Breast Cancer Rehabilitation

Breast Cancer Rehabilitation
Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer File #4 Breast Cancer Rehabilitation Breast Cancer Rehabilitation…………………File #4……….……………………………..…..……….02 Statistics………………………………………………………………………………………..………..04 Niche practice………………………………………………………………………………..………….08 Health Care Reform & ICD 9 Codes………………..……………………………………..…………..13 Psychology and Support Issues…………………………………………………….…..……….…... 18 Pain…………………..…………………………………………………………….……..…..……..……29 Time Out Test………...………………………………………………………………..…………………39 Quality Life through Rehabilitation….………………..…………………………..…….……………...40 Rehabilitation options………………….………………………….….…………..……………………..43 Evaluation scales……………………….…………………………….….……..……………………….46 Lab Values……………………………….…………………………………………………………….…51 General Breast Cancer Exercise Programs…………………….….…..…………………………….56 Documentation…………………………….………………………………………………………..…...70 Post-Surgical Rehabilitation Examples….…..…………………………….……………………….…74 Out-Patient example……………………….………………………………………………….………...99 Research……………………………………..……………………………………………………….…108 Modality contraindications………………….……………………………………………………….…121 Oncologic Emergencies…………………….………………………………………………………….129 Time Out Test…………………………………..……………………………………………………….135

Breast Cancer Rehabilitation
The physical therapy profession is the ideal medical profession to deal with all aspects of establishing and following a safe and realistic mobility and strengthening plan of treatment for the breast cancer patient. This professional has the ability to decipher all medical information presented by the physician and diagnostic studies presented concerning the status of the breast cancer patient. To me cancer care and physical therapy are synonymous.

Role of the physical therapist when treating breast cancer patients:
Educate public of early detection Educate the patient, family, physician and other health care providers of the need for rehabilitation for the patient diagnosed with breast cancer. Follow a safe and functional rehabilitation program with realistic goals for each individual Help improve Quality of Life Promote care to decrease side effects Improve patient’s outlook on recovery Breast Cancer: FYI Resources suggests, “Consider at least one session with a physical therapist if you have any kind of breast cancer related surgery”. By following this treatment role, physical therapist will be the experts dealing with breast cancer rehabilitation. I feel that one of the most important aspects that we offer the physician, is patient safety as well as the ability to prevent post surgical complications.

America Cancer Society, Surveillance Research, 2005 Estimated Breast Cancer In situ and Invasive for Age Groups AGE In Situ Invasive < 40 1,600 9, and older 56, ,730 Under 50 13,760 45, and older 44, ,460 Under 65 37, , and older 21,450 88,170 ALL AGES 58, ,240 Breast cancer patients need to be seen by physical therapist for proper evaluations and exercise programs. Physical therapists may need to solicit these referrals. A physical therapy program can be anything from a post operative instruction plan, completed in minimal visits, to a routine program to progress the patient towards a quality of life goal. (American Cancer Society, 2005)

THE REFERRAL FOR PHYSICAL THERAPY

Who is going to make the therapy referral?
General Practitioner Internist Surgeon Plastic Surgeon Oncologist Radiation Oncologist Radiologist Psychiatrist Pathologist Nurse Social Worker Psychologist Nutritionist Chaplain Family Member Friend Patient Physical Therapist There are many possible choices of professionals that can make a referral for rehabilitation, or request a referral for therapy. Educate potential medical personnel of the need for physical therapy rehabilitation during and after medical interventions for breast cancer. I realize that we are not sales people, but we must make everyone know of our capabilities to deal with breast cancer. Many choices and potential referral sources.

“Despite potential benefits, referrals of cancer patients for rehabilitation are often made needlessly late or not at all” Physician Text: CANCER MEDICINE ************************************************* Physical therapist may need to solicit the benefits of cancer rehabilitation to physicians, other cancer team members and patients. We still need to educate physicians and nurses of the benefits of rehabilitation after the diagnosis of breast cancer. If patients have a knowledge of what physical therapy has to offer them, they will even request a prescription for therapy. (Ragnarsson, 2003)

Could breast cancer rehabilitation be your Niche?
This is just a possible option for a physical therapist. I have always found the profession of physical therapy to allow the therapists many options, as far as what area of therapy they would like to work. This is a benefit that is not available to many professions.

Niche: A place, employment, status or activity for which a person or thing is best fitted. A specialized market As a physical therapist you can pick your own specialty, especially if you can prove the need for your program. (Webster’s Universal Encyclopedic Dictionary, 2002)

What is your niche? Oncology Orthopedics Athletics
Temporomandibular Dysfunction's Urinary Incontinence Pediatrics Soft tissue work Relaxation Programs Administration As a physical therapist there are many areas of treatment you can choose. You need to decide, what type of therapy would be most rewarding to you.

Determining your Niche
The expertise and experience comes from the interest.

Make your own niche Cancer Center Rehabilitation S Search U Understand
C Confidence C Challenge E Excitement S Support S Succeed I feel that these characteristics, which I developed from the word success, make for a pleasant and rewarding profession. The American College of Sports Medicine standards for a fitness facility, which can be used for a breast cancer center. Have an emergency plan Pre-activity screening program Professionals only Signage with alerts of all risk factors Appropriate supervision Conform to all relevant laws, regulations, and published standards Rehabilitation

Health Care Reform ICD-9-CM Codes
Today, you need to have a knowledge of all aspects of patient care. You cannot just be concerned with the treatment plan. With a complete knowledge of reimbursement, you can choose a program that is not only beneficial toreach set goals but affordable to the patient.

