Oncology and Such Flashcards
1
Q
What is the pathogenesis of cancer?
A
- uncontrolled growth and spread of abnormal cells
- starts with some carcinogen, oncogene
- changes in a single cell: altered cell DNA, normal controls on cell growth are ineffective resulting in rapid cellular proliferation
- cells keep mutating-why we see in elderly
- cancer-relevant genes discovered
2
Q
What group are most cancers in?
A
70% are in 65 years old and up
3
Q
What are oncology risk factors?
A
- advancing age
- exposure to viruses: HPV
- lifestyle or personal behaviors
- geographic location and environment
- ethnicity, herditary
- stress
- precancerous lesions
- exposure to hormones
- socioeconomic status
- occupation: fumes, etc
- inflammatory bowel disease: increased risk of cancer
4
Q
When do cancers usually develop symptoms?
A
when they metastasize?
5
Q
What cancers have screening?
A
breast, tongue, mouth, colon, rectum, cervix, prostate, testis, skin
6
Q
Tell me about tumors/neoplasms
A
- benign or malignant
- -better survival rate; metastases
- carcinoma in situ: encapsulated, can be removed easily
- primarily-cells that are local to the structure: determines the type of treatment
- secondary-result of metastasized cancer cells from the primary site
7
Q
Metastases
A
cells break away from the primary tumor and travel via the blood or lymphatic system where they infiltrate organ tissue and grow in a new tumor
8
Q
dysplasia
A
disorganization of cells
-Pap smear
9
Q
Hyperplasia
A
abnormal growth of abnormal cells-onset of tumor
10
Q
differentiation
A
don’t look like original cells
-stage four, poor prognosis
11
Q
Tumor types
A
benign
- non-invasive
- non-metastatic: invasive (basal cell-skin cancer), doesn’t metastasize to another organ
malignant
- invasive
- metastatic (carcinoma, sarcoma): malignant tumor made up of epithelial cells tending to infiltrate surrounding tissue and metastasize (85% of all cancers)
12
Q
Classifications of Neoplasm
A
- basis of cell type
- tissue of origin
- degree of differentiation: biopsy
- anatomic site
- benign vs. malignant
13
Q
HEY
A
go look on your “stuff to know” doc for some beautiful notes and also charts about cancers
14
Q
what is a sentinal node thing?
A
biopsy to determine if there’s metastasis
15
Q
Who do sarcomas effect most often?
A
adolescents, young adults
16
Q
What’s a big thing that happens a lot with sarcomas, and why are they underdiagnosed?
A
- amputations
- usually starts with pain complaint brushed off as growing pains
17
Q
How do they treat leukemias?
A
stem cell transplants
18
Q
What are clinical symptoms of cancer?
A
- early stages asymptomatic
- nausea, vomiting and retching accompanied by anorexia with weight loss common with advanced cancer
- muscular weakness due to fatigue and anemia; anemia and coagulation disorders occur in advanced stages
- pain may or may not occur: early stages 50-70%, late stages 60-90%
- fatigue, fever, decreased immunity with increased infections-get sick and never get better
19
Q
Cancer signs and symptoms: breast cancer
A
abnormal mammogram; lump; skin irritation, dimpling, distortion; nipple pain or retraction
20
Q
cancer signs and symptoms: prostate
A
no early symptoms; weak or interrupted urine flow; inability to urinate or difficulty stopping and starting flow; frequency, especially at night; continual pain in low back, ribs, pelvis, or thighs
21
Q
cancer signs and symptoms: colon/rectal
A
rectal bleeding; abdominal pelvic, back or sacral pain; pain that radiates down LEs; blood in stool; change in bowel habits
22
Q
cancer signs and symptoms: leukemia
A
fatigue, paleness; weight loss; repeated infeciton; bruising easily; nosebleeds or other hemorrhages
23
Q
cancer signs and symptoms: lung
A
persistent cough; sputum with streaked blood; dyspnea; chest or upper back pain aggravated by inspiration; recurring pneumonia or bronchitis
24
Q
cancer signs and symptoms: lymphoma
A
enlarged lymph nodes; itching; night sweats; unexplained weight loss; intermittent fevers
25
cancer signs and symptoms: pancreas
no early symptoms; jaundice; abdominal pain; glucose intolerance
26
Paraneoplastic syndromes
produce signs and symptoms that aren't direct effects of the tumor or it's metastases; 10-20% of patients
- most common produces ACTH causing Cushings syndrome (moon phase)
- cancer arthritis: typically in hands
- symptoms: neurologic changes, anorexia, malaise, diarrhea, weight loss and fever
27
Signs and symptoms of integumentary mets
- skin lesion
- palpable nail bed changes
- bleeding, discharge, tenderness
28
Signs and symptoms of musculoskeletal mets
- idiopathic proximal muscle weakness
- deep localized bone pain
- decreased tolerance of WBing
- soft tissue swelling
- pathologic fracture
- back or rib pain: does not respond to modalities
29
Osteoblastic tumors
- common with prostate, 15-30% with uterine, lung, colon, stomach, kidney
- skeletal related events sequelae: pain and pathologic fractures
- increased bone density
- making bone so fast that it's not well made so you get weak bones
30
Osteolytic tumors
- moth eaten
- common with breast cancer and multiple myeloma
- skeletal related events sequelae: severe pain, pathological fractures, life threatening hypercalcemia, SC compression (neuro exams!)
- risk of kidney damage
- hypercalcemia-joints kidneys (perfuse less)
- increase edema (legs, chest)-SOB, WBing
31
What do you have to watch for with osteoblastic and osteolytic fractures?
most patients with bone mets have evidence of both abnormal bone resorption and formation
-both are at risk fracture
32
How do they diagnose osteolytic/blastic tumors and what do they do for it?
