Principles of Cancer Rehab
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PRINCIPLES OF REHABILITATION MEDICINE
PRINCIPLES OF CANCER REHABILITATION MEDICINE
patient’s personal interest and ability to participate in the rehabilitation program and to pursue the established functional goals, supported by family and friends.
KRISTJAN T. RAGNARSSON, MD DAVID C. THOMAS, MD
APPLICATION OF REHABILITATION CONCEPTS
Medical advances in the diagnosis and management of cancer have markedly increased survival rates. While the treatment for some patients may now result in complete cure and no perceived physical deficits, for others, an aggressive definitive treatment may result in significant physical impairment or disability. To ensure quick restoration of optimal function, early and continued aggressive rehabilitation interventions should be provided, including physical and occupational therapy, prosthetic and orthotic devices, and assistive equipment. Application of rehabilitation techniques frequently results in a swift functional improvement and a reduction of subjective complaints, even when the prognosis for life is considered poor. It has always been difficult to predict with a degree of certainty the life expectancy of an individual with cancer. Modern diagnostic techniques and effective treatment of malignant neoplastic diseases have invalidated old statistics and dogmas regarding life expectancy and thus made accurate prognostication even more difficult for the clinician. No cancer patient, even one with widespread metastases, should be denied the benefits of aggressive treatment, including appropriate surgical intervention, chemotherapy, radiation, and comprehensive rehabilitation. These interventions, when offered in an integrated and timely fashion, prolong life, protect organs and residual healthy tissue, reduce pain, and maximize self-care and mobility skills, and thereby help to reduce the stigma of cancer and physical impairment while providing dignity and a better quality of life for the cancer patient. Early referral for rehabilitation services and good communication among the oncologist, the surgeon, the physiatrist, and the other members of the cancer rehabilitation team are essential to the patient’s successful return to optimal function. Every effort should be made to coordinate the rehabilitation treatment with other types of intervention. A comprehensive and well-coordinated rehabilitation approach that concurrently deals with the physical, psychologic, and social problems caused by the malignancy and the consequent disability usually yields the best results. Most important for success, however, is the
Many persons afflicted by cancer develop some form of functional impairment or disability that will interfere with self-care, mobility, and a smooth transition to their former life style. These patients should be identified early and referred for rehabilitation treatment. Cancer rehabilitation can be broadly defined as the maximum restoration of physical, psychologic, social, vocational, recreational, and economic functions within the limits imposed by the malignancy and its treatment. To make a significant and timely impact on such a wide variety of functions and needs, the efforts of a well-coordinated and goal-oriented multidisciplinary cancer rehabilitation team are required (Table 71.1). Because of the patient’s often uncertain prognosis, most cancer rehabilitation programs focus on quick gains in mobility and self-care skills, and the provision of psychosocial support to the patient and family. Flexibility in goal setting is unavoidable because of the patient’s changing needs, stamina, and medical status. Despite the potential benefits, referrals of cancer patients for rehabilitation services are often made needlessly late or not made at all. Clinical problems amenable to rehabilitation interventions are often identified too late or not at all. Pessimistic prognostication by the oncologist and the rehabilitation specialist may hinder rehabilitation referrals, as cancer patients are inappropriately compared with patients disabled by trauma or other relatively static medical disorders. Fortunately, the prognosis for most types of cancers has improved, and consequently the demand for rehabilitation services for cancer patients with disabilities has grown. Several studies have shown that cancer rehabilitation programs result in measurable benefits when individualized, specific, and realistic goals are set.1 Comprehensive inpatient rehabilitation services
Interdisciplinary Cancer Rehabilitation Team
Physician (physiatrist) Rehabilitation nurse Physical therapist Occupational therapist Prosthetist-orthotist Nutritionist
Speech-language pathologist Social worker Psychologist Chaplain Vocational counselor Recreational therapist
972 SECTION 21 / Principles of Rehabilitation Medicine Table 71.2.
Activities of Daily Living*
Eating and drinking Dressing and undressing Bathing and grooming Toileting Managing bladder and bowel functions Manipulating small objects Caring for health and fitness
Moving in bed Changing position Walking Climbing stairs General wheelchair skills Using a manual wheelchair Using a powered wheelchair
* Rehabilitation indicators: skill indicators.