HEALTH CARE REFORM Wellness reduces Illness Wellness decreases expense
You must know what is going on with health care in your area. This helps you explain your protocol to your administrator or accountant. You will also answer your patients questions concerning coverage or reimbursement for physical therapy cost. Even though it seems realistic to me, it is not always easy to convince your patient and insurance company that wellness decreases medical expense. Wellness reduces Illness Wellness decreases expense

Key Issues of Health Care Reform
Access to Care Quality of Care Prevention Standard Benefits Package Cost Containment Education and Research National Boards State Autonomy Workers’ Compensation As a practicing physical therapist you should keep aware of all Government Issues.The American Physical Therapy Association, Government Affairs Department pays close attention to changes in medical coverage. Realize how important your notes are in providing information that helps substantiate the need for rehabilitation for breast cancer patients. (APTA, 1994)

Helpful breast cancer ICD 9-CM codes
Fatigue – limiting ADL’s……………………….780.7 Nausea – limiting ADL’s.…………………… Generalized pain limiting function…………780.9 Weakness limiting ADL’s…………………… Muscular wasting, disuse atrophy…………728.2 Difficulty walking……………………………… Lymphedema………………………………… Breast Pain……………………………..…………611.71 Adhesive Capsulitis……………………..…… Make sure when you charge a patient, that proper codes are selected, to prevent complications. (McCormack, 2002)

Modified Radical Mastectomy Reconstruction Chemotherapy Rehabilitation
For all of the expensive medical interventions, insurance companies should realize the benefit of physical therapy, to promote wellness and decrease sickness during and after treatment programs for breast cancer. Mammogram Biopsy Pathology Lumpectomy Radiation Modified Radical Mastectomy Reconstruction Chemotherapy Rehabilitation Insurance reimbursement for program services is usually very good. All coding should be assigned to a patients’ functional diagnosis rather than the oncology diagnosis. The diagnosis should be based on whatever functional activities are limited and what is creating the limitation. (McCormack, 2002) The promotion of wellness and quality of life can help you convince the insurance companies of the need for rehabilitation.

Psychology and Support Issues

ARE YOU THE THERAPIST TO TREAT THE PATIENT DIAGNOSED WITH BREAST CANCER
The progress of your program will depend greatly upon your ability to motivate your patient. Treating breast cancer patients is very rewarding, but I am sure it is not for everyone. Just like every specialty in physical therapy. At times treating patients diagnosed with cancer can be very tough on the therapist emotionally.

COPING DISCS In each dish place the name of a family member that you could live without…….Pretty tough! At times you should try to realize what your patient, as well as their family might be going through, in a tough time. Just an idea of how cancer patients and families may think.

Your patient is coping with:
Illness Changes Next holiday could be last Medical environment and caregivers Self Image Relations coping with illness Future If in remission.....When will it return? As a patient care provider you should realize that the patient is dealing with much more than just the diagnosis.

Common fears of cancer patients: The 5 D’s
Death Disfigurement Disability Dependence Disruption of Relationships This becomes a major lifestyle change. (Source unknown)

Criteria for Depression
Persistent low mood (4 weeks) Inability to enjoy oneself Repeated or early waking Impaired concentration Guilt, self blame or burden Irritability and anger for no reason Loss of interest Agitation Suicidal You should always be aware of how your patient is coping with their diagnosis and interventions. If you are aware of any potential problem, do not hesitate to notify the physician.

How patients and families may cope
Laughter can keep you from feeling bad. Notice those that might be worse off. Fight with those around. Important to have knowledge of illness. Refuse to believe that it can happen. Turn to others for support. Stay busy to decrease time to worry. Go over problems in mind. Avoid illness as topic of conversation. New faith in this experience. Many times you will have to deal with family or friends. At times you might be dealing with are attempting to cope with the situation through several methods. (Snyder, 1992)

SELF ESTEEM WIGS that guarantee the hair will look so much like the original hair that the patient is the only one to know it is a wig. NATURAL: HAT DESIGNS for hair loss Be able to supply your patient with information that will be helpful. You should identify your patients desires before you give advice. Some patients may want to cover up their side effects from treatment or surgery where others would rather be natural. If you have this information ready as the patient requests, you will help avoid additional stress.

CAREGIVERS (Survey of 225 Families)
49%...Experienced prolonged depression 74%...Found unknown inner strength 69%...Frustrated 43%...Sad with experience 39%...Associated care with love 46%...Felt appreciated 30%...Felt taken for granted Caregiving and Cancer, should be reviewed to promote this challenge at: ppt Everyone has the potential of getting frustrated. At times you might want to thank anyone that might be helping the patient. Be aware, especially with home care, that you might not get 100% support from the family members.

Support Guide American Cancer Society (ACS) 1-800-ACS-2345
National Cancer Institute (NCI) CANCER Equal Employment Commission State Dept. of Vocational Rehab. Support Guide National Lymphedema Network Job Accommodation National Coalition for Cancer Survivorship Have information available for your patient and their families, to help them find any educational materials or financial assistance that may be of benefit. Again your information helps avoid stress.

AMERICANS WITH DISABILITIES ACT
Legal Protection For Cancer Patients Against Employment Discrimination Make your patient aware that there is help when needed, concerning most complications. An employer is prohibited from discriminating against any qualified individuals on the basis of physical disability. There may be times when a patient may need an employer to be tolerant during medical interventions. Support groups listed on previous slide, can be very helpful for the patient that is undergoing any legal or just stressful situations, due to their diagnosis.

Dealing with Pain

PAIN Be prepared to deal with patients reporting pain and inform their physicians of the benefits of exercise. The American Cancer Society reports that 70 to 90% of cancer patients will experience pain during a phase of the disease or treatment plans.

PAIN Agency for Health Care Policy and Research Guidelines for Cancer Pain Promotes communication between the patient and the health care provider dealing with pain. The American Cancer Society estimates that 70% to 90% of cancer patients will experience pain during some phase of their disease or treatment. The patient has to be honest with the medical staff to receive proper medical attention. A complete understanding of why certain medications are used will help the patient accept programs that they might have thought to be an end stage treatment. An example would be morphine, if administered properly, this medication has proven affective in returning certain cases to work, with control of pain. ( 1999)

PAIN Document location and description of pain.
Rate worse pain, using a 1-10 scale. Time pain is increased and decreased. What increases and decreases pain. This documentation will allow you to objectively assess changes in pain. Refer to the U.S. Department of Health and Human Services, Agency for Health Care Policy and Research Clinical Practice Guidelines for the Management of Cancer Pain, Pain management is almost always manageable. (Hassler, 1994)

Why cancer pain? Biological mechanism Bone destruction Obstruction
Infiltration or Compression Infiltration or Distention Inflammation, Infection and necrosis of tissue. It is important to know why your patient might be experiencing pain. As a physical therapist, you might discover areas of pain that need to be documented and know the importance of notifying the physician. (Otto, 2004)

Pain Medications Soft tissue Nonsteroidal Anti-inflammatory (NSAI)
Bone NSAI (Prednisolone) Compression of nerves (Dexamethasone) Muscle spasm (Diazepan or Baclofen) Fungal tumor Antibiotics Cellulitis Systemic Some examples of medications or types of medications your patient might have prescribed. If controlled properly morphine is a choice for severe pain. Proper dosage has made returning to activities potential for many patients with severe pain. Again, it is most important that the oncology team have expertise in working with this drug. Routine pain treated with NSAI with or without adjuvant medications Persistent pain given weak opiod maybe NSAI and adjuvant. Persistent pain receives strong opiod, maybe NSAI and adjuvant. The program rendered will be that which the physician has found to be most successful.

