Cancer Rehabilitation

1. Cancer Rehabilitation Barbara L Francis Navitas Cancer Rehabilitation

2. The scope of quality cancer care must be broadened beyond what is presently provided to one that fosters health prevention and minimizes dysfunction or disability from illness. Institute of Medicine Report Institute of Medicine � From Cancer Patient to Cancer Survivor: Lost in Transition Need for evidence based survivorship interventions for meeting the unique needs of cancer survivors. LA times- want to be called cancer veteran, conquerors or activists!! Report stresses the need for more communication and coordination among doctors who treat the diverse health problems, including depression, sexual dysfunction and heart disease. Institute of Medicine � From Cancer Patient to Cancer Survivor: Lost in Transition Need for evidence based survivorship interventions for meeting the unique needs of cancer survivors. LA times- want to be called cancer veteran, conquerors or activists!! Report stresses the need for more communication and coordination among doctors who treat the diverse health problems, including depression, sexual dysfunction and heart disease.

3. Cancer Rehabilitation A process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way. (Definition from National Cancer Institute) Return to former or even better quality of life MUltifactoral presentation, more integrated dynamic approach Return to former or even better quality of life MUltifactoral presentation, more integrated dynamic approach

4. The Cancer Patient Patient comorbidities � medical history, activity level, medicines, lifestyle, other stressors Cancer diagnosis � fatigue, bleeding Treatment � neuropathy, fatigue, nausea, loss of strength, Family � young, possibility of not having children, young children, family dynamics Work � decreased time, unable to do job, Financial � co-pays, no insurance, Patient comorbidities � medical history, activity level, medicines, lifestyle, other stressors Cancer diagnosis � fatigue, bleeding Treatment � neuropathy, fatigue, nausea, loss of strength, Family � young, possibility of not having children, young children, family dynamics Work � decreased time, unable to do job, Financial � co-pays, no insurance,

5. Fatigue Immune suppression Thrombocytopenia Anemia Leukocytopenia Loss of appetite Weakness/tiredness Neuropathy Shortness of breath Aching/stiffness in the joints Loss of muscle mass and cachexia Change in blood pressure Change in heart rate Insomnia Diminished concentration and motivation Emotional reactivity Central Fatigue Command chain for voluntary muscle contraction involves numerous steps from the brain to the crossbridge interface May occur when nerve cells malfunction or when there is an inhibition of voluntary effort May be caused by an inhibition of motor areas elicited by nervous impulses from receptors (chemoreceptors) Peripheral fatigue May be most associated with metabolic factors in muscle cells. Simonson (1971) suggested that there are two hypotheses for the cause of fatigue within the muscle. Accumulation Hypothesis Depletion Hypothesis Accumulation Hypothesis Relates to the accumulation of metabolites Hydrogen ions (H+) Calcium (Ca2+) Ammonia (NH3) Inorganic phosphate (Pi) &/or deprotenated phosphate (HPO42-) Depletion Hypothesis Exhaustion may cause fatigue resulting from the depletion of: ATP PCr Glycogen Cancer Treatment Related Fatigue Reactive oxidative stress Necrosis Enzyme kinetics - cascade or reactions, is one is not functioning properly effects the rest, Membrane transport disruptions Inflammatory response Changes in energy production and utilization Biobehavior influences � (Norepinephrine, Serotonin, Cortisol), depression effects physiciological Central Fatigue Command chain for voluntary muscle contraction involves numerous steps from the brain to the crossbridge interface May occur when nerve cells malfunction or when there is an inhibition of voluntary effort May be caused by an inhibition of motor areas elicited by nervous impulses from receptors (chemoreceptors) Peripheral fatigue May be most associated with metabolic factors in muscle cells. Simonson (1971) suggested that there are two hypotheses for the cause of fatigue within the muscle. Accumulation Hypothesis Depletion Hypothesis Accumulation Hypothesis Relates to the accumulation of metabolites Hydrogen ions (H+) Calcium (Ca2+) Ammonia (NH3) Inorganic phosphate (Pi) &/or deprotenated phosphate (HPO42-) Depletion Hypothesis Exhaustion may cause fatigue resulting from the depletion of: ATP PCr Glycogen Cancer Treatment Related Fatigue Reactive oxidative stress Necrosis Enzyme kinetics - cascade or reactions, is one is not functioning properly effects the rest, Membrane transport disruptions Inflammatory response Changes in energy production and utilization Biobehavior influences � (Norepinephrine, Serotonin, Cortisol), depression effects physiciological

6. Integrated Therapies Physician Physical Therapy Occupational Therapy Cardiopulmonary Exercise Therapy Nutritional Counseling Psychological Counseling Other Therapies Massage Acupuncture Relaxation Techniques Lymphatic Drainage