may be economically provided for disabled cancer patients who are considered “cured or controlled,” but precise short-term rehabilitation interventions may enable even those with a poor prognosis to gain the mobility and self-care skills that facilitate early hospital discharge. The physical impairment experienced by cancer patients may result from tissue destruction caused by the cancer itself, prolonged bedrest, or inactivity, or from definitive treatment such as surgery, radiation, or chemotherapy.The exact nature of the impairment may vary, but in essence, it is no different from impairment caused by trauma or noncancerous disease and is customarily managed by the rehabilitation team. A specific rehabilitation goal must be established for each patient and an individualized program prescribed that is designed to obtain measurable early results. The main rehabilitation goals for all people with physical disabilities are, first, to develop maximum skills in the activities of daily living (ADL) (Table 71.2) allowed by the disability and, second, to obtain independent mobility with or without assistive devices, such as wheelchairs, prostheses, orthoses, walkers, crutches, or canes. To reach these goals, the therapist will utilize physical exercise to improve muscle strength, endurance, joint flexibility, and selfcare skills, as well as apply physical modalities to decrease pain and swelling. Prescription, fabrication, and fitting of prosthetic and orthotic devices and other assistive equipment, followed by training in their use, is essential for amputees and individuals with significant muscle weakness, paralysis, or unstable skeletal structures. It is essential to provide rehabilitation interventions that also aim at the often profound psychological, sexual, social, and vocational consequences of the cancer and the physical impairment. Preferably, the anticipated psychosocial difficulties should be addressed when the initial diagnosis is made and when treatment is begun. The goal of cancer care is not just to eradicate or control the malignancy and extend the patient’s life but to maintain or re-establish a life of quality. While fatal or physically disabling consequences of cancer are quickly recognized and usually well managed by the hospital staff, the psychosocial effects of cancer, which frequently manifest after hospital discharge, may remain unnoticed and therefore go untreated. As a result, they may become more disabling than the physical impairment. The rehabilitation goals of cancer patients may be broadly classified according to the different stages of the disease. (1) Preventive rehabilitation therapy is started early after the diagnosis of cancer is made, that is, before or immediately after surgery, radiotherapy, and/or chemotherapy. At this stage no significant physical impairment exists, but therapy is started to prevent functional loss. (2) Restorative rehabilitation therapy is directed at the comprehensive restoration of maximum function for patients considered “cured or controlled” but who have a residual physical impairment and disability. (3) Supportive rehabilitation therapy attempts to increase the self-care skills and mobility of the cancer patient with growing cancer and progressive impairment and disability by the application of quick, effective methods, for example, providing appropriate assistive devices and the teaching of simple techniques for self-care.2 Supportive rehabilitation therapy also includes physical exercises to prevent the effects of immobilization, such as joint contractures, muscle atrophy, weakness, and pressure sores. (4) Palliative rehabilitation therapy aims to increase or maintain the comfort and function of patients with terminal cancer by utilizing physical modalities, simple orthotic devices, and assistive equipment to manage pain, joint contractures, and pressure sores, and to provide at least partial self-sufficiency.2
THE CANCER REHABILITATION AND ADAPTATION TEAM Organized cancer rehabilitation programs can significantly improve a patient’s physical function and community re-integration.1,3 An integral part of such programs is an interdisciplinary cancer rehabilitation and adaptation team (see Table 71.1). The exact composition of the team may vary considerably, depending on the program’s philosophy and size, the type of institution, and the range of disabilities encountered. The team is led by a physician who is either an oncologist or, more commonly, a physiatrist.3 An oncology nurse, social worker, psychologist, physical therapist, occupational therapist, vocational counselor, chaplain, and nutritionist are present on most teams. Other rehabilitation professionals may contribute to the rehabilitation of cancer patients, depending on each patient’s specific physical impairment, including prosthetist, orthotist, speech