Management of Cancer Pain
Evaluation Physical and Neurological Exam Differential Diagnosis Pain history and pattern Present and past medication X-Rays, MRI, CT, EMG, lab results Nutrition history and interventions Functional evaluation Realistic Goals Plan management (Ca / pain / psych) Focus on patient and family Just like treating any patient, a good evaluation can pinpoint location and orgin of pain. A good fitness appraisal will help establish an effective training program, as well as help set and achieve personal goals, which can be completed within patients’ pain tolerance. (Otto, 2004)

Pain Management A vicious cycle
Which modalities are best suited for the patient diagnosed with cancer? List Modalities List considerations List safety You know the most about your treatment plan. What, when, where and Why. Be willing to support your suggested plan of treatment.

Pain Fatigue Anxiety Depression
A Vicious Cycle All paths can lead to complications for the breast cancer patient. All problems can be related. You have to be able to deal with the total patient.

Listed Physical Therapy Modalities
Cutaneous Stimulation Heat Cold Massage, Pressure , and Vibration Exercise Repositioning Immobilization Counter stimulation Transcutaneous Electrical Nerve Stimulation Acupuncture As physical therapists we know the indications, as well as the contraindications of physical therapy modalities better than any other profession. There may be times when you will complete a treatment intervention that is not documented as a positive or negative for cancer, you will have to review your knowledge and treat your patient safely. Most initial treatment plans will be hands on, rather than modalities. (Pfalzer, 1992)

Time Out Test As far as specialization, what is an advantage of being a physical therapist? Wellness can decrease medical cost? T / F A patient diagnosed with breast cancer, only thinks about their diagnosis? T / F As a physical therapist, you might note signs of depression? T / F What are considered the 5 fears of a cancer patient? By supplying information concerning support organizations, you can help decrease patient stress? T/F The pain cycle can lead to what other complications? Fatigue, anxiety and/or depression. Disfigurement, disability, dependency and disruption of relationships; True; You can pick your individual field of interest; True; False; True; Death, ANSWERS

LIVING A QUALITY LIFE THROUGH REHABILITATION

Mission Statement Through emotional support, education, rehabilitation, and exercise we strive to empower the patient diagnosed with cancer to maintain and improve their quality of life. Believe your mission statement. This is the statement I chose for my program, you can select your own. It is most important for you to have a mission statement, which includes your plan and goals, for guidance as well as public information. (Coleman Consulting, 1997)

Philosophy Physical rehabilitation should be synonymous with cancer care. Loss of strength and function, as well as overall physical fitness must be restored in order to maintain quality of life. Our aim is to assist the patient diagnosed with cancer with education, exercise and support throughout the treatment and recovery periods. Promotion of wellness allows an individual the opportunity to meet future health challenges. You must have an idea of what and why you are completing your method of treatment. Again, you can establish your own philosophy. (Coleman Consulting, 1997)

Rehabilitation Options
Prevention: Prevent functional loss in early stages of diagnosis. Restorative: Reach maximal function when physical impairment or disability are present. Supportive: Increase self care and mobility for the patient with progressive cancer and impairment. Teach energy saving methods. Palliative: Comfort and function for those patients diagnosed with terminal conditions. All rehabilitation programs are set for various reasons. Your program will be established to reach goals that are realistic and beneficial for your patient.

General Goals Prevent Deconditioning Maximal functional skills
Emotional Support to patient and family Education of patient of condition Treatment and Home Program Assist in Pain and Symptom Control Assist in Health Promotion You will set your own short and long term goals for your patient. The most important aspect is to make all goals realistic. Having the patient assist you with their goals could be very educational and beneficial. Continual changes in short term goals promote patient care. Conditioning programs should be established for breast cancer patients as soon as possible after diagnosis. Often supervised programs decrease limited function due to depression. Functional skills are needed especially post-operative or post radiation to promote range of motion. Emotional support and understanding can help everyone work together towards set goals. Educating the patient of possible expectations helps understanding of benefits of rehabilitation. Continual education and knowledge of home programs and needed treatments promote care.

Specific Goals Increase Strength and Endurance
Decrease nervousness, irritability & anxiety Increase attention span and concentration Improve Posture Maintain or Improve ROM & flexibility Promote independence (gait/transfer/ADLs) Development of disease education, including treatment program. Important goals when setting your breast cancer plan. As explained in the previous slide, it is most important to make your patient aware of possible expectations form their individual medical treatment program, and understand the benefits of a quality rehabilitation program.

Evaluation Tools

Evaluation Scales Functional Independence Measure (FIM)
Karnofsky Performance Status Scale Zubrod Performance Scale Just methods used at various medical centers, to judge the patients’ condition and prognosis.

FIM 7 Complete Independence (Timely, Safely) NO ASSISTANCE
6 Modified Independence (Device) Modified Dependence HELPER 5 Supervision 4 Minimal Assist (Subject = 75%+) 3 Moderate Assist (Subject = 50%+) Complete Dependence 2 Maximal Assist (Subject = 25%+) 1 Total Assist (Subject = 0%+) ADMIT / DISCHARGE / FOLLOW-UP Self Care / Sphincter Control / Mobility / Locomotion / Communication / Social Cognition I am sure you remember the neurological evaluation techniques listed in this presentation. These will help you understand what the physician might think about the progress of the patient.