7. Immediate need to address symptoms Don�t want to go chronic Immediate need to address symptoms Don�t want to go chronic

8. Exercise Research Adamsen et. al., Supportive Care in Cancer, Feb. 2006 Increases in muscular strength, physical performance, physical activity levels Reduction in fatigue and pain Improvements in physical functioning and role functioning 82 cancer patients � 66 with solid tumors, 16 with blood cancers 9 hours per week for 6 weeks � resistance, fitness, massage, relaxation, body awareness82 cancer patients � 66 with solid tumors, 16 with blood cancers 9 hours per week for 6 weeks � resistance, fitness, massage, relaxation, body awareness

9. Exercise and Cancer Related Fatigue Van Weert et. al., Oncologist, Feb 2006 Rehabilitation reduces fatigue Change in fatigue was mainly associated with change in physical parameters (e.g. muscle force, exercise capacity) 72 patients � 15 week program Had to be older than 18, last treatment more than 3 months ago Life expectancy greater or equal to 1 year Had to be up and about more than 50% of the day72 patients � 15 week program Had to be older than 18, last treatment more than 3 months ago Life expectancy greater or equal to 1 year Had to be up and about more than 50% of the day

10. Exercise and Fatigue in Stem Cell Patients Carlson et. al., Bone Marrow Transplant, May 2006 Decreased fatigue Increase in muscle power output Increase in cardiac stroke volume Decrease in heart rate, blood lactate and perceived exertion Findings immediately after and at 3,6,9 and 12 month post-program 12 patients with only fatigue no psychological or physical issues Aerobic program only very mild12 patients with only fatigue no psychological or physical issues Aerobic program only very mild

11. Activities of Daily Living Performance in Cancer Patients Undergoing Treatment 30 cancer patients (M & F; various diagnoses; surgery and treatment: chemo and/or radiation) 17 exercise; 13 non-exercise Evaluated on fatigue, QOL, balance, sit to stand, stair climb/descent, treadmill walking, lift and carry 17 weeks of exercise (combo: resistance, aerobic, flexibility, balance) Low/moderate intensity; 2 sessions/week; 1 hour/session Results: significant difference on all study variables between exercise and non-exercise (exercisers improved; non-exercisers declined) High adherence rate for exercisers Conclusions Cancer patients are able to attenuate declines in ADL performance, QOL and fatigue and improve in most cases (even during treatment)

12. Brief Review Exercise and Cancer Research Exercise and Research Limitations Most studies presented poor exercise program designs Few randomized controlled trials Relatively small sample sizes Extremely variable sample sizes (studies involving different types of cancer) Summary of Research Outcomes Most reported significant benefits No adverse events Multiple outcomes Physiological Outcomes: Cardiorespiratory endurance, Body composition, NK activity, Flexibility, Muscular strength, Blood cell count Treatment related symptoms: Fatigue, Depression and anxiety, Psychological and emotional stress, Pain, Nausea, Platelet transfusion, Hospital stay, Relative dose intensity. Exercise and Research Limitations Most studies presented poor exercise program designs Few randomized controlled trials Relatively small sample sizes Extremely variable sample sizes (studies involving different types of cancer) Summary of Research Outcomes Most reported significant benefits No adverse events Multiple outcomes Physiological Outcomes: Cardiorespiratory endurance, Body composition, NK activity, Flexibility, Muscular strength, Blood cell count Treatment related symptoms: Fatigue, Depression and anxiety, Psychological and emotional stress, Pain, Nausea, Platelet transfusion, Hospital stay, Relative dose intensity.

14. Exercise and Breast Cancer Courneya, et. al., Journal of Clinical Oncology, Oct. 2007 Randomized controlled trial 82 usual care subjects 82 resistance exercise subjects 78 aerobic exercise subjects

15. Exercise and Breast Cancer Courneya, continued Aerobic exercise Improved self-esteem (P=.015), aerobic fitness (P=.066), % body fat (adjusted P=.076) Resistance exercise Improved self-esteem (P=.018), muscular strength (P<.001), lean body mass (P=.015), chemotherapy completion rate (P=.033) Changes in QOL, fatigue, depression and anxiety were higher in exercise groups but did not reach statistical significance. No lymphedema or adverse events.