pathologist, driver’s trainer, and recreational therapist. The roles of the various team members are described below. The physiatrist, the medical specialist who usually directs the cancer rehabilitation team, needs to be knowledgeable in oncology in addition to having expertise in the field of physical medicine and rehabilitation. The physiatrist is the team’s primary link with other treating physicians. To establish realistic goals and prescribe an appropriate rehabilitation program, the physiatrist needs to know (1) details of the cancer diagnosis with respect to organ site, histology, and grade of anaplasia, (2) the cancer’s anatomic staging (primary site only, involvement of regional nodes, or metastases), (3) the patient’s life expectancy, that is, whether the patient is “cured or controlled,” and if not, the anticipated rapidity of the cancer’s progression, and (4) the definitive treatment plan for the cancer, that is, the timing of surgery, chemotherapy, or radiation, and its anticipated efficacy and potential side effects. The physiatrist discusses this information with the rehabilitation team as the basis for developing a specific and realistic plan of preventive, restorative, supportive, and palliative therapies. The physiatrist introduces the patient and family to the goals of the cancer rehabilitation team and meets regularly with the team, as well as with the patient and family, to direct and coordinate their efforts, while taking into account the patient’s progress and changing needs. The rehabilitation oncology nurse serves primarily as an easily accessible resource to the nursing staff giving care to the cancer patient, as well as to the patient and the family. The nurse evaluates the patient’s specific nursing needs, plans the patient’s care, helps to obtain nursing supplies, educates other nurses, the patient, and his or her family about nursing techniques and the principles of cancer treatment, facilitates patient and family self-management, and monitors discharge plans and assists in the discharge process. After discharge, the nurse may provide advice to the caregivers in the home on the management of the different and complex treatment problems that may arise. The physical therapist teaches the patient to perform specific exercises to strengthen muscles, to increase stamina, and to maintain or improve joint range of motion and trunk flexibility. When indicated, training is provided to improve balance and coordination, as well as functional skills: transfers into and out of bed, wheelchair locomotion, and ambulation with or without assistive devices. Instructions are provided on how to normalize gait patterns and to safely ascend and descend stairs and curbs. Various physical modalities may be used by the therapist to reduce pain, such as superficial and deep heat, cold, transcutaneous electrostimulation (TENS), and massage, but the clinician needs to stipulate that heat modalities and massage should not be applied directly over or immediately adjacent to a site of cancer. Physical exercise is perhaps the most important therapeutic modality in the rehabilitation management of physical disabilities. Muscle-strengthening exercises may be either isometric, isotonic, or isokinetic. Isometric exercise does not involve joint motion, and so is prescribed for painful or unstable body parts, whereas isotonic exercise involves joint motion against variable resistance. Isokinetic exercise, a most effective strengthening exercise, involves the use of specific devices (e.g., the Cybex apparatus) to maintain constant speed of motion independent of the force applied.4 Passive stretching exercises are done by the therapist without the patient’s direct participation to maintain or increase
joint mobility. Task-oriented exercises, such as ambulation or training in self-care, may improve function and safety by repetition and prolonged therapy. The occupational therapist focuses in on upper-extremity exercises and training in self-care activities. The exercises are designed to improve strength, coordination, and skills in the various ADL (see Table 71.2). Different adaptive equipment may be provided to make the patient more proficient in self-care and activities related to work and recreation. When indicated, the therapist fabricates simple orthotic devices, such as hand splints for immobilization or to compensate for weak muscles. When brain dysfunction is present, a gross assessment of cognitive and visual perceptual skills is performed, and therapy is initiated to compensate for deficits in these areas. The home and workplace are evaluated and recommendations are offered to make these sites more accessible and more conducive to complete self-sufficiency and greater productivity. Working independently, or with a recreational therapist, the