- biochemical markers for bone degradation; imaging-bone scan and PET, CT, MRI, radiographs (50% of bone involved before it shows up on xray)
- restricted WBing, surgery
33
Neurologic mets: signs and symptoms
- headaches with nausea and vomiting
- irritability
- confusion
- seizure
- changes in bowel and bladder
- change in DTR, clonus, Babinski
- vision changes
- change in mental status
- balance/coordination problems
- numbness and tingling
34
Pulmonary mets: signs and symptoms
- pleural pain
- dyspnea
- new onset of weakness
- productive cough
35
Hepatic mets: signs and symptoms
- abdominal pain and tenderness
- jaundice
- ascites
- peripheral edema
- right shoulder pain
- general malaise
- bilateral CTS
- 50% of people get liver damage,
36
Staging vs grading
- staging describes the extent of the disease at the time of diagnosis based on primary tumor, regional lymph nodes, metastasis
- staging is more predictive than grading
- systems specific for each kind of cancer
37
BRAIN BREAK
go read the staging and grading slides on page 9&10 of the oncology handout; diagnostic imaging slide (10), lab slide (10)
38
metaplasia
change in cells
| ex-Berret's esophagus
39
anaplastic
very poorly differentiated, no longer look like primary tumor
40
What are the kinds of endoscopy?
- colonscopy
- ERCP: endoscopic retrograde cholangiopancreatography
- EGD/upper GI: esophagogastroduodenoscopy
- sigmoidscopy
- cystoscopy/cystourethroscopy
41
What are you going to see with an endoscopy?
- what the name says
| - colon, esophageal, head/neck cancers, stomach cancers
42
What kind of imaging is used to see cancers?
- endoscopy
- Xrays
- CT scans
- bone scans
- lymphangiogram
- mammogram
- US (breast cancer-determines if follow up is needed)
- MRI (determines extensiveness of tumors/mets, surgical candidates, non-weight bearing status)
43
combined modality therapy
- more than one therapy in treating a pt
- ex radiation and chemo
- better survival rates with CMT
44
adjuvant
treatment given after primary cancer tx is completed to improve chance of a cure
45
neoadjuvant
given before the primary therapy to kill any cancer cells and contribute to the effectiveness of the primary therapy
46
what are 4 treatment options for cancer?
Surgical, Radiation, Chemotherapy, Biotherapy
47
The good thing about combined therapy is that there's a better survival rate? What's a bad thing?
long term implications of multiple treatments
48
What is targeted biologic therapy?
an adjuvant therapy for people with genetic markers for a certain cancer (ex-breast, lung)
49
breast cancer treatments
surgery, chemo, radiation, hormone, targeted biologic therapy
50
prostate cancer treatments
surgery, chemo, radiation, hormone
51
colon/rectal
surgery, chemo, radiation
52
leukemia
chemo, blood transfusion, bone marrow, stem cell transplant
53
lung
surgery, chemo, radiation, targeted biologic therapy
54
lymphoma
Hodgkin: chemo, radiation
| Non-hodgkin: chemo, radiation, stem cell transplant
55
pancreas
surgery, chemo, radiation
56
liver
surgery, chemo, ablation, liver transplant
57
Does surgery help with cancer?
surgical resection alone fails to cure 70% of cancers due to regional and distal mets; not used as a single modality
58
what part of surgery correlates with overall survival
lymph node status
59
What are the types of surgery for cancer?
- curative
- palliative
- preventative/prophylactic
- diagnostic
- staging
- debulking
- restorative
- cryosurgery
- laser surgery (brain cancers-less destructive of tissue)
- electrosurgery
- microscopically controlled surgery (reduce risk of infection, smaller incision)
60
what are the curative surgeries?
- local excision: excise tumor and tissue around it
- -lumpectomy
- -followed by other treatment option
- block dissection: take full section because cancer is in advanced stage
61
What are the two types of surgical margins?
- negative clear: edges of the surgical biopsy are clear of cancer cells
- positive: edges of the surgical biopsy have cancer cells
62
What are advantages of surgical intervention?
- no biological resistance
- no carcinogenic effects
- cure large portion of undisseminated cancer
- assists in quantifying extent/histology of tumor
63
What are complications of surgery?
- non-healing wounds
- lymphedema
- DVTs and emboli
- loss of tissue/disfigurement
- infection
- nerve interruption
- pain
- fatigue
64
What are indications for radiation?
- cure: depends on how radiosensitive the tumor is
- control: shrink tumor before surgery to minimize spreading
- palliative: decrease s/s, shrink tumor to alleviate; poor prognosis, increase quality of life
- prophylactic: done in area where they believe all cancer is gone but want to make sure none is left
- more useful in more localized lesions
65
What's a problem with radiation?
it causes a lot of scar tissue
| ex-breast cancer-decreased ROM in shoulder
66
What are the two ways to deliver radiation?
internal and external beam
67
Describe internal radiation
- very intense, but less damage to healthy cells
- hospitalized
- isolated from others (psychologic implications)
- indicated for breast, prostate, thyroid, head and neck cancers
68
describe external beam radiation
- tomotherapy
- minimal dose-fractionated
- outpatient
- delivered in the form of electromagnetic waves
- proton therapy, laser beam
69
bracytherapy
- often used for prostate cancer; can be used for thyroid and breast cancer
- seeds that release radiation over a period of time; can control the amount
70
what are advantages of bracytherapy?
- OP, minimal hospitalization
- individualized placement of seeds
- few long-term side effects
- return to normal activity
- tolerated by pts in poor medical condition
- good long-term clinical outcomes
- cost effective
71
what are disadvantages of bracytherapy?
- pts experience transient urinary irritative symptoms
- close contact with small children and pregant women avoided in first 2 months after treatment
- hip soreness, knee soreness-in that position for 45 mins to an hour
72
What are side effects of radiation?
- skin erythema or irritation (observe skin reactions while exercising***)
- watch wound healing
- muscle weakness
- fatigue
- CT fibrosis***: hip, abdominal region
- effects on bone: osteoporosis, fractures (osteolytic, osteoblastic)
- lymphedema (radiation fields get lymph nodes)
73
What is the acute tissue reaction to radiation?
(while undergoing treatment) erythema
74
What is the intermediate reaction to radiation?
(up to 6 months) fibrotic tissue changes-ROM
75
What is the chronic tissue reaction to radiation?
