amy hegvik, otr-l maren sand-peck, pt, dpt - …...treatment of parkinson’s disease. maren’s...
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A M Y H E G V I K , O T R - LM A R E N S A N D - P E C K , P T , D P T
Oncology Rehabilitation
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)
60
50
40
3020
10
Percentage of Patients Reporting Impairment
% Frequently Reported Impairments
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
[email protected]@unitypoint.org