Karnofsky Specific: General:
100 Normal, no complaints, No evidence of disease 90 Able to carry on normal activity minor signs or symptoms of disease 80 Normal activity with effort, some signs or symptoms of disease 70 Cares for self, unable to carry on normal activity or to do work. 60 Requires occasional assistance of others, but able to care for most needs 50 Requires considerable assistance from others, frequent medical care 40 Disabled, requires special care 30 Severely disabled, death not certain 20 Very sick, hospital, need support 10 Moribund 0 Dead Able to carry on normal activity, no special care needed. Unable to work, able to live at home and care for most personal needs, varying amount of assistance Unable to care for self, requires institution or hospital care for disease that may be rapidly progressing Used often in neurological situations. This profile allows the physician to explain the reason for a particular treatment plan. You will be able to respond to any changes that occur in physical therapy to help this patient improve or note lack of progress. (Abraham, 2005)

Important information to obtain when evaluating the cancer patient
Medical Information Primary diagnosis / Stage of disease / Surgery / Chemo / Radiation / Blood counts / Prognosis Physical Exam Mental status / Vital signs / Strength / ROM / Reflexes / Pain Mobility State Bed mobility / Balance / Transfers / Ambulation / Assistive devices Psychological State Coping skills Social State Family / Job / Recreation Home Environment To establish a quality program, it is important that you know your patients condition, where they are coming from prior to their diagnosis and where they are looking to go.This is a portion of your evaluation of your patient.

Lab values and guidelines
Information that might explain your patient’s change in condition, on a specific day.

Rehabilitation Treatment Plan
Bone Marrow Transplant Complications: Decreased mobility and joint ROM Decreased endurance Increases fatigue Decreased strength Increased pain Decreased function Decreased motivation Decreased pulmonary function As noted earlier, be aware of the needs of the patient receiving a bone marrow transplant. In a study presented by Carole Schneider (2003), she reports a 42 y/o female who had a stem cell transplant, that worked out during chemotherapy prior to transplant with progress, but due to an increase in RBC during this procedure she had a setback which made her unable to exercise (low intensity ROM and walking) for 2 weeks. Patient then was making progress with her exercise, then acquired a cold which put her out of exercise for two more weeks. Patient then resumed her low intensity program, and is now following an independent exercise program and hikes every week-end. Perseverance is most important, you need to know how to keep your patient motivated to progress when possible. Be able to modify the patients’ program as needed. (Koczur, 1996)

Guidelines when establishing a treatment plan
Platelet Counts: < : Palliation and Support (P&S) No anti-gravity exercise No resistive exercise 25-50,000 : Support and Restoration (S&R) sub-maximal isometrics isotonic exercise (light weights) no prolonged stretching no low speed isokinetics > 50,000 :Restoration and Prevention (R&P) Most programs acceptable Mostly seen while in hospital, make patient aware of the need to tell you of any counts they may be aware of. The goal of either chemotherapy or radiation is to interfere with the cancer cell growth. Some treatments slow or depress the production of blood cells, that is why blood is closely watched during treatment. Remember WBC fight infection, RBC carry oxygen to tissue, and Platelets aid in clotting blood. Under 50,000 can increase the risk of bleeding (Hicks, 1990)

Continual Guidelines Hematocrit (Hct.) / Hemoglobin (Hb.)
< 25/10: Palliation & Support range of motion no aerobics no isotonics 25-35/10-12: Support & Restoration low impact and intensity aerobics (bike ergometer) Isometrics modified isotonics 35/12: Restoration & Prevention most programs acceptable (Hicks, 1990)

Additional Guidelines
PFT’s (Cardio-Pulmonary function impairment): 50% capacity P&S No aerobics 50 – 75%: S&R Low intensity aerobics >75% R&P Most programs acceptable Metastatic or bone tumor > 50% cortex involved P&S No exercise Non-weightbearing 25-50%: S&R Partial weight bearing Range of motion (No stretching) 0-25%: R&P Full weight bearing (Hicks, 1990)

Time to think Exercise The best way to ensure desired outcomes from exercise is to recognize the needs, limitations and capabilities of each individual. Remember your patients’ need for required cardiovascular, pulmonary or muscle strength or endurance training. By enhancing everyday performance activities, your patient will improve mobility and independence; Improve and maintain posture and muscle balance; show an awareness of injury prevention; and promote physical and mental relaxation. Your knowledge of safe exercise programs are why you will receive the breast cancer patient. Donegan and Spratt noted the first epidemiologic study on breast cancer and exercise was published in Life expectancy has been increasing rapidly, since that time. (2002).

Start to establish an exercise program.
You will be responsible for returning this patient to a quality and functional life. Don’t forget to deal with the scar, to prevent complications. What would be your plan of action? (Slide donated with permission to show by: Ronald H. Schuster, MD Board Certified Plastic Surgeon)

EXERCISE Capacity depends on:
Physical Condition Stage and Type of Cancer Treatment Program Side Effects General Health A fitness program differs for a mastectomy patient compared to late stage lung Ca. Exercise brings about immediate or acute physiological responses as well as long term or chronic responses. Your education will allow you to establish a safe and functional program for your patient. I believe many therapist initially follow the programs completed by their mentors.

My Niche General Oncology Rehabilitation
Function / Cardio-Endurance / Energy Conservation / Pain Management / Strength - Balance / Education. 1st Visit...Eval. / OOB 1 hr. / energy conservation / Deep breathing. 2nd Visit..OOB < 1 hr. 2-3 X/day / energy and safe home techniques / Vital signs with ambulation 20-40' / Cool down. 3rd Visit..OOB 2-3 hrs. 2-3 X/day / Continue energy conservation / Ambulate as tol./ Home Program / Eval home. A general program to follow. My Niche

Benefits of Regular Exercise
Weight loss and decreased body fat Lower risk of cardiovascular disease and cancer Lowers blood pressure Decrease insulin use in diabetics Prevents Osteoporosis Lowers serum cholesterol Slows aging of heart and lungs Reduces back pain Improves self-image Review your exercise physiology to determine which programs will benefit or harm your patient. ( 2006)

Benefits of Exercise with Cancer
Increase Accumulation of muscle protein Joint mobility Strength Decrease Edema Pain Anxiety Depression Enhance Immune Function Decrease Infection susceptibility Progress is being made through research completed by exercise physiologist, trainers, physicians and physical therapist to promote safe care for the breast cancer patient. I would like to see physical therapist taking charge of this program. ( 2006

General Breast Cancer Diagnosis Exercise … You Decide?
Aerobic (Walk, Jog, Cycle or Swim) Increase heart rate Increase lung capacity for O2 intake Increase O2 to muscles Increase metabolism to control weight Decrease in blood cholesterol Increase in bone strength Increase in endurance You will be able to plan out your program for your patient. As expressed earlier, review exercise physiology. Make sure you pick the correct program for your patient, the individual.

