Rehab strategies final

Restorative strategy for cancer-related dysfunction

Eun Joo Yang, MD., PhD.Department of Rehabilitation Medicine

Seoul National University Bundang Hospital

Opening

• Cancer journey : – prehabilitation~ palliative

• Cause of impairment :multimodal – Surgery, CTx, RTx, …

• Cooperation and communication– cancer specialist and supportive care

team

Journey

Survivorship Care Continuum

Cancer Journey

Daily routineSleep

Fatigue

Daily routineSleep

StaminaSelf-careCosmesis

Communication

SleepFatigue

ADLVocationCosmesis

SleepFatigue

DisabilityCosmesisVocation

MobilityDependence in self care

Gerber et al, Cancer rehabilitation into the future, 2001

Fun

ctio

n

Gradual changesUnnoticed until the last months

Treatment After treatment Follow-up Recur

Cancer-related disability : Insidious

Acute hemiplegia from a hemorrhagic brain metastasis Myelopathy from a pathologic spinal fracture occur

Cheville AL et al., 2011The loss of the ability to perform at least one ADL as early as 12 mo before death

The disability process

Pathology ImpairmentFunctional

LimitationDisability

Decreased QoL

Verbrugg & Jett (1995)Cancer

progression

Symptom

BurdenPain,

Fatigue

InactivityImmobilit

y

Immobility ~ the need for assistance with ADLs Kurtz et al.

Self-reported fatigue ~total number of steps (r = 0.6) Dahele et al.

Isolated physical impairments explainedvery little of patients’ ability to function

5%-10%

Total Number of Physical Impairments (r==-0.75)

Cheville AL et al., 2011


Diagnosis Acute Cancer Treatment

Prehabilitation

Rehabilitation

No impairments

Impairments

General Exercise/Wellness



M/73 NSCLC, adenoca, RLL, M/lung, bone, brain, stage 4 2014.9.CA 19.9>1000Wt loss 7-8kg loss/3yrex-smoker (30PY, 8YA quit), s/p posterior fixation at L4,5 (2YA)

NSCLC, adenoca, RLL, M/lung, bone, brainEGFR mutation (-),K-ras mutation (-)

LBP with rt leg radiation for 5mo

Pall. RT to L3-S3 and both iliac bone (14.10.2 - 14.10.8)

ECOG 1Independent self gait

CTGC #1D8 (14.10.22-10.30): PD> SDAlimta #1 (14.11.18 - )

Bilateral L3/4 facet joint injection with epidural spread (triam 40mg)

2014.12leg swelling

ECOG 2-3

집에서 숨이 차고 다리가 부어 제대로 생활이 힘들었다고 함 .화장실 정도는 혼자 갈 수 있으나 그 이상 걷는 게 힘들고 , 밥은 1/3 공기 정도밖에 먹지 못하였음 .

2014.9

Pall RT T9half-L1, 10Gy/2fx (15.2.24-)

ECOG 3

short-term Rehab and T/O Palliative care center

2015.3

Functional assessment1. transfer roll-over(+/+), sit up(+) , sit to stand(-)sitting balance: S/D: F/Pstanding balance: S/D: Z/Zassist gait impossible

Pressure ulcer (+) : Coccyx, Gr2 (3x4)

P-bar standing try : min.~mod. assist 30sec (monitoring SpO2)both. L/E AAROM ex.Theravital L/E 10min.



F/36 Cervical ca, endocervical ADCa, FIGO 1B1, pT1b1N0M0

2014.10.302014.10.17LLQ discomfortSmear (+) LEEP

2014.11.25LRH BSO BPLND PALNS (IMA)

2014.12.1Rt. LEx sensation changeRt hip adductor weakness

2014.12.30-2015.1.30Postop CCRT w/ triweekly cisplatin 46 Gy/23 Fx

2015.2.Gait discomfortFalling tendencyHip Adductor P-/ F+

2015.3 EMGRt.AL: Fib/PSW(4+/4+)Rt. obturator neuropathy, with moderately severe axonal involvement



Rehabilitation

No impairments

Impairments


Hip adductor strengthening exerciseCore exercisePelvic floor exercisePubic lymphedema MLD education