(6 months-2 years)
- vascular damage: avascular necrosis-BVs thrombosed, vessels destroyed; lack vascularization in joint, usually hip->necrosis of the joint; surgically treated
- fibrotic changes continue resulting in ROM limitations or chest expansion (irreversible)
- effect on pigment producing cells: vitiligo
- tensile strength compromised
76
When would you use chemotherapy?
- widespread metastatic disease (leukemia, lymphoma)
- adjuvant chemo after surgery or radiation to kill remaining tumor cells
- neoadjuvant to shrink tumor before surgery
77
What does chemotherapy do?
-apoptosis by interfering with DNA, RNA, and protein synthesis and cell function
78
How is chemotherapy given?
- central line
- PICC
- ports (infection, thrombosis, extravasation)
79
What's a major downside of chemotherapy?
immunocompromised
80
What are side effects of radiation?
- weight loss
- infection
- sterility
- pulmonary
- cardiac: pericarditis; long-term implications: hypertrophic myopathy (scar tissue heart), increase in HR, dyspnea with activity
- CNS effects: memory loss, difficulties with emotions, depression,
- late carcinogenic effects
81
What cells take the longest to go through the cycle?
blood cells
| -leukemia: on chemo for 2-3 years
82
How do they use the cell cycle for chemo?
-treatment is 2-3 different drugs that have different effects at different parts of the cell cycle
83
How long does chemo usually last?
3-4 month treatment course
84
How does chemo effect the blood?
decreases RBCs, WBCs, and platelet count
85
What are the classes of chemo agents?
- alkylating agents (platinum compounds)
- antitumor antibiotics
- antimetabolites
- taxanes
- plant alkaloids
86
BRAIN BREAK
read the slides on pages 18-19
87
What is a side effect of antitumor antibiotics?
cardiotoxicity
- can be up to 20 years later
- -pay attention to vitals
- -SVT, dyspnea with exercise, fatigue
- -interval training
- -you'll see poor exercise response, so you see it first
88
What are taxanes?
-paclitaxel, docetaxel, abraxane
89
What are plant alkaloids?
-vincirstine, etoposide, vinlastine
90
What is a major concern with chemo, especially taxanes and plant alkaloids?
- CIPN
- -can contribute to dizziness, weakness, visual problems
- -chemo drugs wrap around nerves
- -vestibular problems, balance issues, increase in visualization problems
- -resolves after chemo for some, some resolves later, some doesn't resolve
91
What are side effects of doxorubicin?
(antitumor antibiotic)
- decrease in blood cell counts
- heart damage
92
What are the side effects of cyclophosphamide?
(alkylating agent)
- decrease in blood cell counts
- lung or heart damage
93
What are the side effects of taxol?
(plant alkaloid)
- arthalgias and myalgias
- peripheral neuropathy
- hypersensitivity reaction
94
What is a side effect of Docetaxel?
(antimetabolite)
| -numbness and tingling in hands and feet (CIPN)
95
What is biotherapy?
stimulates or restores the ability of the immune system to fight cancer, infection, and other diseases
96
What are side effects of biotherapy?
- CV changes-take vitals!
- flu-like symptoms: low grade fever, nausea, frequent diarrhea
- loss of appetite
- GI symptoms
- rash with dry itchy skin
- fluid retention (edema, can effect gait, decreased proprioception)
- CNS effects
97
What are biological response modifiers?
- enhance immune system, enhances other treatments like chemo
- -interferons: direct antitumor effect
- -interleukin-2: trigger immune response
98
Bone Marrow or stem cell transplant
- preventing bone marrow destruction
- allows high doses of chemo and radiation
- used for leukemia, lymphomas, solid tuomrs, neuroblastoma, multiple myeloma, severe aplastic aneumia
- can be autologous or allogenic
- can do through IV-not as invasive
99
What are side effects of bone marrow transplant?
- infection
- fatigue
- malaise
- CNS symptoms
- graft versus host disease: native cells reject donor cells
100
What's the best thing to do for someone after a bone marrow transplant?
mobilize!!
101
Graft versus host disease complications
- loss of end ROM in multiple joints, esp. hip, knee, DFers
- develop bronchiolitis obliterans: chronic cough, dyspnea, and expiratory wheezes; chronic pleural effusions
- significant weight loss
102
What can PTs do for GVHD?
- mobilization and manual soft tissue work to maintain joint motion-chest wall
- comprehensive exercise program
- breathing exercises, bed mobility, theraband in bed
103
What are colony-stimulating factors?
- supports person with low blood counts due to chemo
- acts as a hematopoietic growth factor-erythropoietin, thrmobopoietin
- helps bone marrow recover quicker
- many pts are anemia this increases oxygenation, enhances RBCs
104
What are monoclonal antibodies?
- lab engineered copies of proteins that stimulate the immune system (WBCs)
- used in combo with chemo for colorectal cancers, T cell lymphomas, neuroblastoma, melanomas
- give by IV over 4-6 hours
105
What are side effects of monoclonal antibodies?
- allergic reaction (common-pts take antihistamine->get sleepy)
- wheezing
- fever, chills
- rash
- headache
- nausea, vomiting
- tachycardia
106
What is hormonal therapy?
- used for cancer affected by specific hormones (breast prostate, cervical, uterine)
- blocks or prevents cancer cells from being exposed to hormones that cause them to grow
- ex: Tamoxifen
107
What are side effects of hormonal therapy?
- nausea and vomiting
- hot flashes, sweating
- impotence, decreased libido
- weight gain
- myopathy (proximal muscle weakness)
- hypertension (may need to be on meds)
- altered mental status: cloudy thought, decreased executive function; repeat education
108
What is a specific hormone therapy?
aromatase inhibitors
109
What do aromatase inhibitors do?
- stop estrogen production in postmenopausal women
| - less estrogen available to stimulate growth of hormone-receptor-positive breast cancer cells
110
What's a big problem with aromatase inhibitors?
- aromatase inhibitor associated musculoskeletal syndrome
- -wrist and hand pain in 75%
- -carrying 10lbs is a problem
111
What are 10 types of oncologic emergency?