Decide? Anaerobic: (Weight lifting or Sprinting)
Short burst of intense activity Develop muscles Develop strength Develop speed Develop power Special care with posture when working with the breast cancer patient. Avoid joint and muscle stress that could be completed with weights that might not be ideal for your patient. This exercise regime could be developed for general cancer patients to progress with strength and function during their medical treatment regime.

Walking: Excellent choice of Exercise Increase lung function
Stimulates bone growth and strengthens leg and back musculature METS to LE or back may eliminate running but walking may be approved (Less trauma) In pool gentle yet stimulates heart & lungs Consult M.D. when dealing with metastasis Excellent program, but again, remember posture.

Swimming Good choice with pain of spine, hips or pelvis possibly due to metastasis Increase aerobic capacity if performed far and fast enough Stretches muscles and lung capacity Strengthening against water resistance Consult M.D. when dealing with METS An excellent program, once all drainage tubes have been removed.

Stretching & Yoga Increased flexibility and decreased muscle tension
Increased circulation Well stretched muscles require less energy for movement Important for shortened muscles from rest (Slow stretch prevents muscle tear) Yoga and deep breathing promote an emotional edge due to body awareness. Good program, but must avoid overstretch, which is required in some programs, such as pilate’s.

Exercise Facts: Exercise builds muscle tissue, strengthens the heart, increases lung capacity to take in oxygen and improves circulation. Exercisers report increased energy and stamina with decreased deconditioning. Stretching, Yoga, Walking & Swimming stimulate muscles & circulation without stress. Why would a physician refuse to send a patient for physical therapy rehabilitation? I cannot come up with an answer, as long as they have trust in the therapist.

Psychological Benefits
Increase feeling of well being Give patient sense of control Improve self-esteem Enhances Coping Increased attention span & concentration Decrease Anxiety Decrease Depression Increase Strength, Mobility & Fitness If a patient can learn to deal with their diagnosis and become motivated to progress with an established program, designed especially for them, they are on the way to reaching their realistic goals. (Gavin, 2006)

Functional Assessment
Must obtain measurable benefits (Outcomes) Rehabilitation judged by functional ability that results from treatment Assess function by monitoring changes in activity of self care, mobility, and communication. Your program has to prove beneficial to be accepted by physicians, insurance and the community.

Accurate documentation promotes future progress
Recording all breast cancer programs with progress or poor response, will help promote a generic program that should be beneficial to everyone. Proper recording of all patient activity is needed. If there were a method to record globally, treatment programs and progress, this would certainly help everyone. Maybe someday, the APTA will have a report system for cancer patients, like the trainers association has for injuries.

Documentation Focus on function
Use vital signs for an objective measure Focus on short term goals REALISTIC GOALS Describe teaching sessions Document lab values (Very Important when treating cancer patients) Everything you do should be documented properly, you may just want to use this information for a research study later. When available, you should follow all test results completed for your patient. If documentation is not available to you, continually question the patient of treatments completed as well as those scheduled. Keeping in touch with the physicians office for follow-up reports is a good thing to do. Comisac, 1996

Ideal rehab candidates are those who are/were previously in excellent health, strength and fitness. Everyone is different and should be treated as an individual. Although this may be idealistic, it is something that everyone should be aware of.

Questions to ask ? What can the patient do? What do they need to do?
What do they want to do? You must be realistic with your program. You and your patient must agree on your expected outcomes.

Examples of specific breast cancer rehabilitation programs
These are programs that have been used at various facilities. I would think you would want a starting guide for safety and build your program around experience.

Pre-Surgical Evaluation
Ideal program Education of expectations Introduction helps decrease anxiety & fear. Screen patient’s condition prior to medical intervention (Psychologically, Strength, Mobility & Girth) . Ability to initiate safe and functional rehabilitation program. Avoid undue stress on involved extremity. You should have a routine program with your referring physicians. Start to see patients as soon as possible. You can start with the programs that are presented in this presentation, but be willing to develop your independent program for your patients. You might find the programs listed here are sufficient, then follow as presented.

Post-Surgical Evaluation
Completed as soon as possible. Teach proper elevation for comfort and edema control. Control upper extremity flexion until drains are removed. Teach support program Compare to pre-evaluation Routine education for breast cancer patient and family members.

EXERCISE PROGRAM Range of Motion Components of Exercise Strength
Exercise is essential, but precautions must be taken Range of Motion Strength Endurance Safety Contraindications Your choice, the most important aspect is safety. If your not sure or comfortable with a procedure, don’t do it.

Safe Exercise Program Common sense M.D. Clearance
Limit before lab work / infection /fever If ill from treatment: Wait a day Start Slowly Avoid Pain Caution with low blood counts Avoid infections including foot care Return to M.D. with persistent complaints Common sense is most important. (Coleman Consulting, 1997)

Contraindications to Exercise
Unusual fatigue Unusual weakness Irregular pulse Decreased heart rate with work Leg pain / cramps Nausea, Vomiting or Diarrhea Disorientation Dizziness, Blurred vision or Faintness Pallor or Cyanosis Dyspnea onset IV chemo last 24 hrs. Platelets <20,000 White Blood Count <1500 Always keep aware of your patients, and make sure they are not afraid to ask you for help. (Arnall, 2005)

POSTURE Shoulder depression and internal rotation with scapula protraction Serratus Anterior weakness...Winging due to overstretch of long thoracic nerve. Latissimus dorsi weakness overstretch of thoracodorsal nerve. Pectoralis major/minor weakness.Minor may have been removed; Medial pectoral nerve no longer innervates lateral border of pectoralis major. Many patients have posture deficits, which can lead to numerous complications..