occupational therapist strives to make a resumption of leisure time activities easier for the patient. The prosthetist/orthotist is called on to make artificial limbs (prostheses) or special braces (orthoses) for patients in need of such devices. The prosthetist/orthotist should evaluate the patient with the physiatrist and the therapist and help to select the proper components and materials for the device, as well as determine its general design and methods of fabrication on the basis of the pathology and biomechanics involved. After delivery, the physiatrist checks out the device for comfort and fit, but it is the duty of the prosthetist/orthotist to modify and service the equipment as long as it remains in use. The nutritionist evaluates the patient’s nutritional condition, assesses the additional metabolic demands that the cancer places on the body, and recommends the optimal diet with respect to specific clinical condition, caloric intake, food ingredients of choice, optimal consistency for easy swallowing, and the individual’s tastes. The nutritionist judges total food intake by closely monitoring the patient’s weight and counting calories and, if nutrition is inadequate, may recommend interventions to facilitate adequate intake in the presence of poor appetite and swallowing disorders. The nutritionist should teach the patient and family general and specific dietary principles and consult with the clinical staff on the optimal parenteral nutrition when the need for that arises. The speech-language pathologist evaluates and provides therapy for impaired oral communication and works closely with the occupational therapist and nutritionist in the assessment and care of swallowing disorders. The social worker has many important roles in the rehabilitation of the cancer patient, but especially with respect to discharge planning, facilitating a smooth transition from the hospital to the community, ensuring continuity of care, and securing appropriate follow-up services after discharge. The social worker helps the patient to secure financial resources, including health insurance coverage, and Social Security and disability compensation, as well as to obtain authorization and payment for necessary devices and home help. Before hospital discharge, arrangements need to be made for transportation, attendant, or nursing care, home modifications, and other appropriate posthospital services. This may involve transfer to and placement in other health institutions. The social worker often acts as a liaison among the patient, the family members, and the various health care professionals. The psychologist assesses the patient’s cognition and behavior, including intelligence, personality (i.e., ideational, emotional, behavioral, and character patterns), personal history, motivation, reaction to the illness, and coping skills. Following the diagnosis of cancer and the development of a disability, both the patient and family members may experience reactive depression or grief, which often is expressed in diverse ways, including denial, anger, anxiety, panic, fear, dependent behavior, depression, and the unmasking of previously controlled psychopathology. The primary role of the psychologist is to assist the patient and the family in coping, as well as to counsel and consult with the rehabilitation team members in managing the emotional reactions. The effectiveness of psychosocial intervention has been successfully demonstrated with cancer patients.5,6 A chaplain or religious counselor is often included in the cancer rehabilitation team. This professional may be able to relate to the
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patient and the family in a way that can help them use their faith to adjust to the illness and disability. A vocational counselor should participate in the care of physically impaired cancer patients who have any potential of returning to work. An initial interview should be conducted at the hospital and vocational services continued after discharge. These services may include detailed evaluation, counseling, testing, career exploration, and educational planning. The counselor will have to proceed to the extent and at a pace that are sensitive to the patient’s need and readiness to resume vocational activities, whether education or employment. At the proper time, the counselor may make visits to work or school sites and consult with employers and teachers to facilitate the transition from disability to productivity as a worker or student. For school-age children, home tutoring may have to be arranged. Patients who are unemployed may be taught skills to seek jobs successfully. The Office of Vocational Rehabilitation (OVR) in each state can be a source of funding for various vocational rehabilitation services, that is, certain aspects of