Sue Sandahl MA OTRL CBIS On The Horizon of Oncology Nursing Updates and Current Treatment 2016 Cancer Rehabilitation An Interdisciplinary Approach On With Life Our History Started 25 years ago by 8 families who came together to support their loved ones with TBI ID: 910519
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Gina Beecher, DPT, CBISCourtney Huber, MS, CCC-SLP, CBISSue Sandahl, MA, OTR/L, CBISOn The Horizon of Oncology Nursing: Updates and Current Treatment 2016
Cancer Rehabilitation:
An Interdisciplinary Approach
Slide2On With Life – Our HistoryStarted 25 years ago by 8 families who came together to support their loved ones with TBIInpatient rehabilitation Long term care
Glenwood
,
IASupported community livingNeuropsychologyOutpatient Therapy
Slide3Presentation ObjectivesParticipants will learn the role of interdisciplinary rehabilitation (PT/OT/SLP/Case Management) in the treatment of different cancer types.
Participants will learn the difference between courses of rehabilitation depending on a person’s personal goals and medical prognosis.
Participants will learn of resources for rehabilitation services in the local area.
Slide4Cognitive Rehab for “Chemobrain”Research suggests that for extracerebral cancers, neurocognitive deficits may be present
without
the presence of brain
mets and before treatment has been initiatedCommon treatments, while effective in treating the cancer, have a neurotoxic effectIn some people, the neurocognitive impairments do not resolve following medical treatment
Slide5Cognitive Rehab for “Chemobrain”Common neurocognitive deficits secondary to extracerebral cancer:
Memory changes
Decreased attention (distractible; unable to multitask or shift between tasks)
Slowed mental processingChanges in executive function (organization; reasoning; awareness of deficits)Difficulty with word-finding
Fatigue
Motor coordination
Slide6Cognitive Rehab for “Chemobrain”Unfortunately, few survivors receive treatment for cognitive deficits secondary to extracerebral
cancer
Primary cancer centers rarely offer cognitive rehabilitation
Traditional rehabilitation centers do not target marketing to this population due to concerns related to poor prognosisSurvivors may be ashamed to admit to continued problems due to surviving a horrible disease
Slide7Cognitive Rehab for “Chemobrain”Comprehensive neuropsychological testing is indicated for differential diagnosis of cognitive changes vs. mood disturbances, aging, or neurodegenerative disease
Neuropsychological testing may be useful prior to beginning medical treatment to establish cognitive baseline and compare to status during and following treatment
Neuropsychological assessment is allowing for investigation of neurocognitive outcomes in clinical trials of new antineoplastic agents
Slide8“Prehabilitation” for “Chemobrain”?Cognitive rehabilitation prior to medical treatment fits with the 3 key purposes of
prehabilitation
:
Protect the brain from further neurocognitive compromise associated with progression of disease and cancer treatmentImplement compensatory behavioral strategies designed to circumvent probable problems before they progress to life-limiting disabilitiesDecrease patient and caregiver distress by introducing supportive counseling and psychoeducational programs
Potential outcomes
Increased QOL for survivors/families?
Health care cost savings by reducing severity of disability?
Slide9Cognitive Rehab for “Chemobrain”Many of the same compensatory techniques used in acquired brain injury rehabilitation can be applied to cancer rehabilitation
Skilled
rehabilitation therapies (speech-language pathology; occupational therapy) is indicated to train survivors and their family members on use of these compensatory approaches
At
this time, there is no evidence to support drill-oriented approaches for remediation of memory or attention function
Slide10Case Study – C. P.55 year old woman, referred to OWL for cognitive impairment3 years prior, was treated for breast cancer with chemotherapyNoted worsening memory, attention, and executive function throughout treatment without resolution of symptoms when treatment endedMRI ruled out brain
mets
Cognitive changes resulted in her being terminated from her job of 11 years
Tried to return to work on multiple occasions; unable to hold a job for more than 2 weeksRelevant medical history: peripheral neuropathy; anxiety/depression; stomach ulcers; hypothyroidism
Slide11Case Study – C. P.Assessment results: low average results for domains tested on the Repeatable Battery for the Assessment of Neuropsychological Status; significant impairment in written and verbal reasoning on the Functional Assessment of Verbal Reasoning and Executive Strategies
Interpretation: mild cognitive-communication impairment
Recommendations: speech-language pathology services at 1-2x/week; individual counseling to address depression/anxiety; consider neuropsychological testing for comprehensive cognitive baseline data
Slide12Case Study – C. P.Speech-Language Pathology plan of care:Start use of planner as a memory/planning/organization deviceIntroduce template (Goal-Plan-Do-Review) for task segmentation, sequencing, and review of performance on personal goals
Trial organizational strategies to sort and file paperwork that has been “piling up” in home environment
Identify vocational interests and explore appropriate accommodations for return-to-work
Slide13Case Study – C. P.Treatment duration: 21 visits over period of approximately 3 monthsMet all plan of care goalsConsistently using planner to write daily to-do lists, upcoming appointments, information to remember for later, and to reschedule tasks that were not yet completed
Utilized task segmentation for various situations such as applying for jobs, completing basic household management tasks, and filling out complex paperwork
Returned to work part-time as a travelling health care provider for wellness fairs (e.g., flu shot clinics) and was reporting job satisfaction
Reported overall improved quality of life
Slide14Rehabilitation for Non-Progressive Brain Tumors Traditional RehabNDTNeuro-IFRAH
Aphasia/Apraxia rehab
Vision and Vestibular rehab
Strengthening and Activity ToleranceFatigue managementAdjust treatment intensity based on any follow-up chemo or radiation treatments
Slide15Case Study – J.R.JR is a 23 year-old male who lived with his parents and worked full time in an accounting job. He was independent in all ADL, IADL, work, mobility, and driving. He began noticing changes in June 2016 when his right leg was not working properly and led to his involvement in a car accident. He was also experiencing signs and symptoms of a stroke.
