Inventory (MDASI) 1

2 _L=IMG J IMG J0I30K1J0I8I30K1J0I24K1.DKG1DXORLIS#IMGRC=_ CANCER RELATED FATIGUE (CRF) SOME LOOK FATIGUED... AND SOME DON T Fatigue is by far the most common symptom affecting people with cancer. At its worst, cancer-related fatigue is a draining, ongoing exhaustion that limits one s ability to enjoy life and do activities. 1 CRF is experienced by % of cancer patients while receiving chemotherapy May continue to be disruptive in healing for months and even years after treatment ends May also cause a patient to not continue with treatment CRF linked to: pain, depression, inactivity, sleep disturbance, poor nutrition, medications and comorbidities. 1. National Comprehensive Cancer Network (NCCN). Retrieved September 12, 2017: CRF SCALES EXERCISE & CRF Systematic Review in 2009: Minton, Stone. (2008) A systematic review of the scales used for measurement of cancer related fatigue. Annals of Oncology 20: (Included this in your packet) This review looked at over 7889 studies. Brief Fatigue Inventory and Fatigue Severity Scale are both Likert scales. The Functional Assessment of Cancer Therapy Fatigue (Fact F) scale is one of a range in series of quality of life measures for specific cancers. Tomlinson et al, performed a meta analysis and found that exercise such as aerobic, resistance, strengthening, walking, yoga, stretching and tai chi had a moderate effect in reducing fatigue, depression and sleep disturbance. Tomlinson et al. Effect of exercise on cancer-related fatigue: a meta analysis. AM J Phys Med Rehabil 2014; 93: START EARLY VERSUS... JUST HANGING OUT 2

3 SURVIVOR FALL RISK FALLS/BALANCE OUTCOME TOOLS Age CIPN Pain Depression Incontinence Impaired cognition Vestibular dysfunction Impaired vision Use of assistive devices Impaired physical performance Environmental issues Screen for fall risk in all setting TUG: older adult who takes > 12 seconds to complete is at high risk for falls (CDC 2016) Mini Best Test: 14 items, scored from 0-2, max score is 28 CANCER SURVIVORSHIP & EXERCISE FUNDAMENTALS OF EXERCISE PRESCRIPTION Must take into account: Fit into ongoing treatment regimen Ongoing medical comorbidities Pain Testing: prescription exercise or modification Patient goals Extent of CRF Support Reality check FITT principle: frequency, intensity, time (duration) and type. Exercise must be at a level to bring about a physiological change in muscular strength and endurance. One type of program does not fit everyone. It must be unique. Accomplished in different ways but it must take into account: heart rate, BP, heart rate reserve, safety, flexibility, balance, strength, etc. ACSM guidelines are excellent for setting up a program based off of these parameters. EXERCISE TOLERANCE OUTCOME ASSESSMENT CLINICAL PRESENTATION CIPN 2 minute walk 6 minute walk Stair Climbing Test 30 second sit to stand Quick DASH Pain, burning, tingling, loss of feeling Trouble using fingers to p/u items, poor balance, tripping or stumbling Sensitivity to heat/cold/touch/pressure Shrinking muscles, weakness, trouble swallowing, constipation, BP changes, decreased reflexes Accessed October 2,

4 RECOVERY FROM CIPN TREATMENT FOR CIPN Lack of evidence for complete resolution There is a plethora of information on different homeopathic/naturopathic methods, traditional medicine, chiropractic, infectious disease, toxicity, etc. Some regeneration is found which is dependent on many factors General rule: 1 inch per month for regeneration under optimal healing conditions may take place Treatment is supportive in nature: muscle strengthening, falls prevention, gait training, orthoses, desensitization, good nutrition, hydration, sleep, pain management, energy conservation for CRF and adaptive equipment. Few things will help the nerve regenerate faster other than providing optimal healing conditions during and after chemotherapy is discontinued. CHEMOBRAIN SURVIVORSHIP Higher order mental functioning affected May happen, may not happen, may be transient What is a clinically significant decline, a statistically significant decline? May be dependent on subject age Decline in cognitive functions: Concentration, reduced capacity to multitask, forgetfulness, may take longer to process information. Executive function may be impacted as well. National Children Cancer Society: An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Family members, friends, and caregivers are also impacted by the survivorship experience and are therefore included in this definition. SURVIVORSHIP CHILDHOOD SURVIVORS Late Effects begin/recognized long after treatment ends... Lymphedema Secondary cancer Cognitive changes Cardiovascular changes Osteoporosis 13 years after treatment: median age 22 58% had at least 1 chronic medical problem 32% had at least 2 chronic medical problem Psychosocial issues Cognitive & Learning disabilities Anxiety/depression Employment issues Skinner. Lancet Oncol. 2006; 7:

5 EXERCISE PRECAUTIONS WITH PERMISSION-M. WAMPLER-KUHN, PT, DPTSC Oncology patients tend to be older: Mean age at diagnosis is 56 YOA Balance Fall risk Strength (UE and LE) Abnormal gait patterns Cardiovascular status Psychological status (Yancik, 2001) 5