Strength Training Weight training to build musculature
Must control resistance and calories with proper monitoring Machines safer than free weights to assure good posture and functional mobility Manual resistance exercise regime may be utilized to promote strength I believe that increased reputations with lighter weights are safer than using heavy weights, post surgically.

EXERCISE Even with advanced disease exercise can help decrease depression, tissue loss and fatigue Passive mobility program may be appropriate Exercise with pain meds more beneficial Guide towards individual challenges: Marathon / Bike Ride or a Walk around the block. This will be established between the patient and the therapist Be R-E-A-L-I-S-T-I-C Additional study results follow, which will help benefit you to expand your knowledge of the benefits of rehabilitation for breast cancer survivors.

The Coleman 10 Step Program
I Individualism II Physical Therapy Evaluation III Ancillary Services IV Patient Education V Rehabilitation Program VI Progress Step VII Group Exercise Program VIII Follow-Up IX Out Reach Program X Home Maintenance A 10 step program I devised to promote a total program from diagnosis to discharge. (Coleman Consulting, 1997)

R E H A B I L I T A T I O N Rehabilitation interventions should begin at bedside, getting patient OOB as soon as possible to work towards discharge. Intense rehab after discharge is determined by patients life expectancy (> 1 year) and medical capabilities to participate (including motivation and mental considerations). After discharge to home setting, it is important to assure that patient has proper equipment and supplies. All follow-up programs must be set (including proper referrals) at time of discharge. Progressing the patients motivation towards working to promote a quality of life, makes all programs possible.

Follow a safe post-operative breast cancer program
Remember to: Review diagnosis Medical interventions Safe technique Contraindications Motivate Acknowledge: Research Other programs Realistic goals Good common sense in establishing your program. You will use this plan along with your evaluation to determine the proper program for your patient. This patient can be diagnosed with breast cancer and following any set interventions established by the physician. Although benefits have been diagnosed with rehabilitation to progress a patient and decrease some uncomfortable side effects, you need to attempt to get these patients as early in their diagnosis stage as possible.

Rehabilitation examples to remember:
Protocols for individual Protocols depending on medical intervention Even with a diagnosis, your treatment plan cannot be developed until you evaluate the medical interventions, that have been scheduled.

Breast Cancer Therapy begins 2-5 days post-op.
Deep breathing & relaxation are beneficial Range of motion (gentle) Movement with support as needed Isometrics of involved elbow/ wrist/ hand Once drains removed increase exercise (active shoulder mobility) Home exercise program to promote independent plan Possible complications that need to be prevented include: Inflammation, scar formation, obesity, thrombophlebitis, and poor arm position. You can develop your own program once you feel confident.

BREAST CANCER GOALS: FUNCTIONAL EMOTIONAL COSMETIC
FUNCTIONAL: Shoulder Range of Motion; Neurological Changes; Postural Deficits; Skin Integrity; Possible Lymphedema; ADL's

Post-Surgical Rehabilitation TRAM
Immediate Post-operative Distal hand exercise to assist shoulder stabilization. Incisional splinting techniques to increase comfort with movement Day 2 or 3 Reach to opposite shoulder & knee ADL’s with active range per individual Example of an excellent rehabilitation program post-operative. You can follow this set regime if you desire. You should be aware that it is estimated that 10% of abdominal strength is lost following a single TRAM flap procedure. (Grant, 1994)

Post-operative Two to four weeks according to M.D.
Active / Passive ROM to involved shoulder including overhead stretch Gentle resistive exercise Progressive cardiovascular fitness program performed within safe limitations Risk of complications with a total flap loss is 2%. (Grant, 1994)

Post-operative Six weeks (depending on patient)
Aggressive stretching and strengthening of shoulder Strengthening of trunk and abdominals Cardiovascular cross training Return to work activities (Assimilation) Arm edema maintenance / prevention Scar tissue management (Decrease adhesions) Fitness through other medical interventions. (Grant, 1994)

Post-operative Long Term Management
Maintain stretching and muscle tone, especially in radiated areas. Posture management program Quality of Life fitness program Awareness of any problems You want your patient to continue with an independent home program once discharged from your service. (Grant, 1994)

Post-Operative TRAM This could be an example of your patient. You not only have to treat functional activity, but treat or teach the patient to deal with scar tissue. (Slide donated with permission to show by: Ronald H. Schuster, MD Board Certified Plastic Surgeon)

Free Flap technique (Slide donated with permission to show by: Ronald H. Schuster, MD Board Certified Plastic Surgeon)

Education We must educate the patient, family, community, physician and other health care providers of the benefits of rehabilitation for the patient diagnosed with cancer. With this diagnosis you cannot just use modalities and deal only with the patient. It is not possible to treat a breast cancer patient with a tunnel vision type program.

Supply educational materials
Free information supplied by several cancer agencies, that you should have available for your patient.

General breast cancer programs used in my facility to promote safe techniques with functional mobility and activities of daily living

OUT-PATIENT ONCOLOGY REHABILITATION
Patient care management Promote wellness Cost effective protocols Decrease risk of adverse outcomes Provide forgotten rehab Program Establish continual case studies Provide continual education programs (Coleman Consulting, 1997) .

* BREAST WELLNESS CENTER Treatment program discussed with pt.
Comprehensive care dealing with the total patient, not just the diagnosis Treatment program discussed with pt. Sensation change Shoulder mov't guidelines Lymphedema Posture Prosthesis Lifting precautions Fatigue Exercise Guide UE Elevation Deep Breathing Elbow/Shoulder controlled program Capsular Exercise Active Exercise Functional Shoulder * (Designed by Coleman Consulting)

Breast Center in Health Club
My programs were located in women’s fitness clubs, as well as a private practice. (Public Relations Photo – Breast Wellness Center)

(Public Relations Photo – Breast Wellness Center)
Gradual mobility Photo from my out-patient center. (Public Relations Photo – Breast Wellness Center)

( Public Relations Photo – Breast Wellness Center)
Control exercise Monitor your patients’ condition, before during and after therapy. Document all findings. ( Public Relations Photo – Breast Wellness Center)

(Public Relations Photo – Breast Wellness Center)
Posture and mobility (Public Relations Photo – Breast Wellness Center)

Program Development As you gain expertise and physician confidence, you will also note an increase in patient compliance. Realize the benefits you offer your patient. Donegan reports, “Most people who begin an exercise program develop better eating habits, lose weight and reduce smoking.” (2002) Use common sense.