rehabilitation, education, training, job placement, and equipment and environmental modifications, if these will enable the disabled person eventually to return to school or work. The counselor makes the initial referral to OVR and maintains a close cooperative and effective relationship with the OVR representatives. The recreational therapist offers activities to meet the different needs and interests of disabled individuals both in and out of the hospital, such as art therapy, music therapy, attending art shows and sports events, going to theaters, eating at restaurants, and shopping. Family and friends may join in these recreational activities, which serve to enhance socialization, leisure-time activities, and positive attitudes. The trips into the community may facilitate the institutional discharge for the physically disabled person and re-integration into community life. FUNCTIONAL ASSESSMENT A medical intervention should not be offered unless measurable benefits will result. Unlike other fields of medicine, the outcome of rehabilitation interventions cannot be measured by survival or by the disappearance of symptoms. The effectiveness of rehabilitation interventions is judged by the patient’s degree of functional independence. The terms impairment, disability, and handicap have been carefully defined by the World Health Organization to clarify the impact of a physical deficit.7 Impairment is “any loss or abnormality of psychological, physical, or anatomical structure of function,” for example, paralysis. Disability is “any restriction or lack (resulting from an impairment) of an ability to perform an activity in a manner within the range considered normal for a human being,” for example, paralysis resulting in an inability to walk. Handicap is “a disadvantage for a given individual resulting from an impairment or disability that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual,” for example, the person is paralyzed and unable to walk and thus is unable to meet the requirements of the job and so cannot return to work. To assess and monitor function accurately, the performance in different activities of self-care, mobility, and communication must be numerically rated according to the patient’s level of independence: completely independent; independent with devices; requires assistance (supervision, “spotting,” reminding, physical help); or completely dependent. This requires the collection of numerous diverse data by various means, including physical examination, observation, and a review of records and reports from the various rehabilitation team members, as well as the gathering of information directly from the patient and family. Several evaluation scales exist. Some are simple and easy to use but provide incomplete information, whereas others are detailed but time consuming, as they address a whole range of quality-of-life factors, which include mobility, self-care, employment, income, education, family activities, living arrangements, and transportation. Computer technology has made the gathering, analysis, and plotting of data easier and has enabled clinicians to document the patient’s progress numerically, during inpatient and outpatient rehabilitation care. The functional evaluation scale that currently is gaining the widest acceptance by rehabili-
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tation professionals is the Functional Independence Measure (FIM) (Table 71.3).8–10 but for cancer patients, the Karnofsky Performance Status Scale has been most widely used (Table 71.4).11 A new scale developed specifically to measure quality of life and functional outcome for patients with cancer, the Cancer Rehabilitation Evaluation System (CARES) has been shown to be valid, reliable, and sensitive to changes in status.12,13 THE REHABILITATION PROCESS Rehabilitation services are frequently requested too late in the care of the cancer patient. The physiatrist should be consulted as soon as it may be anticipated that the cancer will result in a physical disability. The rehabilitation interventions may thus be planned and explained to the patient before, during, or immediately following definitive treatment. Physical and occupational therapy is initially provided at the bedside, but the patient should be mobilized out of bed as soon as possible and escorted to the rehabilitation area, where facilities and equipment are conducive to better performance. Other members of the rehabilitation team become involved in the care of the disabled cancer patient as deemed appropriate by the physiatrist. If these interventions allow the patient to become selfsufficient and ambulatory, he or she should be discharged home directly from the acute service, when medically indicated, having received proper instructions, equipment, and referrals for specific nursing interventions.
