Oncology Rehabilitation AMY HEGVIK, OTR- L MAREN SAND- PECK, PT, DPT

Oncology Rehabilitation AMY HEGVIK, OTR- L MAREN SAND- PECK, PT, DPT

About Us Maren Sand-Peck, PT, DPT Maren is a 1999 Graduate of Iowa State University with a Bachelor of Science in Psychology. Master of Science of Physical Therapy from Des Moines University in 2002 and later completed her Doctorate of Physical Therapy from Des Moines University. Maren is a certified Oncology Rehabilitation Specialist from the Physical Oncology Rehabilitation Institute in Denver, Colorado. She is also an LSVT Big clinician for the treatment of Parkinson s Disease. Maren s clinical interests include neurological rehabilitation, Parkinson s disease, balance disorders, and oncology rehabilitation. She has a true passion to help patients and their families during their rehabilitation journey.

About Us Amy Hegvik, MS, OTR/L Amy is a 2007 graduate of Wartburg College with a Bachelor of Science in Psychology. She received her Master of Science in Occupational Therapy from Washington University in St Louis in 2009. Amy has since worked for Unity Point therapy with clinical interests in hand therapy, neurological and oncology rehabilitation. She is a certified Oncology Rehabilitation Specialist from the Physiological Oncology Rehabilitation Institute in Denver, Colorado. She has a passion for helping patients maximize functional return to exercise, hobbies, social and occupational life.

Cancer Rehabilitation Certification Programs PORi- Physiological Oncology Rehabilitation Institute Foundations course plus the following options: Breast Cancer Head & Neck Cancer Pelvic, GI, Digestive Cancer Chemotoxicity & Cancer Exercise Management

PORi Program Founded by Julia Osborne, PT, CLT-LANA in 2009, Oncology Rehab is a national clinical leader in oncology rehabilitation and has been instrumental in creating, progressing, and setting the Standard of Care needed for rehabilitative patient management. She has combined her deep understanding of the lymphatic system with her wealth of clinical experience and the latest oncology research to develop her own treatment protocols - these form the foundation of the Oncology Rehab's clinical approach It is PORi s vision that rehabilitation will be prescribed to all patients who undergo treatment for cancer as a STANDARD COMPONENT of their cancer treatment.

Certification Course 5 day Assessment-based certificate in Physiological Oncology Rehabilitation Physical Therapists & Occupational Therapists (now some courses open to SLPs) Integrated treatment models designed to include: Myofascial Trigger Point Release, Joint Mobilization, Neural Mobilization, Lymphatic Manual Drainage, Pain Mitigation and Functional Restoration. Study of the impact of cancer treatment on: Epidermal, Dermal, Myofascial, Skeletal, Lymphatic, Vascular and Neural Systems, and the treatment protocols instructed by PORi relate to the optimal resolution of signs and symptoms within these body systems. Live patient presentations and labs Written final exam Practical Exam: Instructor observed breast cancer treatment session

Cancer Statistics Projected number of cancer patients will increase to 18 million survivors by 2022 Also increased number of cancer diagnoses in addition to this increase in survivorship Study of 529 old adults with cancer 65% reported functional deficits Only 9% received PT/OT! Pergolotti M et al. The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer. J Geriatric Onc 2015.

Comprehensive Approach to Cancer Care Oncology Rehab is evolving from simple support and palliative care to now include comprehensive Rehabilitation Interventions Remediate functional loss Allowing the patient to fully participate in daily activities Restore body systems/organs structure and function (post treatment)

Physiological Basis for Treatment of Oncology Patients 1. Physiology of tumor formation and cancer behavior (how the tumor behaves in the body) 2. Side effects of surgery, chemo, radiation, adjuvant therapies 3. Physiology of repair and recovery how the body heals from the above interventions 4. Restoring Function cancer is a chronic disease process This is a comprehensive, multi-system approaching to treat the cancer patient holistically

Body System Approach for the Oncology Patient Epidermal and dermal system Myofascial system Skeletal system Visceral system Lymphatic system Vascular system Neural system Musculo-skeletal system