Tips for building an Oncology Rehabilitation program
Increase visibility of rehabilitation into oncology treatment plans with early intervention to prevent functional decline and, increase the ability to restore a quality life. Increased involvement in clinical studies to include outcomes for the oncology patient. Organization of Rehab team to assure quality of care to promote functional outcomes. Progress treatment plans to map out vocational and psychological programs. (Coleman Consulting, 1996)

Research supporting physical therapy rehabilitation
Promotion of a quality life for patients diagnosed with breast cancer

Research completed by Drum and group in the Medical Science of Sports and Exercise, 2003
Case study of female diagnosed with breast cancer, age 29 receiving a modified radical mastectomy and at age 57 same procedure to opposite breast. Chemotherapy and radiation followed second surgery. Following medical interventions presented, patient followed a six month exercise program at the University of Colorado. Increased muscle strength, cardiovascular function and attenuating career related fatigue and depression. Suggest health professionals collaborate with rehabilitation to increase work capacity to progress a quality life for the patient diagnosed with breast cancer. Various research studies will show how physical therapy rehabilitation has become effective for the patient with breast cancer, and very beneficial towards reaching a quality of life. (Drum, 2003)

Study by Holmes in the American Medical Association Journal in 2005
Study followed the health of 122,000 female nurses, 2,167 were diagnosed with breast cancer. The physical activity of the subjects was recorded. This activity was measured up to 16 years, most subjects walked for exercise. Breast cancer survivors that exercised 3-5 hours per week lived longer than those that had minimal activity. Also noted those who completed regular exercise were less likely to die from their breast cancer. Patients will receive major benefits from modest exercise. As simple as it might seem, many patients without proper instruction and confidence in their instructor, will not complete routine exercise programs. You might be attempting to promote a quality of life program, who feels like they would just like to be left alone. If the patient insists of being alone, you must honor their feelings, therefore don’t look for second chances if you did not sell your confidence the first time around. (Holmes, 2005)

Mastros’ study published in the American Medical Association website 2004
Study of 49 women with breast cancer, 28 were assigned to a six month exercise program. Blood testing was used to determine immune response. Revealed that breast cancer patients that completed an assigned six month exercise program had better immune response and less inflammatory complications. Appropriate exercise can help breast cancer survivor’s strengthen their immune system with exercise. Another positive response to exercise following the diagnosis of breast cancer. (Mastro, 2004)

Following numerous searches in the medical library and database search engines, no remarkable negative changes with exercise following the diagnosis of breast cancer were noted. Studies have shown that exercise should be a natural part of breast cancer treatment.

Research by Winningham
Exercise may enhance Quality of Life Interval Aerobic Training (Rest & Exercise) enhances cardiovascular efficiency, overall functional ability and reduces incidence rates of nausea from chemotherapy. Heavy prolonged exertion associated with hormonal and biochemical changes can have a detrimental effect on the immune system Learn from others to establish a safe and beneficial program. Additional research results completed by Winningham, Segar, Pinto, Durak and Bernstein all report a positive Quality of Life with a safe exercise regime. (Winningham, 1989)

Research by Segar Regular aerobic cycling decreased depression and anxiety as well as increased self esteem. Continual information presented by researchers. (Segar, 1998)

Research by Pinto Surveyed 72 Stage I and II breast cancer patients. Those who exercised reported less depression and enhanced Quality of Life compared to the sedentary control group. (Pinto, 1998)

Research by Durak Health Club Study
Breast cancer program : Aerobic exercise / PRE’s on machines 2x/wk for 20 weeks Results: CA pts. Showed: 60% increase in upper body strength 31% increase in lower body strength 35% increase in aerobic machines Progress ADL’s, Strength & Endurance Decreased Pain and Decreased Nausea Nothing but benefits. You just need to educate from the studies of others. Durak completes his program at a fitness center in California. (Durak, 1997)

Research by Bernstein Women who have been physically fit for many years reduce their incidence of breast cancer. 3.8 hours of exercise per week reduces risk This proves that everyone should be completing a routine exercise program. (Bernstein, 1995)

.Additional research on the benefits of exercise for the breast cancer patient is becoming available. Support of the benefits of exercise are to increase functional capacity, decrease body fat, increase lean muscle mass, decrease nausea & fatigue, improve quality of life. American College of Sports Medicine guidelines for exercise following breast cancer: Frequency: 3-7 days /week; Intensity: 40-80% aerobic capacity; Duration: min. of aerobic activity Suggest normal fitness assessment: heart rate, blood pressure, body composition, strength, flexibility, aerobic capacity. ONLY BENEFITS REPORTED It is difficult to argue with the results of many studies. The more positive information that you present to your referring physician, the harder it is to refuse treatment plans. (ACSM, 1997)

Harvard Medical asst. professor Michelle Holmes,MD, studied 3,000 women noting little exercise increases chances of surviving breast cancer. 3 MET (Metabolic equivalent task) hrs. per week of 2 to 2.9 miles per hour for 1 hour decreases risk of dying from breast cancer by one half. Anne McTiernan, MD, PhD, author of Breast Fitness: An Optimal Exercise and Health Plan for Reducing Your Risk of Breast Cancer, stated “Women don’t have to become athletes, just get up and get moving”. ( 2005)

Breast Cancer FYI, suggests that a patient should consider at least one session with a physical therapist if any surgical procedures, due to breast cancer, have been performed . In the Yale Exercise & Survivorship Study, it was revealed, despite the evidence suggesting that regular physical activity can decrease breast cancer risks and improve prognosis, efforts to encourage this program were not a routine part of cancer treatments.