Functioning Independence Measure (FIM)
A more comprehensive and intensive rehabilitation program on an inpatient rehabilitation service is provided for physically disabled cancer patients who do not gain independence in ADL and mobility with daily therapy on the acute service, who are medically capable of actively participating in the program for at least 3 hours daily, and who are motivated and mentally capable of following instructions and learning the different tasks. The inpatient rehabilitation unit should be in a hospital with an inhouse physician on call and the various medical and surgical consultation services available at all times. Here the disabled cancer patient is re-evaluated by the physiatrist, who obtains a detailed medical and social history and performs a careful physical examination to assess the general medical and the precise musculoskeletal and neurologic condition, as well as the current functional ability. The physiatrist writes the routine medical orders, as for nursing care, medications, and disability-specific diagnostic tests, including radiologic studies, urologic evaluation, pulmonary function tests, electrodiagnostic studies, and blood and urine analyses. The physiatrist at this time sets the general rehabilitation goals and prescribes evaluation and interventions to be undertaken. The physiatrist prescribes the specific exercises and training methods to be given by the physical and occupational therapists, as well as interventions by the psychologist, speech pathologist, vocational and recreational counselors, and others when they are needed. The rehabilitation program begins promptly after transfer to the inpatient rehabilitation service. Initially, the actual participation of patients on the program may be impeded by the physical deconditioning or by special evaluations and tests, but after the first few days, 4 to 6 hours each day are spent in an active therapy program in addition to different ward activities, such as self-care training, management of bowel and bladder dysfunction, and educational and recreational activities. When serious medical complications arise during the course of rehabilitation that interfere with the patient’s ability to attend the rehabilitation program for at least 3 hours a day for more than 3 consecutive days, the patient should be transferred to the appropriate medical or surgical service for definitive care. Within 1 week of admission, an initial team conference is held at which the patient’s medical, functional, psychologic, social, vocational, and recreational status, as well as the rehabilitation potential and prognosis, are presented and discussed. More specific rehabilitation goals are set, needs for equipment and personal assistance are assessed, and a discharge date is predicted. Soon after this conference, the physiatrist meets with the patient and the family, together or separately, to discuss these issues and answer questions regarding the patient’s medical condition and rehabilitation program. Team rehabilitation conferences are held biweekly to discuss the patient’s progress and plans for discharge. While the patient is making continuous and measurable progress toward the set functional goals of independence in ADL and mobility, continued inpatient stay may be justified. Communication among members of the rehabilitation team, a most critical component, is facilitated through informal meetings during which specific concerns are shared and discussed. When a patient is discharged home, it is most important to ensure that needed equipment and supplies have been obtained, family members or home health aides have been instructed and trained in the patient’s care, follow-up by the visiting nurse service has been arranged, and referrals have been made for continued therapy and visits with various physicians, including the oncologist, surgeon, physiatrist, and family doctor. CANCER OF THE BRAIN
Copyright 1990 Research Foundation - State University of New York.
Brain damage may result from primary tumors of the brain, from metastatic disease, or from treatment of the cancer—surgery, radiation, or, more rarely, chemotherapy. The symptoms and disability that may result vary extensively but, in essence, are similar to those that are seen in patients who have sustained traumatic brain injury or a stroke involving different parts of the brain (Table 71.5). The main difference, however, is the potentially progressive or recurrent nature of the brain cancer and its uncertain prognosis. The greatest deficits are frequently seen immediately after surgery or during radiation and chemotherapy, after which remarkable improvement may occur. Late brain injury from radiation with infarction or necrosis also may occur, but the resulting dis-
Karnofsky Performance Status Index General
Able to carry on normal activity, no special care needed
100 90 80
Normal, no complaints, no evidence of disease Able to carry on normal activity, minor signs or symptoms of disease Normal activity with effort, signs or symptoms of disease
Unable to work, able to live at home and care for most personal needs, varying amount of assistance needed
70 60 50
Cares for self, unable to carry on normal activity or to do work Requires occasional assistance from others, but able to care for most needs Requires considerable assistance from others, needs frequent medical care