He
was diagnosed with Neoplasm of the brain and cerebral
cysts, s/p resection of a left fronto-parietal benign tumor July
2016.
He discharged to home with his mother six days post-surgery. JR had residual global aphasia, right-sided weakness, and spasticity.
He
was referred to On With Life Outpatient Neurorehabilitation for Speech Language Pathology, Occupational Therapy, and Physical Therapy
.
Slide16Case Study – J.R.Assessment Results: Aphasia and Apraxia, Dominant RUE/RLE weakness, spasticity, gait disturbance, Modified Independence BADL; Moderate/Maximum assistance IADL; Driving – dependent; Work – unable.Recommendations: OT, PT, SLP 2-3 times per week.
Speech
Language Pathology:
Traditional aphasia/apraxia rehabPhysical Therapy: Traditional rehab
Slide17Case Study – J.R.Goal: JR’s main goals were to return to driving and work as work was a significant priority for him.Occupational Therapy Plan of Care:RUE gross and fine motor control retraining including modified constrain-induced treatment, keyboarding and
mousing
Dynavision
: Visual-motor reaction time assessment and retraining in preparation for return to drivingTherapeutic exercise for strengthening
RUE
BADL retraining specifically for donning RLE orthotic
Slide18Case Study – J.R.Treatment Duration: OT 23 treatments, PT 23 treatments, SLP 20 treatmentsJR met all OT goalsMod I in all BADL/IADL
Improved RUE strength from 2-3/5 to 4-5/5
Improved RUE grip from 31.6# to 62.5#
Improved RUE 9-Hole Peg Test from unable to 56.14 seconds Returned to driving – initially with supervision adult passenger, then independentlyReturned to work initially at 4 hours per day and gradually worked up to 8 hours per day
OT, PT, SLP and Office Case Manager collaborated with JR regarding return to work and driving
readinesss
.
Slide19Rehabilitation for Aggressive Brain TumorsAnticipates and prevents suffering in order to ensure maximal quality of life (as they define and interpret it)Can increase tolerability of treatments, decrease need for hospitalization, and increase patient and family satisfaction
Help them to make the most of each day
Frequent re-assessment of symptoms
Treatment of pain
Slide20Case Study – M.R.58 year old female, referred to OWL for OT/PT/SLP following diagnosis of glioblastoma (right frontal) one month prior to evaluation dateUndergoing radiation and chemotherapy treatmentExperiencing left sided weakness resulting
in decreased
mobility and a
recent fall at homePMH significant for Spinal fusion C5-6, breast lumpectomy, factor V mutation (currently with blood clot in left lower leg), migraines, depressionM.R. states she is retired but previously very active, working out and watching young grandchildren once a week
Slide21Case Study – M.R.Assessment results: Bilateral LE weakness (L>R) and left UE weakness, walking up to 40 feet without assistive device minimal assistance, impaired midline perception, Berg 9/56, TUG 57 seconds, SBA – min A for ADL’sRecommendations: OT 1-2x week, PT 2-3x week for treatment of deficits to improve functional mobility for
ADL’s, SLP one visit
eval
and DC
Slide22Case Study – M.R.Patient goals: increase independence, improve strength, return to bakingPhysical therapy plan of care: gait training – adding assistive devices, AFO as needed, family training to assist with mobility
transfer training – initially increasing independence, then needing more family training on transfers, bed mobility, body mechanics
therapeutic exercise – educating M.R. and spouse on safe strengthening and endurance exercises for home
MAIN FOCUS – maximize function as long as possible working towards a family
goal
for M.R. to
stay home as long as possible
Slide23Case Study – M.R.Benefit of multidisciplinary approachSLP – evaluated and educatedOT – evaluated and treated for 6 visits to increase strength and activity tolerance for ADL’s
PT – gait, transfer training, family education
CM – provided family education, counseling, coordination with hospice
Slide24Case Study – M.R.Physical therapy treatment duration: 24 visits in a little under 3 monthsDuring that time cancer progressed despite the chemo/radiation treatmentM.R. was discharged with hospice services and passed away 3 months following discharge
Slide25Utilizing Rehabilitation ResourcesPhysician’s orderIf not sure what services are needed, request PT/OT/SLP eval/treat
If skilled rehabilitation services are not indicated, evaluating clinician will provide recommendations, education, and discharge
If skilled rehabilitation services are indicated, clinician creates discipline-specific plan of care and submits to the physician
Slide26Questions?If you have specific questions regarding this presentation or our referral process, please contact us!Tammy Miller, Outpatient Clinic Manager
tmiller@onwithlife.org
(515) 289-9662
Gina Beecher, Physical Therapist
gbeecher@onwithlife.org
(515) 289-9643
Courtney Huber, Speech-Language Pathologist
chuber@onwithlife.org
(515) 289-9641
Sue Sandahl, Occupational Therapist
ssandahl@onwithlife.org
(515) 289-9644
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