Results of studies on exercise during breast CA
Authors Samples Design Intervention Outcome Results Bremer et al 109 breast CA survivors (post-op) Cross-section Self reported exercise Psychology adjustment No difference with or without exercise Courneya & Friedenreich 167 breast CA survivors Retrospective Quality of Life Moderate to strenuous exercise = best quality of life Cunningham 66 breast CA survivors with METS Prospective Survival With regular exercise lived longer MacVicar and Winningham 10 on chemo 6 healthy controls Test Pre/Post Supervised exercise Exercise test and mood Exercise lead to increase in function and mood with both McBride et al 500 early stage breast CA pts. Various tx. Self reported stage of change measure Psychology impact Winningham 24 breast CA pts. On chemo Home program Body weight & composition Exercise dec body fat, inc mass; Opposite for controls Additional positive research to promote exercise for breast cancer. (Courneya, 2002)

Physical Therapy Modalities

Which modalities are safe in treating the patient diagnosed with breast cancer?
Moist Heat Cold Deep Heat Traction Electrical Stimulation TENS Compression Pumps Manual Therapy Modalities (Pfalzer, 1992)

Progressive Relaxation Exercise
Close your eyes …… Deep Breathing Image: Ocean, Mountains, etc See it / Hear it / Feel it Contract --- Relax Mildly with 5 count Forehead / Face / Neck / Shoulders / Upper Arms / Forearms / Hands / Chest / Abs / Gluts / Upper Legs / Calves / Feet Deep Breathing .. Total Body contract/relax Repeat total process One of the best methods of dealing with patients initially, avoiding any contraindications, is the promotion of relaxation. There are many modalities to promote this condition, including the contract relax method listed in the slide, biofeedback techniques and possible water programs. Always a safe technique.

Modality Contraindications
Cold Over dysvascular tissue Transient increase in blood pressure Delay in wound healing Nerve injury Peripheral Vascular Disease During Radiation Possible Metastasis Know why specific contraindications are a problem. (Pfalzer, 1992)

Contraindications Deep Heat Over dysvascular tissue
Over poor sensation Increase in bleeding Directly over tumor Over acute injury Open wounds Elevated temp. Metal implants Pacemaker or other implanted device As we know heat can increase activity. By using a method of deep heat, do we have a chance to promote metastasis? Lola Rosenbaum completed a study showing an increase in tumor size in a mouse, with ultrasound. (Pfalzer, 1992)

Contraindications Traction Compression Pump Manual Therapy
Structural Changes possible pathologic fx. Compression Pump Active disease .. Metastasis can occur through pump activity Manual Therapy Manual therapy can promote increased internal activity, which could be contraindicated. Although this is considered a contraindication, many therapist disagree and complete these techniques. (Pfalzer, 1992)

Contraindications Electrical Stimulation TENS
Possibility of pathologic fractures Implanted device Cardiopulmonary Insufficiency Active phlebitis TENS Implant Directly over wound Again the idea of promoting body activity can initiate metastasis. Just know your modalities and what effects they have on the body. (Pfalzer, 1992)

REHABILITATION “The recognition and acceptance that breast cancer is a treatable disease even when it is metastatic has helped professionals and patients alike accept rehabilitation efforts.” Stephen Gudas, 1992 Has the profession of physical therapy progressed, in the care of the breast cancer patient since 1992, when Stephen Gudas, a pioneer of the Oncology Section, of the APTA made this statement? I believe over the past 14 years, there has been excellent progress, any many paths are available, if the physical therapist chooses to follow. You have the knowledge and responsibility to develop a plan of treatment for the patient diagnosed with cancer.

ONCOLOGIC EMERGENCIES
Most important to be aware of life threatening situations. Must be anticipated and recognized for early attention.

Reference to the GUIDE TO PHYSICAL THERAPY PRACTICE A.P.T.A.
“Through the examination, the physical therapist identifies impairment, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes to establish the diagnosis and the prognosis and to determine the intervention”. As a physical therapist, especially in a self referral state, you will have to be able to complete all stages of treatment. ( 2006)

The Guide: A goal and prognosis will help establish the plan and frequency of visits for the cancer patient. Interventions to produce a change in condition are established by the plan of care, anticipated goals and desired outcome. Reexamination needed to evaluate clinical findings to promote care or observe failure of response. Some examples of ICD-9-CM Codes related to cancer: Carcinoma in situ Neoplasm's of unspecified nature Additional information to establish a quality physical therapy treatment regime. ( 2006)

Physical Therapy Evaluation
Range of Motion Manual Muscle Testing Shoulder Assessment Sensation Testing Girth Measurements Posture Analysis Cardiovascular Fitness Body Fat Analysis Additional tools you may need for assessment: Skinfold caliper Spirometer Heart rate monitor Hand grip dynamometer Your normal evaluation with only a few additions, which help identify complication which may be present due to breast cancer complications..

Effective Assessment Guidelines of Rocky Mountain Cancer Rehabilitation Center
Each parameter relevant to patient progress Procedures valid and reliable Administrate with rigid control Protect patient’s rights Regular interval testing Review and explain to patient

Organ Toxicity and Life Threatening Complications.
Problems seen: Hematologic (Dealing with blood and blood forming organs) Obstruction Increased Pressure / Fluid Accumulation Metabolic (Dealing with chemical processes of living organisms) Pathologic Fractures Information that can help your knowledge of your patient. (Kirchner, 1996)

Oncology Emergency Signs
Infection Fever Ecchymosis Bleeding (Possible gums) Headaches Chest Pain Dizziness Fatigue Insomnia Swelling Local or Radicular Pain Neurological Deficits SOB Abdominal Pain / Cramp Nausea / Vomiting Constipation / Diarrhea Hypertension / Hypotension Tachycardia Changes in Urine Loss of Appetite Blurred Vision Change in Mental State Seizures Respiratory Changes Weight Changes Depression Fractures Coma Death Notify the physician with any problems. Know when to call 911 or the nursing staff if in the hospital. I have always felt that there is no problem that should not be documented. Some of these symptoms could possibly be normal behavior for your patient, you really need to know your patients normal activities to access abnormal signs. (Otto, 2004)

Time Out Test Oncology Emergencies only pertain to the elderly? T / F
The main mission for treating cancer in rehabilitation? Palliative therapy is really not needed? T / F What helps you establish your plan of treatment? When was the first epidemiologic study on breast cancer and exercise published? Functional assessments must document what? Although there have been many negative changes, due to rehabilitation, it is still prescribed? T / F What medical information appears important when working with patient’s diagnosed with cancer? What are the advantages of pre-surgical evaluations? Measurable benefits; False, No negative findings; Lab values;To many to list. False; Maintain and improve Quality of Life; False; Prognosis and Goals; 1985; ANSWERS

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