- SC compression
- pathologic fracture
- superior vena cava syndrome
- increased ICP (brain tumor, inflammatory response to exercise)
- pericardial effusion/cardiac tamponade
- pleural effusion
- tumor lysis syndrome
- uretal/intestinal obstruction
- hemarhtrosis
- hypercalcemia
112
What are signs of superior vena cava syndrome?
- life threatening!
- facial/arm edema-immediate
- headaches
- vein distension
- tachypnea
- dyspnea
113
What do they do for superior vena cava syndrome?
radiation immediately
114
What are signs of increased ICP?
- headaches
- nausea and vomiting
- decreased cognition
- change in mental status with a chronic headache
115
What is pericardial effusion/cardiac tamponade? What are signs of it?
- tumor growing, lymphoid tissue accumulates in chest, pushes on heart, lungs, etc
- life threatening, needs to be treated immediately
- dyspnea, cough, chest pain; tachycardia; anxiety; hypotension; peripheral edema
116
What are signs of pleural effusion?
dyspnea, cough, dull chest pain, tachypnea, anxiety, labored breathing
117
What is tumor lysis syndrome?
Pt has rapid response to chemo, dead cells accumulate in pts body (usually they pee them out); kidneys don't function correctly; watch for change from yesterday to today
118
What are signs of tumor lysis syndrome?
- proximal muscle weakness
- twitching tetany
- seizures
- paresthesia
- bradycardia
- nausea and vomiting
- lethargy
119
What do they do for tumor lysis syndrome?
short-term dialysis (makes pt more weak!)
120
What are signs of hemarthrosis?
- increased swelling
- bruising
- petichia
- decreased ROM
121
What are signs of hypercalcemia?
- muscle wasting and fatigue (mets, osteolytic lesions)
- confusion
- apathy
- N&V
- renal failure-dialysis
122
What can you do for hypercalcemia?
- weight bearing activities!
| - educate family on fall risk
123
BRAIN BREAK!
Read the 2nd slide on pg 26!
124
What can exercise do for cancer?
- predx: reduce risk
- pretreatment: enhance treatment tolerance
- treatment: maintain function, strength, QOL
- survivorship: improve general health, strength, endurance
- end of life: pt control and assist family (educate family on body mechanics, etc when helping pt)
125
CAUTIONS
- screening OPs for cancer
- Changes in bowel/bladder
- A sore that doesn't heal
- Unusual bleeding or discharge
- Thickening or lump
- Indigestion/difficulty swallowing
- Obvious change in wart or mole
- Nagging cough, hoarseness
- Supplemental signs/symptoms (weight loss, confusion, N&V, anxiety
126
How long does it take for things to appear after chemo/bone marrow transplant?
- effects usually occur 7-10 days after chemo
- bone marrow starts to return to normal 15-21 days after treatment
- so don't discharge them before that!
127
What are precautions for oncology pts?
- resting HR>100-110
- vital signs that decrease with activity
- develop an arrhythmia or change an arrhythmia during activity-tell your nurse!
- blood counts should be read prior to each treatment
- myelosuppression is suppression of bone marrow which produces RBC, WBC, and platelets
128
What is thrombocytosis?
- over 1 million cells
| - caused by iron deficiency, neoplasm, infection, inflammation
129
What is thrombocytopenia?
- less than 150,000 cells
- heavy bleeds-GI, CNS
- coagulation factor deficiency
- no aggressive ROM
- black, tarry school
- hypotensive response
130
What are peds signs for thrombocytopenia?
- nose bleeds
- bruising
- fatigued
- pale
- diaphoretic
131
What are communication problems chemo pts may experience? What can you do for them?
- LDs, mental depression, decreased libido, sterility, impotence, altered mental status, hot flashes/hormonal symptoms, alopecia, pain, weight gain
- last a long time from chemo, hormone therapy
- write down education, repeat education, make them say it back
132
What are CPGs for psychosocial health care?
- effective communication between pts, fam, HCPs
- systematically monitoring, evaluating and reevaluating, and adjusting plans
- identifying psychosocial needs
- link to psychosocial services
- establish comprehensive pt education programs
133
What are integumentary complications?
- non-healing wounds
- lymphedema
- loss of tissue/disfigurement
- fibrosis of CT
- decreased rate of wound healing
- skin is atrophic
- skin is easily damaged (diarrhea, incontinence)
- infection
- mucositis
134
What are limb volume outcome measures?
- bioelectric impedence-can predict lymphedema
- perometry: fluid; not FDA approved; reliable and valid
- water displacement
- circumferential measurements
135
Can you exercise if the pt has radiation erythema?
- yes, if only erythema
- no exercise if there is blistering of the skin until skin is healed
- exercise can aggravate erythema
136
What are musculoskeletal impairments?
- movement disorder
- generalized weakness
- myopathy
- effects of bone
- fibrosis
- axillary web syndrome
137
Musculoskeletal Outcome Measures for oncology
- Pain VAS
- goniometry
- sit and reach/flexibility
- grip strength
- MMT
- DASH: disabilities of arm, shoulder, hand test; lymphedema (entire arm)
- PENN shoulder score
138
What is the best predictor of total body strength and survival?
grip strength
139
What interventions should you do for someone with multiple myeloma or bone mets?
non-WBing- risk for fracture or severe deconditioning (cycling, rowing, swimming)
140
What interventions should you do for someone if they have a risk for osteoporosis?
weight bearing
141
What kind of weight training should you do for a more conditioned patient? For an elderly patient?
- high rep, low weight circuit program
| - low intensity, low reps
142
What is axillary web syndrome?
threadlike tissue bands in axilla and medial UE
143
When do people usually get axillary web syndrome?
- 20% with sentinel node biopsy, 72% with axillary clearance (lymph nodes)
- 25-40% of patients
- shows up 2-8 weeks after surgery, but can show up years later
144
What is axillary web syndrome associated with?
- risk of lymphedema
| - most times with breast cancer
145
How do you treat axillary web syndrome?
- stretching and scar release
| - non-aggressive because aggressive can make inflammatory response worse
146
What does axillary web syndrome cause?
pain and limitation of flexion, abduction
147
What are cardiopulmonary complications?