16. Exercise As Therapy Best before or early into treatment Exercise interventions are low to moderate intensity (40-70% of predicted maximum heart rate) Interventions are progressive, dosage is varied and individualized (mean frequency is 2X/wk, mean duration is 40 min, for 12 to 16 weeks). Interventions involve cardiovascular and muscular endurance, strengthening, ROM, flexibility and static/dynamic balance. Balance between anaerobic and aerobic work is tilted in the direction of anaerobic activities. Physician approval Pre-treatment � improves recovery from surgeries have higher level of lean body mass so less decrements Early treatment � mitigate some of the side effects high surveillance of possible side effects Exercise Interventions High metabolic cost of aerobic activity � tend to do more resistance and other activitiesPhysician approval Pre-treatment � improves recovery from surgeries have higher level of lean body mass so less decrements Early treatment � mitigate some of the side effects high surveillance of possible side effects Exercise Interventions High metabolic cost of aerobic activity � tend to do more resistance and other activities

17. Exercise as Therapy Physical training in patients with chronic heart failure enhances the expression of genes encoding antioxidative enzymes. PV Ennezat, et.al. J AM Coll Cardio 2001;38: 194-8 Exercise training increases capacity of skeletal muscle to buffer increased reactive oxidative stress (ROS). Decreased ROS-decreased inflammation-decreased skeletal muscle catabolism-increased skeletal muscle function Adraimycin (Doxorubicin) and Herceptin � Her2neu+ breast cancer patientsAdraimycin (Doxorubicin) and Herceptin � Her2neu+ breast cancer patients

18. Exercise as Therapy Low intensity exercise training (LIET) during doxorubicin treatment protects against cardiotoxicity. AJ Chicco, et.al. J Applied Physiology 2006;100: 519-527 LIET during Dox treatment protects against cardiac dysfunction following treatment by enhancing antioxidant defenses and inhibiting apoptosis ratsrats

19. Exercise as Therapy Exercise therapy effect on natural killer cell cytotoxic activity in stomach cancer patients after curative surgery. Y Na et.al. Arch PM&R 2000;81: 777-779 Early moderate exercise beneficial effect on function of in-vitro NK cells

20. Exercise and Stage III Colon Cancer Meyerhardt, et. al. Journal of Clinical Oncology, 2006 Subjects compared with patients who engaged in less than 3 MET hours per week of physical activity The adjusted hazard rate for disease-free survival was 0.51 for 18-26.9 MET-hours per week, 0.55 for 27 or more MET-hours per week. Post diagnosis activity was associated with similar improvements in recurrence-free survival (P for trend=.03) and overall survival for trend = .01) 832 patients � reported on various recreational physical activities 6 months after completion of adjuvant therapy, and observed for recurrence or death 832 patients � reported on various recreational physical activities 6 months after completion of adjuvant therapy, and observed for recurrence or death

22. Exercise Therapy Value Reduce work of breathing Improve pulmonary function Normalize arterial blood gases Alleviate shortness of breath Increase efficiency of energy use Correct poor nutrition Improve participation in physical functioning and activities of daily living Restore a positive outlook Improve emotional state Decrease health-related costs May impact lengthen survival

23. Cardiovascular Analysis 8 weeks, control 20 Experimental 100 Prevent deconditioning����not training. 8 weeks, control 20 Experimental 100 Prevent deconditioning����not training.

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25. Integrated Supportive Care Nutritional Counseling Helps maintain healthy weight Healthy nutrition habits for transition from treatment Maximize cancer preventive potential of the diet Evaluate the risks and benefits of nutrition-related supplements Massage Decrease pain, stress Increase sense of well being

26. Integrated Supportive Care Psychological counseling Decrease stress Regain a sense of control Mitigate family/work issues Increase sense of well being Acupuncture Decrease nausea, pain, stress Reiki Decrease stress

27. Integrated Supportive Care Manual Lymphatic Drainage Improve function Decrease lymphedema Decrease pain

28. Starting an Exercise Program Physician approval Finding professional assistance One Size Does Not Fit All Developing an individualized program Starting and progressing slowly Exercise Program components Cardiovascular Strength Flexibility Relaxation

29. Summary Safe and feasible to exercise during treatment to improve physical functioning and various aspects of quality of life Moderate exercise improves fatigue, anxiety, self-esteem, cardiovascular fitness, muscle strength and body composition Goal � maintain/improve activity level

30. Summary Rehabilitation Full integration of multiple disciplines (physical therapy, psychology counseling, acupuncture, cardiopulmonary exercise, nutrition, occupation therapy, massage, acupuncture, lymphatic drainage Improve quality of life Healing and caring environment

31. To be healthy does not mean to be free of disease; it means that you can function, do what you want to do, and become what you want to become. ��Rene Jules Dubos1901 - 1982

32. You must do the things you think you cannot do. -Eleanor Roosevelt

33. Initial lack of sleep, nervous breakdown, weakness Decrease commitments to others����..do things for yourself more than others Psych under control, physical improved, more control Grave yard ���..he is still on the right side of the fence it is a good day.Initial lack of sleep, nervous breakdown, weakness Decrease commitments to others����..do things for yourself more than others Psych under control, physical improved, more control Grave yard ���..he is still on the right side of the fence it is a good day.

34. Thank YouQuestions?