4 most frequently reported health problems in common solid tissue tumor types 1. Arthritis movement/function 2. Heart cardio toxicity/chf/decrease output 3. Vestibular/peripheral neuropathy 4. Hormone and thyroid issues fatigue, weight gain, depression Schultz, PN; Beck, ML; Stave, C; Vassilopoulou-Sellini, R: Health Profiles in 5836 Long Term Cancer Survivors. Int. J. Cancer: 104, 488-495 (2003)

% Frequently Reported Impairments 60 Percentage of Patients Reporting Impairment 50 40 30 20 10

Side Effects of Chemotherapy 1. Myelosuppression 2. Cardiotoxicity 3. Cancer related fatigue 4. Chemo induced peripheral neuropathy 5. Cachexia 6. Cognitive changes

Chemotherapy Implications of chemotherapy: All patients on systemic drugs will have Myelosuppression Affecting RBCs, WBCs, Platelets Patients will reach the point of NADIR, the lowest lab values Usually 2 days after chemo is given, patient can be overly fatigued NADIR lasts around 3-5 days In acute care, even with low lab values the patient should still get up and move within their room

Chemotherapy All cancers grow/change in different ways. If researchers can figure out the growth, they can target treatment to address this. Lots of research with breast cancers. More research is needed with other cancers. Targeted therapies: Growth factors block growth Proliferation target DNA of fast growing cells Angiogenesis target vascular Metastasis studies underway to block cell mobility Immunotherapy Cancer cells hide in checkpoints to avoid attack by the immune system; drugs target checkpoints affected with cancer cells

Chemo Induced Peripheral Neuropathy CIPN in lower extremities can cause pain, numbness, tingling, hypersensitivity, and feelings of heaviness This in turn affects balance and mobility Sensory nerves can be affected as well as motor nerves Gait deficits you may see: Limited toe clearance Wider base of support Lack of heel strike Unsteady gait Need for assistive device

Treatment of CIPN: Comprehensive/whole system approach that includes: Functional testing of balance and gait Monofilament testing of protective sensation Balance activities Sensory activities Manual therapy Strengthening activities of lower extremities and core Stretching/ROM activities to address tightness

Chemo Induced Peripheral Neuropathy CIPN in upper extremities can cause pain, numbness, tingling, hypersensitivity, and feelings of heaviness Fine motor coordination deficits Weakness with grip and pinch Pt s often reports difficulties with typing, handwriting, fastening clothing, etc. OT works on both neurological re-education as well as adaptive techniques to help improve functioning

Estrogen- why it matters in therapy Estrogen is important for muscle tone, strength, and tensile properties Estrogen deprivation effects all women as we move into menopause Post-menopause majority of estrogen is produced in the adipose tissue, muscle tissue, and adrenal glands Weak core/flabby abdominals, stress incontinence, etc Effects cancer patients due to treatments that block estrogen production *** importance of core stabilization exercises Decline in estrogen levels and lead to inflammation, decreased cartilage turn over, decrease in vitamin D levels, and weight gain

Radiation Radiation causes scar tissue fibrosis in soft tissues ligaments, tendons, nerve sheaths, muscle, vascular tissue What we have seen in Oncology Rehab post-radiation Lung Cancer Breast Brain Colorectal Every time a patient receives radiation, their tissues are re-injured

Radiated Tissue Can cause pain and tightness in surrounding areas Therapy treatment may be altered during radiation Burns Keeping tissue depth consistent (not wanting to move edema) *Therapy does not have to stop during radiation treatments Working with physicians and communication is key

Phases of Tissue Healing Acute inflammation peaks around 2 weeks and then drops off Proliferation approximately 2 months Remodeling after 2.5 months; last 12-18 months Our jobs as therapists is to assist in transition of healing phases

Surgery Surgical considerations depending on area effected as well as tissue healing Physician dependent Type of surgery performed

Post-operative conditions Axillary Web Syndrome Cording Pre-treatment Post-treatment

Post-operative conditions Our goal is to get to patients before Clinical Edema is present We have a team approach with the Lymphedema Clinic LE clinic therapists help with fitting for compression garmets

Lymphatic System Lymph fluid is not just in a patient s interstitium. It runs through joints, nerves, muscles, tendons and ligaments. Lymph vessels are interspersed all around our muscles. The tighter the muscle, the less the lymph system can work We need to engage this system as a whole to assist with healing.