- DVTs/emboli
- cardiac toxicity
- pulmonary toxicity
- pericarditis
- later carcinogenic effects
- cancer related fatigue****
148
What cardiopulmonary outcome measures should you use?
- HR, BP, RR, O2 sat, dyspnea, pulmonary function tests
- graded exercise test
- 6MWT or 2MWT
- Borg scale
- SPADI (shoulder)
- EORTC QLQ C30 (quality of life, validated)
- SF-12 (pt interpretation of health and QOL)
149
What is the most common unmanaged symptom of cancer treatment?
Cancer Related Fatigue
150
What factors related to cancer contribute to fatigue?
- anemia
- cachexia/nutrition
- infection
- paraneoplastic syndrome (especially with small cell carcinoma lung cancer)
- metabolic disorders (DM)
- pain
- emotional distress, stress, depression, sleep disturbances
151
What is the FACIT-F?
a fatigue questionnaire; asks about ADLs, QOL
152
What intervention has the strongest evidence of therapeutic effect?
aerobic exercise
153
Why should you be careful to have a good warm-up and cool down for oncology patients?
- risk for cardiotoxicity
| - on beta blockers
154
When should you start exercise programs?
begin with cancer treatments and continue on
155
General standards for:
- exercise level
- HR
- METS
- Borg
- low levels, progress to moderate levels
- 50-70% max HR
- 3-5 METS
- 9-11, progress to 11-13
156
What causes CIPN? Is it sensory or motor?
- things bind around nerve and interfere with axonal transport
- -can effect ganglion or nerve
- primarily sensory (stocking glove)
157
What are good outcome measures for CIPN?
- TUG
- timed sit to stand
- Berg and Tinetti Scales
- Purdue pegboard scale
- pain quality assessment scale
- QOL: fact-g, modified total neuropathy scale, ped-mTNS, CIPN-20, brief fatigue inventory
158
How do you treat CIPN with meds?
- use lower does of their chemo, or a different kind of chemo
- protective agent
- vitamin E
- glutamin (nerve growth factor)
- NSAIDs
- antidepressants
159
What should you educate your patients with CIPN on?
- cold allodynia (can't tolerate cold)
- mechanical allodynia (can't tolerate blanket on legs)
- AD if lack of sensation effects gait
- check feet, wear shoes, check water temp
- fall prevention, balance training (progressive static and dynamic, 45-60 mins, 2x/week for 4 weeks; HEP 2x/day)
- TENS for pain
- MIRE (not reimbursed)
160
What are the top four kinds of cancer?
- breast
- lung
- large bowel
- prostate
161
What are types of breast cancer?
- 80% infiltrating ductal adenocarcinomas (unilateral)
- 10% lobular (small cell carcinoma)-diffuse, often bilateral
- -usually requires full masectomy
- 10% medullary, squamous cell (need radical masectomy)
- ductal carcinoma in situ
- inflammatory breast cancer (dimpling, read streaks, see hair follicles, skin around breast changes, discharge)
- -infiltrates lymphatic system quickly, under diagnosed
162
What are risk factors for breast cancer?
- age, long menstrual history
- obesity after menopause
- genetics, family history
- lack of exercise=more estrogen in body
- previous chest wall radiation (past risk of lymphedema)
163
What is a sentinnel node biopsy?
take 1 or 2 lymph vessels (increased lymphedema risk)
164
What's a MS effect of a modified radical mastectomy?
involves muscles, can involve nerves
| disfigurement
165
What are breast reconstruction impairments?
- exercise delayed (don't see for 2-3 weeks)
- pectoralis on tension
- postural adaptations
- pain
- decreased shoulder ROM
166
What muscles can they use for breast reconstruction?
- abdominal: long-term complications; start with small pelvic tilts, body mechanics; 2 weeks after-have to stay in flexed position
- latissimus: need special operation table; decreased shoulder ROM, lose sensation; back, arm, shoulder weakness; no pushing or pulling (in and out of bed, hair), no repetitive motions until drains come out
167
What are complications of breast reconstruction?
- neuropathies
- mastodynia pain syndrome
- fatigue
- weight gain
- lymphedema
- decreased strength and ROM in abduction and flexion, and lateral rotation
- menopause symptoms
168
BRAIN BREAK
page 43, slide 1, 2
169
What is a risk reduction program for breast reconstruction?
- reduce post op swelling
- glenohumeral/scapula complex ROM
- reduce scar tissue formation: scar massage
- restore neuro muscular control and strength of the glenoumeral scapular musculature (rhomboids, midtrap)-abductors, scapular stabilizers
- lymph drainage (if radiation therapy)
- minimize risk of infection (hand and arm care)
- -they are immunocompromised
- education of early signs and symptoms
170
BRAIN BREAK
page 44 levels of evidence slides
| page 45 slides 1 and 2
171
What nerve palsies might you see with breast reconstruction?
- long thoracic (serratus anterior)
| - thoracodosal nerve (strengthen rhomboids)
172
How do you assess for lymphedema?
- c/o heaviness, tightness, swelling
| - >2cm at any of the 4 measurement points
173
How do they diagnose prostate cancer?
- digital exam
| - PSA
174
What are late symptoms of prostate cancer? Does it grow fast or slow?
- urinary retention, urethral obstruction
| - slow growing
175
How do you treat prostate cancer?
- surgery
- Rad rx hormones
- androgen deprivation therapy: deprive tumor of testosterone, increased risk of stroke diabetes and CV disease, cognitive decline in pts with PD or Alzheimer's
176
What do you do in rehab for prostate cancer?
- spinal mets
- LE lymphedema
- incontinence
- cancer related fatigue
- resistance exercise
- progressive aerobic exercise
177
Colorectal cancer: ranking, dx, growth, treatment, rehab
- 3rd leading cause
- colonoscopy
- slow growing
- sx, rad rx, chemotherapy
- wellness, deep breathing, function, ostomy precautions
- -exercise, healthy eating
178
BRAIN BREAK wow so many
page 46 slide 2, 3
179
How do they treat lung cancer?
