July 8th Comprehensive Cancer Rehab

1. July 8th Comprehensive Cancer Rehab Chris Wilson PT, DPT, GCS PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in Practice July 2013

2. Types of Cancer

3. Types of cancers Cancers are named by their origin: • carcinomas • sarcomas • lymphomas • leukemias

4. Sarcomas Sarcomas are cancers that arise from cells of connective tissue, bone, muscle etc. • osteosarcoma • myosarcoma • liposarcoma • synovial sarcoma

5. Lymphomas Lymphomas are cancers that arise from cells of the lymph nodes, lymph system and the body’s immune system • Hodgkin's Disease • Non-Hodgkin's lymphoma

6. Leukemias Leukemias are cancers that arise from cells of the bone marrow and blood stream. • Acute lymphocytic leukemia • Chronic myelocytic leukemia

7. Carcinoma • Most common type of cancer • Carcinomas arise from the cell linings of body surfaces • Usually involve organs

8. Types of carcinoma • lung • breast • colon • prostate

9. Lung Cancer • Second most commonly diagnosed cancer in men and women • Leading cause of death in men and women • Stage 1 – 4 • Usually diagnosed in more advanced stages • Difficult to screen for • Frequently metastasizes to the brain

10. Lung Cancer Screening

11. Types of Lung Cancer

12. Prostate Cancer

13. Prostate Cancer • Most commonly diagnosed cancer in men • Second leading cause of cancer deaths

14. Prostate Cancer Grading • A pathologist looks for cell abnormalities and "grades" the tissue sample from 1 to 5. • The sum of 2 Gleason grades is the Gleason score. • These scores help determine the chances of the cancer spreading • They range from 2, less aggressive, to 10, a very aggressive cancer. • Gleason scores helps guide the type of treatment.

15. Colon Cancer • Third most common cancer • Third leading cause of cancer deaths • Very effective screening • Screening can lead to prevention

17. Prostate cancer surgery

18. Colon cancer surgery

20. Lung cancer surgery

21. Overview of “Historical” Physical Therapy for Cancer • Patient complains of pain, dysfunction, disability • Doctor identifies a need for physical therapy • Patient is scheduled for physical therapy services • Receives a bout of care and is commonly discharged without follow up by P.T. • Very little to no communication between therapists or physicians as a patient transitions from setting to setting • Physical therapists often outside “routine” cancer management model

22. Philosophy of Rehab Prevention Intervention Sustained Wellness “Empower patients to maintain their own health and commitment to healing, through an individualized exercise and wellness program” = PRISM PRISM

23. Prevention Phases • Why Rehabilitation? • PT/OT treats impairment, such as mm weakness, fatigue, restricted joint motion and poor cardiac respiratory fitness. Impartment could lead to disability and limitations. • PT/OT aim to decrease or prevent disabilities and promotes safe activity, at home, work, or recreational activities • PT/OT promotes participation and re-integration to society, by treating impartments and disabilities

24. Prevention and Wellness of the Oncology Patient • Primary prevention – Prevention of a disease in a potentially susceptible population – impacting the active pathology stage • Secondary prevention – Decreasing the duration and severity through intervention – impacting the impairment and functional limitation phase • Tertiary prevention – Decreasing the degree of disability in those with irreversible disorders – impacts disability

25. Program Model

26. Rehabilitation Program Flow

27. Screening and Consultation • Patients scheduled for free consultation/screening • Wilson Resource Cancer Center (Troy)  Started June 2011 • Breast • Breast cancer surveillance program pre/post surgery • GU • Lymphedema treatment when appropriate • All other cancer diagnoses • Rose Cancer Center (Royal Oak)  Started September 2012 • Breast • GU • All other cancer diagnoses • Grosse Pointe  Started July 2012 • All types

28. Exercise and Wellness • Cancer Survivorship – Exercise & Wellness Program  Similar to Cardiac Rehab- Phase III • SOLA or community fitness • Home Exercise Program • Referrals as needed for other services • Cancer Resource Centers • Local Support Groups – Org/Regional services • Integrative Medicine • American Cancer Society

29. Paradigm Shift of Healthcare Models • Patient Centered Medical Home • Increased access, quality, decreased cost • Accountable Care Organizations • Creating facility/physician based organization to better coordinate management of disease • Shared profit and risk for savings and clinical and patient outcomes • Managed Care Systems • Focus on Use Management and Controlling Visits • Integrated Medical Records • Payment models shifting toward less visits • copays or private pay

30. Oncology Rehabilitation7 Comprehensive Oncology Rehabilitation Began in 1922 Program Success Management Plan Advanced certifications Informed stakeholders