Oncological Emergencies Cancer related pain Pain develops from tumors compressing structures- can develop quickly Superior vena cava syndrome Compromised venous drainage of the head, neck, and upper extremities & thorax through superior vena cava May look like edema around upper chest and neck but is symmetrical, lymphedema is often asymmetrical. It is important NOT to do MLD techniques if suspecting SVCS may see petechia in chest from fluid pressure Neural compression/infiltration Spinal mets compressing the spinal cord

Oncological Emergencies Bony Metastasis: Osteolytic, osteoblastic, sclerotic lesions need to be aware of weight bearing status with bone mets T-shirt pattern: spine, pelvis, ribs, proximal long bones- rare in distal bones Interesting fact- 70% of people with advanced breast or prostate CA have bone mets Hypercalcemia w/ bony mets, calcium leaking into the blood Cachexia Weight loss of >5% over 2-6 months from pre-illness weight DIC (disseminated intravascular coagulation) Small clots formed inside the blood vessels Causes abormal bleeding Found in very acutely ill patients usually w/ leukemia, lymphoma, and myeloma avoid heavy lifting and joint stress during therapy

Exercise Program Need to be aware of any potential local and/or systemic side effects Strength/ROM/core stability Yoga and pilates, tai chi Cardiotoxicity Variation in exercise intensity using VO2Max percentages as guidelines Karvonen Formula to Calculate Target HR Balance and Coordination exercises

Karvonen Method

Functional Testing/Assessment Forms Grip strength Upper and lower limb circumference Shoulder abduction and flexion DASH 6-minute walk test Gait speeds 5xSTS FACT questionnaire ABC% AM-PAC UEFI Monofilaments BERG/DGI/miniBEST test Additional testing not here depending on Pt situation/functional impairment

Other treatment considerations Constant 1: ALWAYS a body systems approach to treatment that includes the neuro, muscular, skeletal and lymphatic system Constant 2: Basic PT/OT categories of care (pain, ROM, strength, posture, balance, function) Constant 3: Phases of soft tissue healing (from inflammation to proliferation to remodeling phase) Constant 4: Lymphedema is part of the cancer story (whether subclinical or clinical)

Supportive Services/team approach Chemo Brain- Speech therapy Classes offered at John Stoddard or individual tx Lymphedema Clinic Women s Health Vestibular Therapy Dry Needling

Experts in this field Oncology Rehabilitation is a new academic area of clinical expertise in cancer treatment Just as patients have the right to see an Oncology physician and nursing team, they deserve the same right to be seen by an Oncology Therapist Our goal: To grow Oncology Rehab Surrounding rural areas Patient s having greater access to treatment

Oncology Rehabilitation Referrals Any patient who has developed or shown: Change in functional status Reports falls Reports difficulties with fine motor activities Difficulty clearing feet when they walk Generalized weakness or fatigue Tissue tightness post radiation or surgery Incontinence or vaginal stricture

What we see as therapists Patient s having more deficits than they report or is easily seen The positive changes in mobility and balance after outpatient therapy Improved ability to use hands Benefits of the comprehensive team approach Improved overall well-being and ability to engage in life

FACT Scores- patient questionnaires Physical Well-Being Social/Family Well-Being Emotional Well-Being Functional Well-Being

FACT Form from Patient

FACT Form from patient

Patient Feedback I have more energy and I am getting out of my house more. I actually feel like putting my earrings on again. A lot of people have been telling me that I have been walking better! I feel good! My arm always feels so much better when I leave therapy! Oncology Rehab has truly saved my life.

Lab/Questions Trigger Point Release Based on Travell s trigger point manual Myofascial Stretching, Tissue/muscle bending Joint mobilization Fluid movement Functional tests Area specific exercise ROM, strength, neuro/balance specific, neural tension, cardiac

Travell s Trigger Point Chart

Thank You! Thanks for coming today to learn more about Oncology Rehab! Feel free to e-mail us if you have any questions amy.hegvik@unitypoint.org maren.sand-peck@unitypoint.org