- sx for localized cancer
- radiation/chemo-higher stages
- -higher doses=high risk for CIPN
180
What are rehab issues with lung cancer?
- decrease chest expansion, trunk mobility, ambulation tolerance
- monitor vitals
- -SpO2
- paraneoplastic syndromes: peripheral neuropathy, proximal myopathy, tibia tenderness, hypercalcemia (bone mets)
181
What are interventions for lung cancer pts?
- breathing techniques, pulmonary hygeine
- chest expansion
- diaphragmatic breathing
- strengthening
- aerobic exercises
- physcial modalities for pain
- interval training-don't tolerate continuous training
- fall prevention
182
Head and neck cancers: risks, common signs, when, men/women, psych issues, rehab
- smoking and alcohol
- dysphagia, hoarseness, lump in throat, difficulty swallowing, trouble eating
- 5th and 6th decades
- men
- isolated, withdrawn due to aesthetic problems
- secondary to surgery, limited ROM
183
What impaired sensation might you have with head and neck cancers?
-lose spinal accessory nerve for a short period of time
184
Where the hell would you get edema with head and neck cancer?
cheek and tongue-trouble eating
185
What are barriers to participation for head and neck cancer patients?
- dry mouth or throat
- fatigue
- drainage in mouth or throat
- difficulty eating
- SOB
- muscle weakness
186
BRAIN BREAK
read page 49, page 50 slide 3
187
What is PRET?
-progressive resistance exercise training
188
What is the goal of PRET?
enhance scapular stability and strength of upper extremity
189
What do you do with PRET?
- progressive strengthening of rhomboids, levator scap, biceps, triceps, infraspinatus, subscapularis, post delt, middle delt, supraspinatus
- proper posture, may need taping at first
- -facilitates neuromuscular feedback
190
How is trismus related to cancer?
- limited ROM in 50% of head and neck cancer pts
- can occur years later
- pts with head and neck cancer difficult to treat w/ exercise therapy
- TheraBite increased mouth opening more than exercise
- -exercise alone not effective
- -decreased compliance
191
Should you use modalities with radiated skin?
NOPE
192
brain tumors: who, peak incidence, adults vs kids
- 2nd most common cancer in children
- peaks during infancy and childhood and again in 5-8th decades
- adults: mostly cerebral hemispheres, children: cerebellum and brainstem
193
What are rehab implications for brain tumors?
- ICP concerns (headaches, slurring words, behavioral changes)
- early mobility-start in ICU
- avoid valsalva/resistive exercise
- identifyfunctional impairments
- identify functional limitations
- monitor vitals
- monitor neurologic changes
- meds to reduce N&V
- increased DVTs, PE
- cognitive impairments
- fall prevention
- seizure precautions
194
leukemia
- malignant tumor of the blood forming cells that replaces normal bone marrow with a malignant clone of lymphocytic or myelogenous cells
- inhibits normal cell production
195
BRAIN BREAK
classifications on page 52 slide 2
196
acute vs chronic leukemia
- acute: accumulation of immature lymphoid or myeloid cells in the bone marrow and peripheral blood
- accumulation of mature lymphoid or meyloid cells
197
What are the 3 main leukemia symptoms?
- anemia
- infection
- bleeding tendencies-thrombocytopenia
198
AML: who, tx, survival
- acute myelogenous
- most common in adults; difficult to treat in children
- initial therapy aimed at eradicating the leukemic clone, bone marrow transplant
- long term survival 60%, 75% with complete remission will relapse in 2 years
199
CML: what, signs, tx, outcomes
- chronic myelogenous
- philadelphia chromosome
- fatigue, fever, night sweats, splenomegaly
- treatment is palliative to control WBC and platelets
- poor outcome
200
ALL: who, tx, outcome, risks, problems
-acute lymphoblastic
-children
-prolonged chemo, CNS prophylaxis
-good outcome, high treatment success rate
-high risk for CIPN
ADD, LDs following chemo; deficits in motor performance, balance
201
Chronic lymphocytic leukemia
- palliative chemo tx
- incurable
- 1-10 year survival
202
Hodgkin's lymphoma
- lymphocyte-predominant; lymph nodes enlarged (neck-hoarseness, chest-difficulty breathing)
- hella curable
- chemo and radiation
- -PET scans for tx effect
- does not respond: autologous stem cell, peripheral blood stem cell transplant, last ditch effort
- monoclonal antibody-based therapies
- due to treatments, high risk for fatal MI, development of solid tumor
- -radiation trauma-close to heart
203
Non-Hodgkin's lymphoma
- lymphadenopathy
- -large lymph nodes in chest
- superior vena cava syndrome: dyspnea; rescue care needed-emergency radiation
- slow growing tumors-palliative
- aggressive treatment for fast tumors: stage 1 or 2 radiation, widespread chemo or radiation; immune modulators, BMT
- -fibrosis everywhere-get up and moving ASAP
- -chemo before BMT
204
BRAIN BREAK
page 54 slide 3, page 55, slide 1,2
205
Multiple Myeloma: what, presentation, treatment
- overproduction of IgG, IgA antibodies
- presents as back (bone) pain, anemia-check vitals
- chemo, surgery, spinal decompression and fusion
206
Rehab issues for multiple myeloma
- WBing activity valuable to minimize further calcium loss
- avoid torsion
- safe mobility education: OP precautions
- -pain with WBing-get the Dr (osteopathic fractures)
- splinting/bracing
- TENS/palliative pain measures
- if positive for bone mets, dr has to clear them for exercise
- sub max pressure for MMT, just make sure they can move against gravity
207
Multiple myeloma: exercise program
- aerobic exercise: 4-5x/week, 15-30 mins, moderate intensity (55-70% HR max, 11-16 RPE)
- resistance exercise: 5-8 reps, 3 days/week for 20 mins with theraband
- -chair stands, knee flexion/extension, bicep/tricep curls, upright rows, leg curls
- flexibility exercise: 3 days/week, slow static prolonged stretch for 10-30 sec hold
208
Childhood cancer survivors: brain function
- increased risk with brain tumors or ALL
- brain cells in the early years grow very quickly, making them very sensitive to radiation
- cognitive impairments: lower IQ, problems with memory and attention, poor hand-eye coordination, slower development over time,behavioral problems; non-verbal skills like math more likely to be affected
- seizures & headaches