31. Management & Administrative Structure Comprehensive Oncology Rehab Team Members Professional Communications Timing of Access to Patients Protocol Guidelines Advanced Training of Personnel Professional resources, settings, equipment Reimbursement, funding, costs to patients Research

32. Advanced Education Requirements Oncology and Rehabilitation Cancer Pathology & Staging Cancer Treatments Evolution of side effects Timing of education & interventions Prevention activities Intensity of interventions- education, manual therapy and exercise (flexibility, strengthening, aerobic) Current Research Rehab throughout the continuum of care

33. Education of Stakeholders Physicians Nurse Navigators Patients Caregivers Social workers, nutritionists, chaplains, OT, SLP, radiation therapists Insurers Universities & Residency Programs Research

34. Advanced Education Opportunities APTA Oncology Section Courses Upcoming Certification Examinations Oakland University Graduate Certificate in Oncology Rehabilitation Annual Oncology Symposium Deb Doherty and Jackie Drouin

35. Documenting progress and justifying future care • An important part of therapy is using functional tools to document and validate progression or regression of care • We use established, evidence-based, researched outcome measures called functional tools to document the patient’s progress or current status

36. FUNCTIONAL OUTCOME MEASURES • Berg Balance Training • 10 Meter Walk Test • Modified Borg Test • 5 Times Sit to Stand Test • FACIT • FACT – G • FACT – B • Etc… • Functional Reach Test • Modified Reach Test • Cognitive Assessment • Bicep Test • Fear Avoidance Behavioral Questionnaire • SF-36

37. PT FUNCTIONAL OUTCOME MEASURES BALANCE ASSESSMENTS • Provide direction in terms of strength and areas of deficits or weakness • Used a predictability tool • Provide risk factor information

38. PT FUNCTIONAL OUTCOME MEASURES Berg Balance Assessment • Determine falls for older adults • Scored from 0-56 • High Fall Risk – 36 or lower • Medium Fall Risk – 37 - 45 • Low Fall Risk – 45 or greater • Helps with determining discharge disposition and predictive validity for future falls

39. 10 Meter Walk Test • Gait speed assessment • Gait speed is predictive of disability, fall risk, and future need for ECF/Nursing Home • Therapist uses a stopwatch to quantify duration for a patient to ambulate 10 meters. • The more slowly a person ambulates the higher risk of falls, injury, and need for assistance at home • Predictive of future morbidity and mortality

40. 5 Times Sit to Stand • Measures functional lower limb muscle strength • Quantifying functional change of transitional movements • Therapist asks pt to stand up and sit down 5 times as quickly as they can • Time the patient how long to complete test

41. Rate of Perceived Exertion Scale • Rating of how tired a person is on a 1-10 • Therapy grades the patient on this scale to determine intensity of treatment

42. FUNCTIONAL OUTCOME MEASURES COGNITIVE • Orientation • Alertness/Attention Span • Communication • Safety Awareness • Motivation ASSESSMENT • Ability to follow commands • Memory • Insight regarding deficits

43. FUNCTIONAL OUTCOME MEASURES COGNITIVE ASSESSMENT Allen Leather Lacing Test • Screening test • Provides estimate of cognitive functioning, information processing and ability to learn • Assists with goal setting, treatment planning and determining discharge location

44. FUNCTIONAL OUTCOME MEASURES FUNCTIONAL REACH TEST • Completed in standing • Single-task dynamic test that defines functional reach as “the maximal distance one can reach forward beyond arm’s length while maintaining a fixed base of support in a standing position”

45. FUNCTIONAL OUTCOME MEASURES FUNCTIONAL REACH TEST • Dynamic test that measures a person’s margin of stability during a functional task • Predicts risk for falling in the next 6 months

46. FUNCTIONAL OUTCOME MEASURES MODIFIED REACH TEST • Adapted for patients that are unable to stand • Completed in sitting

47. FUNCTIONAL OUTCOME MEASURES BICEP CURL • Test of upper body strength and endurance • 30 seconds of repeated biceps curls • Therapists count how many repetitions the patient can perform in 30 seconds

48. Functional Assessment of Cancer Therapy - General

49. Nutrition and Physical Activity5 • American Cancer Society: • ~1/3 of the cancer deaths in US each year due to • poor nutrition • physical inactivity • excess weight • “Maintaining a healthy body weight, being physically active on a regular basis, and eating a healthy diet are as important as not using tobacco products in reducing cancer risk.”

50. Exercise and Wellness Program Overview Exercise and Wellness Program Goal: Empower patients to maintain their own health and commitment to healing, through an individualized exercise and wellness program.