Unable to care for self, requires institutional or hospital care or equivalent, disease may be rapidly progressing
40 30 20 10 0
Disabled, requires special care and assistance Severely disabled, hospitalization indicated; death not imminent Very sick, hospitalization necessary; active supportive treatment necessary Moribund Dead
ability has a less favorable prognosis for recovery. All patients with brain cancer and impaired function in mobility or ADL should be referred for rehabilitation services. The majority can be helped with simple rehabilitation measures, whereas others may require comprehensive inpatient rehabilitation, which should be provided when longer life expectancy allows. Following definitive treatment of primary brain tumors in children, it has been shown that rehabilitation significantly improves outcome in self-care activities, transfers into and out of bed, and locomotion by a wheelchair or walking.14 Most commonly, the rehabilitation intervention starts after surgical resection or removal of the brain tumor. When medically stable, the patient should be helped to sit up, get out of bed, and start on an active restoration program that is designed according to the patient’s general condition. The location and size of the cerebral lesion clearly determine the clinical symptoms encountered. The variability of the symptoms precludes a standard rehabilitation approach but demands an individual evaluation and treatment plan. Broadly, the problems of patients with cancer of the brain are physical, psychological, social, and vocational. Table 71.5 gives a detailed list of problems that are most commonly found and are briefly discussed below. Paralysis, often in the form of hemiplegia, can be a conspicuous consequence of brain cancer. While the paralysis is most profound just after the brain surgery, a certain return of motor power is common and may continue for several weeks or months. As a rule, the earlier the return, the greater the recovery. However, muscles that are still totally paralyzed 4 to 8 weeks postoperatively generally remain so. At this point, functional improvement can still occur through physical training and provision of appropriate assistive devices (orthoses or canes). When the medical condition is unstable, the patient is kept in bed, resting on a firm mattress with a soft surface, such as sheepskin, to prevent pressure sores. He or she should usually lie in the extended position with the affected arm abducted, externally rotated, and slightly elevated. Joint range-of-motion exercises should be applied to the paralyzed parts and active exercises to the uninvolved parts twice a day. Mobilization training starts when the patient is ready to be transferred out of bed. Depending on the extent of the paralysis, the patient may be taught to ambulate with assistive devices or to maneuver a wheelchair. When the motor dysfunction is severe, the patient is first placed on a tilt table to decrease orthostatic hypotension and fear of the upright position, to stimulate antigravity muscles, and to improve body balance. Upon regaining some degree of body balance and lowerextremity strength, the patient is stood up between parallel bars for balancing exercises and early ambulation training. At this stage, the knee extensors on the affected side may be weak and require stabilization with a temporary knee-ankle-foot orthosis (KAFO), which locks the knee in extension for weight bearing. As the body balance improves and the patient has learned to lean consistently to his or her good side, ambulation outside of parallel bars can begin, with the patient using a broad-based cane carried in the unaffected upper extremity. Usually, some knee extensor strength returns, allowing the patient adequate knee support, but the ankle dorsiflexors and invertors still may be weak. Here a plastic ankle-foot orthosis (AFO) may be prescribed to prevent foot dragging during the swing phase of gait. This
orthosis is easily inserted into most shoes. It is cosmetically superior to the old metal orthoses and usually provides equal or better function. If knee extensor strength does not return, fabrication of a KAFO may be considered, but the prognosis for functional ambulation with such a device is poor. Training and elevation activities, such as climbing and descending stairs, ramps, or curbs, are started when a good gait pattern on level ground has been achieved. Patients with severe neurologic deficits may require a wheelchair, either for mobility at all times or only when ambulation endurance or safety is impaired. The major goal in the rehabilitation of the patient with cancer of the brain is independence in ADL, which may be obtained through training, prescription of proper assistive devices, and possibly modification of the patient’s clothing and the architecture of the patient’s home. Spasticity frequently interferes with mobility and performance of ADL. Factors that may aggravate the spasticity (e.g., skin lesions, infections, and anxiety) need to be identified and treated. Thorough stretching of all joints should be performed daily. Medications— dantrolene sodium, baclofen, or diazepam—may be of some benefit but should be used sparingly