- effects on pituitary gland: poor appetite, fatigue, listlessness, cold inolerance
209
Childhood cancer survivors:vision
- most common in retinoblastomas
- radiation can cause cataracts, slow bone growth causing changes in eye shape as child grows
- chemotoxic to eye and may lead to blurred vision, double vision, glaucoma
- children with stem cell transplants may be at higher risk for eye problems if they develop chronic graft-versus-host disease
- other late effects: dry eye, watery eye, discolored sclera, poor vision, light sensitivity, poor night vision, tumors on the eyelid, drooping eyelid
210
Childhood cancer survivors: hearing
- chemo, radiation, and antibiotics may cause hearing loss (especially high-pitched sounds, higher risk in children who are young at the time of treatment)
- other late effects: ringing in the ears, trouble hearing with high background noise levels, dizziness, hard, crusty ear wax
- trouble with background noise
211
Childhood cancer survivors: growth
- delayed growth
- radiation: head and neck can affect overall growth and development by damaging the pituitary
- may affect bones, height, full maturity
- very young children most likely to be effective
- growth hormone may reverse some effects when pituitary gland is damaged
212
Childhood cancer survivors: thyroid
- affected by radiation or surgery to the head and neck or some stem cell transplants
- affect growht, development, metabolism
- most often hypothyroidism-extreme fatigue, dry skin, unexplained weight gain, constipation, slowed bone growth, thinning hair
- hyperthyroidism less likely but possible
- greater risk for thyroid nodules
213
Childhood cancer survivors: muscle and bone
- bone, soft tissue, muscle and blood vessels sensitive to radiation during times of rapid growth (young children and growing children at greatest risk)
- late effects: unequal growth, bone pain, joint stiffness, changes in gait, increase susceptibility to fractures, decreased calcium
- high doses of chemo or corticosteroids to treat leukemia or lymphoma can cause osteonecrosis
- gait changes, proximal muscle weakness
214
Childhood cancer survivors: sexual development- males
- radiation and chemo can reduce sperm production
- treatments that alter testosterone can lead to failure to complete puberty, delayed or accelerated puberty, decreased sexual desire or impotence
215
Childhood cancer survivors: sexual development- females
- high doses of chemo can damage ovaries causing changes in menstrual cycle-more at risk after puberty
- at risk for early menopause and reduced fertility-early menopause increases risk for OP and coronary heart disease
- increased risk for miscarriage, low birght weight, premature birth
216
Childhood cancer survivors: heart and lungs
- increased cardiac mortality in adult survivors
- chemo: damage to heart muscle, dysrhythmias, decreased left ventricular function associated with reduced contractility and excessive afterload; fibrosis and pneumonitis
- radiation: CHF, dysrhythmias, heard valve abnormalities, and damage to coronary arteries; decrease lung volume, SOB, constant cough, pulmonary fibrosis, pneumonitis, increased risk of infections, increased risk for lung cancer, decreased chest wall growth
- heart transplants
- increased SOB, increased arhythmias-red flags
- watch activity levels and changes in CV response
- more likely to have a heart attack
217
Childhood cancer survivors: teeth
- mostly effects from chemo or radiation in children who were treated before the age of 5
- include small teeth, missing teeth or delayed development, abnormal tooth enamel, increased risk of cavities, sensitivity to hot or cold, gum disease, short roots
- salivary glands affected: decreased saliva and dry mouth
- malnourished
- dry mouth: increased risk of fungal infections in mouth->sores
- -stay hydrated
218
Childhood cancer survivors: obesity
- ALL and brain tumors at greatest risk due to chronic steroid therapy and cranial radiation
- more likely to have diabetes type 2
- development of metabolic syndrome: obesity, HTN, dyslipidemia or impaired glucose tolerance
- -increased cholesterol
219
Childhood cancer survivors: second cancers
- increased risk associated with: younger age, female, family hx of cancer, and primary diagnosis
- chemo therapies associated with secondary incidence of AML and myelodysplastic syndrome (also known as preleukemia)
- most common: breast, thyroid, bone cancer
- -higher risk areas treated
- -Hodgkin's lymphoma survivors at highest risk of secondary cancers
220
Risk factors for HIV/AIDS
- unprotected sex
- more than 6 partners
- poverty
- illegal drug use
- poor access to health care
- communities with high prevalence
221
Does everyone exposed to HIV get it? Do they all get AIDs?
no and no
222
Pathogenesis of HIV
- progressive destruction of Tcell (cell mediated immunity)
- destroys and inactivates T4 lymphocytes (CD4 cells); macrophages and B cells also affected
- -every system relies on CD4 cells
- migrates from serum into tissue to blood destroying lymphocytes
- cell containing CD4 antigen serve as a receptor during DNA replication
- HIV contains reverse transcriptase
- -HIV viruses take over CD4; dropping CD4 determines tx, when they get symptoms
- high mutation rate
223
What is the first sign of HIV/AIDS usually?
- worst flu they've ever had, reoccuring flus or pneumonias
- infection they can't get rid of
- fluctuations in CD4/T cell counts
224
What are symptoms in the early stages? Middle? Late?
- skin infections, fatigue, night sweats, weight loss
- mild symptoms increase
- pneumocystis pneumonia, CMV, neurologic (coma), cancer
225
What are five symptoms of aids?
- fatigue, depression
- frequent recurrent infections (enlarged lymph glands, joint pain)
- diarrhea (malnutrition, weight loss)
- Kaposi's sarcoma (w/ it and under 60-get tested)
- altered neurologic function
226
What do infections look like for HIV patients?
1 or 3 forms
- immunodeficiency with unusual malignancies and opportunistic infections (25-40% have Hep C)
- autoimmunity such as RA, pneumonitis and production of autoimmune antibodies
- neurologic dysfunction, AIDs, dementia, HIV encephalopathy and peripheral neuropathies
227
What is the difference between acute infection and clinical latency and AIDS?
