Management of a patient with a Spinal Cord Mass and lymphoma (Acute CARE)

1. BeccaShonsey DPT 774 Management of a patient with a Spinal Cord Mass and lymphoma (Acute CARE)

2. Put yourself in his shoes • Imagine feeling weak • Imagine being told nothing is wrong • Imagine a month goes by and you start to get leg numbness • 1 week passes and you can’t walk • Each step of the way something changes

3. PURPOSE • Our prime purpose in this life is to help others. And if you can't help them, at least don't hurt them. ~Dalai Lama • Help you help your patient with a spinal compression and lymphoma in acute care

4. Objectives • The student will be able to identify the signs and symptoms of spinal tumor compression • The student will be able to differentiate between spinal tumor signs and lymphoma signs • The student will be able to develop a treatment plan for a patient with cancer in an acute care setting • The student will be able to determine the prognosis of a patient with both a spinal tumor and lymphoma

5. Patient History • 42 year old white male • Homeless • 12 pack of beer each week • 25 packs of cigarettes a year • Mid thoracic and abdominal pain, decreased renal function (April) • CT on chest, abdomen and pelvis (April)-no significant findings • Pt reports: 1 week ago LE numbness, 48 hours ago LE weakness

6. Examination • PIP: Progressive weakness and inability to walk • HR: 82 • Oxygen Saturation: 94% • BP: 140/77 • Negative: hypotension, fever, chills, sweat, weight loss, nausea, vomiting, headache, facial paresis, spinal tenderness with palpation

7. Examination • Positive: • Renal function decrease • Numbness below nipples to saddle • Reflexes 3+ • UE strength 5/5 • LE Strength : • Bilateral hip flexion 2/5 • Bilateral knee extension 3/5 • R dorsiflexion and plantarflexion 2/5 • L dorsiflexion and plantarflexion 4/5

8. Knowing spinal compression • 15% of all CNS tumors are primary spinal tumors3 • Spinal cord tumors • Primary are rare? • Compress the cord and surrounding nerves • Sx: pain or numbness in back, arms or legsX • Decreased ms strengthX • Loss of bowel or bladder control (sometimes)X

9. Physiotherapy Functional Mobile Profile (PFMP): 26/63 • The intra-rater reliability ICC=.99 and inter-rater reliability ICC= .97 in acute care setting1 • Quick and easy to perform • Has been used on patients following surgery of the spine2 • Higher score means higher function/ independence

10. Evaluation • Weakness, numbness, renal decrease = possible spinal tumor • Decreased independence with bed mobility, sit to stand and walking according to PFMP • Further examination: MRI thoracic and lumbar • Mid thoracic dorsal and right lateral mass • At T7

11. Treatments • Medically: Immediate surgery performed followed by radiation • Review of patients with spinal cord compression. 46% after surgery were able to walk and 49% after radiation4

12. Treatments • Physical Therapy (Day 2) • Increase mobility • At an oncology unit the policy was changed to have PTs see pts within the 1st 48 hours. Pts were getting up sooner and ambulating. The results were a 14% decrease in patient length of stay within 1 year5 • Increase ambulation • Increase strength • Gait training • Case series of 79 patients with spinal cord compression treated by radiation with 9 receiving an operation. Median age of 60 years. The collaborative team determined that walking was the most important factor. 90% of patients who walked before radiation walked after radiation6

13. Changes • Day 4: medication decreased and patient has increased R LE numbness, patient returned to max A for all activities, another MRI • Day 5: Oncology reports no MRI changes • Day 6: PET/CT = lymphoma axillary, groin and behind the heart • Refused PT

14. Lymphoma7 • 56,000 people in the US each year • Signs and symptoms • Painless/swollen lymph nodes • Unexplained weight loss • Fever • Night sweats • Chest pain • Weakness and FatigueX • Abdominal or back painX

15. Re-examination and evaluation • Pt feels pins and needles • Decreased proprioception/ foot slap • Min A with most ADLs and mobility (PFMP 46/63) • Strength • L Hip flexion and knee extension 3/5 • L dorsiflexion and plantaflexion 3+/5 • R Hip flexion and knee extension 3-/5 • R dorsiflexion and plantarflexion 3/5 • Possible discharge

16. New treatment (Day 7-9) • Gait training/ walking • A systematic review of cancer patients reported that studies have found a decrease in symptoms and increase in function with patients participating in a walking program8 • Wheelchair training • A retrospective cohort study looking at 83 patients post spinal surgery. Therapy included respiratory exercises, bed mobility, sit to stand, walking in the room and hall, stairs and wheelchair ambulation. Those patients in their 40s and had operations at one level had the most significant increase in PFMP scores (P<0.05) with wheelchair locomotion, bed mobility and walking2 • Day 10: Discharge to transitional care unit and then to Washington with father to begin chemotherapy • PFMP 52/63

17. Prognosis • Poor • In a case series all three patients had spinal tumors removed surgically followed by radiation. A 61 year old died after 6 months, a 23 year old after 1 year and a 51 year old after 11 months9 • A retrospective cohort study reported on 60 patients whose mean survival was 3-4 months10 • Drinker, smoker, lymphoma, uninsured

18. Summary • Important to recognize signs of spinal tumor compression and cancer • In acute care focus on patient function • More research needs to be done on the best treatment in acute care • In the future a quality of life outcome measure may be useful

19. Your understanding • Your patient with back pain comes in and reports progressive weakness in their UE, having difficulty urinating, and having numbness • Refer them to get tested (MRI, PET, CT) • A patient is in the hospital with cancer and is going through radiation. Do you walk them or let them rest in bed all day? • Walk them while monitoring symptoms

20. References • 1. Brosseau L, Laferriere L, Couroux N, Marion M, Theriault J. Intra- and inter-rater reliability and facorial validity studies of the physiotherapy functional mobility profile (PFMP) in acute care patients. Physiotherapy Theory and Practice. 1998;15:147-154. • 2. Yildirim Y, Kara B, Arda M. Evaluation of patients with spinal operation according to functional mobility. NeuroRehabil. 2009;24: 341-347. • 3. Class notes and expert opinions of Julia Osbourne, PT, CLT-LANA. • 4. Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol. 2005;6:15-24. • 5. Crannell C, Stone E. Bedside physical therapy project to prevent deconditioning in hospitalized patients with cancer. OncolNurs Forum. 2008;35(3):343-345. • 6. Kovner F, et al. Radiation therapy of metastatic spinal compression: Multidisciplinary team diagnosis and treatment. J NeuroOncol. 1999; 42:85-92. • 7. Non-Hodgkins Lymphomas Page. Available at: http://www.medicinenet.com/non-hodgkins_lymphomas/page3.htm. Accessed July 3, 2010. • 8. Visovsky C. Exercise and cancer recovery. J Issues in Nursing. 2005;10(2):1-8. • 9. Arnold P. Floyd H, Anderson K, Newell K. Surgical management of carcinoid tumors metastatic to the spine: resort of three cases. ClinNuerolNeurosurg. 2010;112:443-445. • 10. Guo Y, Young B, Palmer J, Mun Y, Bruera E. Prognostic factors for survival in metastatic spinal cord compression: a retrospective study in a rehabilitation setting. Am J Phys Med Rehabil. 2003;82:665-668.

21. QUESTIONS • ??????????????