No impairments

Impairments

Risk factor Natural course



F/40 Breast ca, Rt UOQ (IDCa), cT3N2M0

2013.12-2014.4AC #3 D #4

2014.5.13Rt MRM

2014.11 (5month after surgery)3-4 일전부터 우측 상지가 부어요Volume difference (ml) 156.89

2014.6-7PMRT to Rt C/W& SCL2014.5 zoladex+tamodifen

2014.6POD 10 days

Successful management of lymphedema

Early diagnosis using sensitive measurement Prospective Surveillance Model

Surveillance Protocol for Patients with High Risk of Lymphedema

OP day10 days 3-6 mo

Initial Sx & Sign

Lymphedema?Yes

No

Lymphedema CP

3-6 mo

Preventive Life Style modification

Initial Sx & Sign

Lymphedema?Yes

No

Lymphedema CP


3-6 mo

Initial Sx & Sign

Lymphedema?Yes

No

Lymphedema CP


Initial Sx & Sign

Lymphedema?Yes

No

Lymphedema CP


Dominantratio >1.066 Non dominant ratio >1.106

Subjective symptom Heaviness, tension, bursting pain or aches, and changes in the limb during the day

Stemmer sign If agreed:ACTIVE Program

Clinical Pathway for the Prospective Rehabilitation Model of Care

Breast Cancer Diagnosis

Pre-Operative Measurement

Stage 0-1

ECW ratioDominant >1.066

Non dominant >1.106

Post-Operative Surveillance – 3 month interval follow-up

No lymphedemaStemmer sign (-)

ECW ratioDominant <1.066

Non dominant <1.106

Stage 2-3

CircumferenceWater displacement

Fibrotic change

Lymphedema CPBandage, Garment, MLDMedication, Exercise

Sleeve and MLD education

Progressive Exercise Risk reduction Education

Vol ↑

Vol ↓Vol ↓

Wellness RehabilitationTreatment

RehabilitationService

Precachexia and early intervention

J Cachexia Sarcopenia Muscle (2011) 2:87.93



Prehabilitation

Rehabilitation

No impairments

Impairments


Cancer Survivor Health & Function Trajectory

Above baseline?!

Preop function and prognosis

High: > 18 meters (solid line)Low: < 18 meters (dashed line) Log-rank test p = 0.003

Ann Thorac Surg. 2012;93:1796-800

0.155 meters

Preoperative stair-climbing test Stage I non-small cell lung cancer

Function damaged by neoadjuvant therapy?

DLCO, diffusing capacity of the lung for carbon monoxideBefore induction chemoradiotherapy (T0), 4 weeks after induction chemoradiotherapy and before surgery (T1), 1 (T2),3 (T3), 6 (T4), and 12 months (T5) after surgery

J Thorac Cardiovasc Surg. 2010;139:1457-63

>65 yearsCOPD

Perioperative rehabilitation in operation for lung cancer Timeline

Diagnosis Surgery

1 day 1 wk 2 weeks 6 weeks 14 weeks

2 weeks

Home-based

In-patient Early Initiated

rehabilitation

High-intensity

assigned for curative lung cancer surgeryPerformance status 0-2 (WHO)

moderate to severe COPD?

Consult to OPD Rehab

Consult to Rehab dept. 퇴원시 1st OPD 예약

Perioperative rehabilitation in operation for lung cancer Timeline 2

Diagnosis Surgery

Interval trainingOPD based exercise

1 day 1 wk 2 weeks 6 weeks 14 weeks

In-patient

Early Initiate

d rehabilitation

High-intensit

y

stage III non–small cell lung cancer (NSCLC) induction chemoradiotherapy (IT) >65 years, smoker, Respiratory impairment (Forced vital capacity <80% predicted or forced expiratory volume in 1 second/forced vital capacity <70%)

induction chemoradiotherapy (IT)

Consult to OPD Rehab

Consult to Rehab dept.

