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WOW. Women onto Wellness™ Naomi Aaronson, MA OTR/L, CHT Ann Marie Turo, OTR/L, Pilates, Yoga, and Reiki Master MAOT Annual Conference 2010. Course Objectives. Upon completion of this course, participants will be able to: Describe both local and systemic treatments
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WOW Women onto Wellness™ Naomi Aaronson, MA OTR/L, CHT Ann Marie Turo, OTR/L, Pilates, Yoga, and Reiki Master MAOT Annual Conference 2010
Course Objectives • Upon completion of this course, participants will be able to: • Describe both local and systemic treatments • List the effects of treatment and their impact upon physical , psychological and mental performance • Describe 2 Pilates exercises from each phase 3
Course Objectives • List the rehabilitative and exercise implications of breast cancer treatment • Identify the benefits of Pilates • List the principles of clinical Pilates • Describe a safe, effective and appropriately challenging program using Pilates • Describe the modifications, indications, and “things to be mindful of” when using a Pilates based approach 4
Cautionary Statements • Please be advised that breast cancer treatment is continually evolving on a daily basis. New research is regularly performed which changes treatment protocols. This can vary from one region of the country to another. This course is not intended to serve as a substitute for medical advice ,but only to inform health professionals regarding available options at present. Please seek consultation from your medical provider
Cautionary Statements • Each patient is unique, and requires treatment tailored to their medical status. Every patient should consult their doctor before participating in this or any rehabilitative or exercise program.
Words of Wisdom • “Learning to live with cancer is an art, not a science. Each person must find her own way, in her own style. What is important to realize is that a way can be found regardless of the circumstances and prospects.” Jane Brody • Can occupational therapy practitioners help in that journey ???? ABSOLUTELY!! We are the experts since we can address all aspects of healing.
Jane’s Journey • Jane is a 48 year old lawyer who went for her annual mammogram in November of 2007. Her mammogram revealed breast cancer in the right breast –Infiltrating Ductal Carcinoma • This was determined after a biopsy, hormone / HER-2 tests, blood tests, bone scans, ER/PR tests, and physical examination 9
Staging of Jane’s breast cancer • Staging is done 2x- once before and once after surgery to determine the severity of cancer • One considers whether the cancer is invasive or not, tumor size, how many lymph nodes are involved and where, whether the cancer has spread, physician recommendations, and patient accessibility to medical facilities before recommending treatment • Based on the size of tumor and it being sensitive to hormones, Jane’s cancer was determined to be stage 2 b cancer. 10
Jane’s Journey • Stage 2b cancer is cancer that is larger than 2 cm but less than 5 cm. Her cancer had spread to approximately 1-3 axillary lymph nodes. • However, the staging is not definite until after surgery. The tumor must be analyzed by the pathologist. • Breast cancer is divided into 4 stages with stage 1 being the least severe according to tumor size or spread to lymph nodes • Stage 4 disease is metastatic disease or cancer that has spread to the brain, bones, or lungs 12
Elizabeth Kubler-Ross - On Death and Dying Denial “ This isn’t happening to me !” “They read the wrong mammogram.” Anger “ Why is this happening to me, I am a healthy person!! Bargaining “ I will try to take better care of myself.” Depression “ I just don’t care anymore.” “Nothing will help” Acceptance “ I have cancer but I will do my best to beat this disease.” -May take a long time to achieve or sometimes is never reached What are the psychological and cognitive affects? 13
Psychosocial continued • Loss- - Loss of Hair( head, eye brows and lashes), very traumatic, varies but occurs approximately 14 days after the start of chemotherapy. Recommendation: Wig evaluation prior, head wraps, light weight caps or hats. Revitalash for eye lashes. Look Good Feel Better Program - Loss of a sexual organ - Loss of Self, self worth, loss of role, fear of loosing job • Fear of Death- Cancer is life threatening, and a life altering disease. 14