- acute: CD4>500
- latency: CD4=200-500
- AIDS: CD4=<200
228
BRAIN BREAK
read page 5, slide 2, because i'm not sure what you're supposed to get out of that. Good luck!
229
Clinical Manifestations of AIDS
- persistent generalized adenopathy
- weight loss, fatigue, night sweats, fevers, weakness
- opportunistic infections (examples on page 6 if you care)
- Nervous system: peripheral neuropathies, foot drop, balance issues; pain-burning, tingling, hypersensitivity and proprioceptive losses; severe dementia; incontinence (neurogenic->lose sensation to bladder); paraplegia, dizziness
- more restricted exercise
- osteomyelitis, bacterial myositis, non-Hodgkin's
- sternocleidomastoid infection if drug user
- chronic diarrhea, fever, malnutirion
- pelvic inflammatory disease in women (back pain)
- polymyositis
230
What is polymyositis?
- autoimmune disorder-inflammation of proximal muscles bilaterally; can occur in face and neck
- improves with plasmapheresis, corticosteroids
- exercises to maintain and improve strength and flexibility and advise an appropriate level of activity
231
What is plasmapheresis?
- large catheter in vein in neck or upper leg
- blood taken out plasma filtered, add donor plasma, return blood cells
- done daily until platelets return to normal levels
- can be done OP
232
How do you treat HIV/AIDS?
- no cure
- prevention
- HAART meds: goal- control growth of virus, improve overall immune system function, suppress symptoms, produce as few side effects as possible
233
What is HAART?
- highly active antiretroviral therapy
- for when CD4 is <350
- classes (use at least 2)
- -reverse transcriptase inhibitors (nucleoside or non-nucleoside)
- -protease inhibitors
- -entry inhibitors
- -integrase inhibitors
234
What do nucleoside reverse transcriptase inhibitors do?
Stall reproduction of HIV by forcing the virus to use faulty version of building blocks
-Combivir, emtriva, retrovir, trizir, epivir, videx, vreaed
235
What do nonnucleoside reverse transcriptase inhibitors do?
Interrupts early stage of the virus making copies of itself
| -Rescriptor, viramune, sustiva, intelence, rilpivirine
236
FUN FACT
- the FDA has approved 2 one pill OD products which serve as a combo of different RT inhibitors
- -Complera
- -Aripla
237
RT inhibitors: side effects
- decrease in RBCs or WBCs
- inflammation of pancreas
- painful nerve damage
- avascular necrosis of femoral head
- AZT myopathy (proximal muscle wasting)
- metabolic disorders: lipodystrophy, dyslipidemia (early atheroscloerosis and insulin resistance)
238
Avascular necrosis of femoral head
- lack blood flow-pain with weight bearing, tell Dr
| - have to have joint replacement
239
Lipodystrophy
- arm, leg, face weakened, fat taken to abdomen
- high levels of fat accumulation
- insulin resistance, elevated blood sugars
- Buffalo hump, lipomas (fatty tissue build up)
240
Protease inhibitors: what they do, side effects
- interfere with enzyme that HIV uses to create infectious viral particles; nucleoside reverse transcriptase
- nausea, diarrhea, GI symptoms
- -any fast growing or quickly cycling cells will be effected
- Norvir, Invirase, Viracept
241
Integrase inhibitors: what do they do?
- block insertion of viral DNA into the host cell DNA
- -stop virus from spreading it's unhealthy DNA
- isentress
242
Entry inhibitors: what they do, side effects
- help block HIV's enry into healthy cells
- dyspnea, chills, fever, skin rash, blood in urine, vomiting, low BP, fatigue, malaise
- -apoptysis of cells: immune response
- -fells like they have the flu for 40 years
- Seizentry
243
What is the leading cause of death for HIV/AIDS?
kidney or liver failure
244
opportunistic infections
-CMV, pneumonia, pneumocystic pneumonia
245
Candidiasis/thrush
fungal infection in mouth
extremely painful
lack nutiriton
246
What do therapeutic interventions do for HIV/AIDs patients?
- normalize insulin resistance caused by lipodystrophy
- improves QoL
- provides pain relief
- improves appetite
- enhances immune function
- improves pulmonary function and prevents pneumonia
247
Stage 1 therapeutic intervention
- no limitation to exercise
- competition acceptable but overtraining not advised
- -worsens immune system-cortisol
- --tired, malaise, fatigue-they have a hard time relowering
248
Stage 2&3 therapeutic intervention
- functional capacity reduced, can't do some ADLs
- require individualized program and lower intensity
- competition not advised
- energy conservations
249
BRAIN BREAK
page 13, slide 1
250
What are screening tools for neuropathy?
Total Neuropathy Score (good reliability), Subjective Peripheral Neuropathy Screen, Brief Peripheral Neuropathy Screen, Neuropathy Severity Score, Single Quest Neuropathy Screen
251
Aerobic exercise parameters
- graded exercise test for Stage 2 or 3
- 60-80% max HR with RPE 14
- 20 minutes (constant or interval)
- -interval for later stages, someone having ADL trouble
* *if you're teaching energy conversation you should be teaching interval training
- 3x/week
252
What are safe CD4 levels for exercise?
100-1000 cells/mm3
253
Progressive resistive exercise parameters
- weights, resistive machines, theraband of large muscle groups
- goal: minimize or reverse muscle wasting, weight gain
- -big concern: lipodystrophy-enchance muscle function and bulk
- 3x/wk
- 20-25 mins
- 50-90% 1 rep max
- 1-5 sets of 4-18 reps
254
But with exercise you should...
couple aerobic and resistive!!
255
What does the evidence say about exercise and HIV/AIDs?
go read page 14. slides 2-3 and page 15, slide 1 to find out!
256
What are 4 complimentary therapies for HIV/AIDs?
- nutritional counseling
- acupuncture: increased energy, decreased side effects of meds, pain control
- homeopathy, herbs: increased energy, stimulate immune system, decreased side effects of meds; not regulated
- -can counteract HAART meds
- Meditation, Yoga, Tai Chi: decreased stress
257
Read those cases bro
congrats you're done after that!