퇴원시 1st OPD 예약


• Cause of impairment :multimodal – Surgery, CTx, RTx


team

폐암과 기능장애

일상생활기능저하

최대산소흡수량 12-15mL/kg/min

견부 통증 진단 및 치료 흐름도견관절 통증

위치특정위치

상완와관절 혹은 상완

견관절외압통 , 유발 , 초음파 검사

견봉쇄골관절흉골쇄골관절

윤활낭

국소주사운동

관절가동범위 제한

전방향성 방향성

압통 , 유발 , 초음파 검사

유착성관절낭염1 기

관절강내 주사

수압팽창술과 물리치료

2 또는 3 기

압통 , 유발 , 초음파 검사

MRI, CT

회전근개 건증 , 파열 , 석회화

예국소 주사 , 운동 ,

흡인술 , 수술

아니오

회전근개병변

관절와상완인대

국소주사운동

수술

경부기원

경추에 대한 치료

액와막 증후군Axillary web syndrome

대흉근 단축Pectoralis tightness

Breast cancer

액와막 증후군Axillary web syndrome

대흉근 단축Pectoralis tightness

14117680 고문숙

Head and neck cancer : Dysphagia +α

Lymphedema Muscle contracture Weakness

Gynecological cancer

Lung cancer rehabilitation

Chest expansion exerciseChest wall mobilization

Spiro-ball\25,000

Inspiratory muscle training

Diaphragm breathing

Strengthening exercise

Brain

SCI

MSPediatric

Pul.

Elder

Cancer

Rehab

Rehabilitation Service : Traditional? vs New?

Cancer-common, Cancer-specific dysfunction

Treatment related dysfunctionChemotherapy” Cognitive impairment, peripheral neuropathySurgery related Dysfunction per organ

Traditional

Novel

What?Matching the Traditional Rehabilitation Service for Cancer Survivors

Developing the New Rehabilitation Service for Cancer Survivors




team

중증도에 따른 단계별 접근

통합지지센터

암정보교육센터

치

료진단 치료

지지 및 치료

안녕상태

장애상태

교육 및 상담

통합지지 진료

Bruera E , and Hui D JCO 2010;28:4013-4017

Team works: Physician to physicianGovernment

National Cancer Center

Local Cancer Center

Local medical center

Nursing home

Hospital

Primary care

Information service

Social service

Psychological service

Physical service

GSOncolog

y

Radiooncolog

y

Comprehensive supportive care center

Community

Care Plan

Care Plan

국내 재활의학 전문의 인식도

　 Lymphedema 　Upper　limb　dysfunction　in　breast　cancer

　

Pelvic　floor　dysfunction　in　gynecological　cancer

Brain　tumor Spine　tumor　　 Mobilization 　 Prevention　of　lymphedema

　 OR 95%CI P 　 OR 95%CI P 　 OR 95%CI P OR 95%CI P OR 95%CI P 　 OR 95%CI P 　 OR 95%CI P

Patients 0.67 0.19-2.26 0.514 1.2 0.35-

4.04 0.789 1.35 0.26-6.97 0.72 3.01 0.85-10.34 0.081 1.31 0.38-

4.48 0.668 2.04 0.59-7.11 0.26 2.03 0.60-

6.89 0.253

Oncologist 0.73 0.23-

2.29 0.593 0.4 0.13-　1.27 0.121 2.19 0.26-

18.38 0.47 0.48 0.15-1.51 0.482 0.71 0.23-

2.26 0.569 0.96 0.27-3.36 0.947 0.48 0.15-

1.51 0.211

Physiatrist 1.86 0.83-4.17 0.13 2.4 1.04-

5.63 0.041 1.28 0.39-4.14 0.68 1.89 0.81-4.44 0.141 1.42 0.62-

3.28 0.408 1.48 0.61-3.62 0.386 1.58 0.68-

3.67 0.283

Refer　system 1.61 0.91-

2.83 0.101 　 1.8 0.96-3.25 0.067 　 2.16 1.02-4.59 0.04 1.16 0.66-

2.05 0.605 1.54 0.85-2.81 0.153 　 1.76 0.96-

3.23 0.066 　 1.81 1.01-3.26 0.047

　Yang,　　Lim　et　al.　Cancer　research　&　Treat　2015

Surgery

Postop~

3M

3M~

6M

BCS: Breast conserving surgery TM: Total mastectomy ALND: Axillary lymph node dissection SLNB: Sentinel lymph node biopsyCDPT: complex decongestive physical therapy Text book: Instructions on lymphedema prevention and upper limb dysfunction

Surgery (GS, PS)

F/U

F/U

Chemotherapy

RadiationTherapy

No

Pectoralis Tightness

CDT & educationUpper Limb Rehabilitation

ImpingementSyndrome

Adhesive Capsulitis Lymphedema Others

Education for prevention

&F/U

Upper Limb Dysfunction

Yes

Proper Mx for each Dx

InitialevaluationBreast Cancer Treatment Clinical Pathway

Closing …




team

사랑합니다 .

Rehab strategies final

Health & Medicine

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