Psychosocial Continued • Physical Reminder: - Loss of a Breast(s) disfigurement - Lymphedema- clothing doesn’t fit, unable to button sleeve, need to wear lymphedema sleeve (hot), can’t wear jewelry, it is a reminder of the disease on a daily basis unable to get manicures, always a problem IV’s, can effect work/family/leisure participation. Ganz, PA., Coscarelli, A., et al (1996) describe the psychosocial concerns and quality of life of breast cancer survivors evaluated 2 and 3 years after primary treatment. Breast cancer survivors usually attain maximum physical and psychological recovery after 1 year. However, they reported a number of persistent problems associated with sexual interest, sexual function, body, image and recreational and physical activity participation. 15
Psychosocial Continued • Loss of Femininity & Sexuality – Fobair, P., Stewart, SL.,al. (2006) found that among 549 women age 50 or younger, body image and sexual problems were experienced in the early months after diagnosis. Among sexually active woman mastectomies were associated with greater body image problems. • Early Menopause • Sensation- no longer the same • Know when to refer out for help, suggest a support group. Psychopharmacology evaluation may be needed. • Breast Cancer – affects men/women of all ages. 16
What are the cognitive effects of breast cancer ? • “ Chemo Brain “ a real phenomena • CRCD- Chemotherapy Related Cognitive Dysfunction • Approximately 20 -30 % of patients treated with chemotherapy develop cognitive problems. • Bender et AL. (2006) studied 3 groups of women n= 46. There was a control group. Women who receive chemotherapy plus tamoxifen exhibited deterioration on measures of visual memory and verbal working memory. Those women who received no chemotherapy or tamoxifen did not exhibit this deficiency. Authors concluded that chemotherapy can be associated with memory deficit. 17
Learning new tasks, attention, concentration, word finding, multi-tasking, and organizing can be difficult. • Low Tech Ideas: Exercise, make lists, keep a calendar, keep notebook of tests and results, keep mind active, get plenty of rest, leave messages on answering machine , keep things in the same place. Keep your mind sharp via puzzles, games • Keep home exercise program limited to 2-3 exercises. 18
High Tech Ideas- Software Program • Posit Science Brain Fitness Program Classic – is a series of 6 computer based programs designed by neuroscientists. • The study was presented at the 28th annual National Academy of Neuropsychology (NAN). 2008
Robbi Peele of Posit Science - 19 women participated in the study who were breast cancer survivors ,and who had gone through chemotherapy. 94% showed positive changes in quality of life, improvements in cognitive functions, and over all well being. • The study showed that when using this program there was an improvement in memory, and in the ability to process information quickly.
Jane’s Journey • Based on her medical status, and physician recommendation, Jane decided to have a modified radical mastectomy. Surgery is usually the first line of treatment. It is considered to be a local type of treatment, which means that it is focused on one part of the body. • Size of the tumor, presence of multiple tumors, whether the tumors are hormone dependent or HER-2 positive, and lymph node involvement dictate the surgical options and treatment choices. 21
Local Treatments • Local treatment includes surgery and radiation as they are done to a specific area. • We will be taking a look at the surgical options for breast cancer. Please note the amount of tissue removed and think about the musculoskeletal implications 22
What are the surgical options? • Radical Mastectomies- rarely performed today; breast tissue/pectoralis major/minor removed, and all lymph nodes • Modified radical mastectomies • Simple mastectomies • Breast Conservation- lumpectomies 23
Jane’s surgery- modified radical mastectomy • Jane had removal of all of her breast tissue plus level 1 and level 2 axillary lymph nodes • This is the most common form of mastectomy performed today • However, on rare occasions a radical mastectomy may be performed which involves removal of breast tissue, all axillary nodes, pectoralis major/minor . This is usually performed only when the cancer has spread to the chest walls 24
Total or Simple Mastectomy • Jane felt that she was at high risk for cancer in her left breast and decided to have her left breast removed as a precaution. In this surgery, no lymph nodes are removed ,only breast tissue. However, they can be removed at a later date through sentinel node biopsy or axillary dissection if necessary • Simple mastectomies are good for prophylactic treatment or DCIS. 27
Skin sparing mastectomy • Nipple/areola and the old biopsy scar are removed • Remaining breast tissue is shelled out from underneath the breast skin- most of the breast skin is left intact • Plastic surgeon has more tissue to work with and more natural result
Lumpectomy • Although Jane was not felt to be a candidate for this type of surgery, research shows 5 year survival rates to be the same for lumpectomies> radiation in early stage BC compared to modified radical mastectomies (Veronesi et al., 2002) • This is a less disfiguring surgery, as only the tumor and a margin of tissue is removed. It may or may not be combined with an axillary node dissection or sentinel node biopsy • Also known as breast conservation 30
Picture of lumpectomy- post surgery with scars for breast/node incisions 32
Axillary Lymph Node Dissection • This is used in treatment of invasive cancer. Jane had to receive this procedure as well as removal of the breast tissue • Extensive dissection predisposes one to lymphedema • Usually a sampling of lymph nodes at Level 1 and Level 2 are removed (10-15) • Jane had to stay overnight with drains in place 33
Drains • Drains are tubes attached to a vacuum suction bulb that collects excess fluid • Emptied dailyust be empt • Usually • d/c ed • When < 20- • 30 ml. in 24 • hours 34
Axillary Dissection • There are 3 levels of nodes which are determined by their relationship to pectoralis minor • Level 1 nodes are lateral to pectoralis minor • Level 2 nodes are below pectoralis minor • Level 3 nodes are by the top border of pectoralis minor 35
Sentinel node biopsy • A newer procedure is now being used for stage 1 or stage 2 women without palpable lymph nodes • This procedure is called a sentinel lymph node biopsy • Dye is injected into the tumor to see which node or nodes is the first to receive lymphatic drainage called the sentinel node. There may be 2 -3 nodes involved • No need for drain , faster recovery, less pain and decreased lymphedema risk (still a possibility) 37
What are the anatomical structures affected by breast cancer surgery? • Breast • Lymphatic system • Skin • Neurological • Musculoskeletal 39
Breast • Made up of lymphatic tissue, 1/3 fatty tissue, connective tissue, and is a mammary gland • Situated over pectoralis major, serratus anterior, external oblique, and rectus abdominas • The breast area is considered to start proximally from the clavicle and end at the last 4 ribs. Medially it begins at the sternum and ends in the axillary area. • This is a huge part of one’s anatomy if removed! 40
Breast Tissue • Ducts are the milk passages • Lobules are the milk producing glands
Lymphatic system • Helps the body to maintain fluid balance while filtering out waste products • Made up of nodes, lymphatic capillaries, ducts and collecting vessels • Has immunological function • 30-45 nodes in the axillary region • Right side of the head and neck, right arm, and upper right quadrant drain to the right lymphatic duct • Left side including the left side of head and neck, left arm and upper quadrant, lower trunk, and both legs drain to the left lymphatic duct via the left thoracic duct 43
Lymphatic system • The lymphatic system works on changes in pressure from muscle contractions which allow protein rich fluid to return to the heart • Deep abdominal breathing such as that performed in Pilates enhances pumping to the thoracic duct. In addition, muscle contractions performed in a specific sequence from proximal to distal can promote lymphatic return • However, too much activity, infection, or weight gain can increase the fluid that the lymphatic system has to pump resulting in lymphedema
Skin • Effect of scar on mobility of the myofascial system can decrease range of motion and increase pain • Scar can also cause psychological as well as physical pain • Needs to be managed efficiently and effectively 46
Neurological System • Brachial plexus runs under the clavicle and through the axillary area • Lateral pectoral nerve innervates pectoralis major and the medial pectoral nerve innervates pectoralis minor. Nerves can be severed during surgery • This results in numbness, motor atrophy, and decreased sweat production in the armpit and arm • Long thoracic nerve which innervates serratus anterior and the thoracodorsal nerve which innervate the latissimus dorsi are vulnerable 48
Neurological System • If the intercostobrachial nerve is damaged during surgery, the consequences can include numbness along the medial arm which can result in a disabling pain syndrome and diminished sweat production • Numerous cutaneous nerves which may be damaged during surgery can cause sensation changes in the upper arm and chest wall • In addition, breast reconstruction using flaps can result in a loss of sensation dependent on where tissue has been taken. It can be taken from the back, stomach, and gluteal regions 49