in view of their potential side effects. Selected nerve blocks with dilute solutions of phenol or motor point blocks with botulinum toxin are usually effective in reducing local spasticity, but surgical procedures for reduction of spasticity in patients with cancer of the brain are rarely indicated. Joint contractures, whether due to muscle imbalance, spasticity, poor nursing care, improper bed positioning or an inadequate exercise program, may change the rehabilitation prognosis significantly. A 10degree flexion contracture of the knee, for example, will greatly increase oxygen consumption during ambulation and thus markedly reduce endurance. Knee contractures that exceed 15 degrees will usually make functional ambulation impossible for the patient with brain cancer and hemiplegia. Development of a frozen shoulder may make independent dressing impossible. Prevention of contractures by proper joint range-of-motion exercises is imperative from the onset of the disability, since treatment of contracture is relatively ineffective. Pain in different parts of the body may be experienced in patients with neurologic deficits caused by cancer of the brain. Dysesthetic thalamic pain is notably refractory to treatment, although various centrally acting agents may be helpful. Pain with motion of the hemiplegic shoulder is common, perhaps due to muscle imbalance at the shoulder girdle and recurrent minor trauma to the periarticular structures. Table 71.5. Brain
Rehabilitation Problems Associated with Cancer of the
Paralysis Spasticity Joint contractures Pain Sensory deficits Visual field deficits Diplopia Aphasia
Dysarthria Aprosodia Dysphagia Ataxia Visual-perceptual deficits Cognitive and behavioral deficits Psychosocial-vocational problems
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Shoulder support by an arm sling or a lap board, administration of analgesics, application of heat or cold modalities, and gentle range-ofmotion and strengthening exercises may all help to reduce the pain and improve shoulder function. Complex regional pain syndrome, formerly known as reflex sympathetic dystrophy, may occur and requires similar treatment, but more effective relief may be obtained by simply administering oral steroids, for example, prednisone 5 mg four times a day for 2 to 3 weeks.15 Sympathetic nerve blocks may be performed when symptoms are more persistent. Sensory deficits of varying degrees are commonly seen in patients with brain cancer, either in the distribution of the cranial nerves or on one or both sides of the body. Cancer affecting the parietal lobes of the brain may cause severe sensory loss with little muscle weakness. This may interfere with balance and mobility since the patient who cannot feel motion is unable to control it. Although physical exercise cannot decrease the sensory loss, training with adaptive gait aids (i.e., canes, crutches, or a walker, and wearing of proper shoes) may help the patient to ambulate functionally again. Visual deficits, such as double vision or visual field deficits, are commonly seen as a result of cancer in the lower brain or above the tentorium, respectively. While double vision may improve spontaneously, the use of unilateral or alternating eye patches or special prism glasses may be helpful. The value of exercises for retraining the eye muscles is uncertain. Homonymous hemianopsia—blindness to the affected side of the body due to a contralateral brain tumor—rarely resolves spontaneously. While a patient with a left brain lesion usually learns easily to compensate for hemianopsia through scanning of the environment, the patient with right brain lesion may experience severe difficulties owing to accompanying anosognosia, that is, lack of awareness of the affected left side of the body and of the surroundings. Specialized programs of cognitive remediation have been found to be effective with these patients.16 Aphasia may be seen in patients with cancer in the left dominant hemisphere of the brain. This is an impairment of the central language process, with reduced capacity for interpretation and formulation of the symbols for communication. Although all components of language—listening, speaking, reading, and writing—are usually affected, they are not affected to an equal extent, and thus several types of aphasia are recognized.17,18 Expressive or nonfluent aphasia is caused by lesions in the Broca area of the brain and is characterized by reduced language production, vocabulary and use of grammar. The patient is well aware of these difficulties and becomes very frustrated. Less well known is receptive or fluent aphasia, which is caused by lesions in the Wernicke area of the brain. Here, the patient primarily has difficulty in understanding language, both his or her own, and that of others. The patient thus may be able to speak continuously at normal speed and with normal intonation without giving any pertinent information or being aware of the errors. Most aphasic patients, however, understand nonverbal sounds and enjoy listening to music, and frequently some automatic speech is retained. Different objective tests can be performed to assess the patient’s language and communication skills, but many patients perform better during a conversation than on such tests, since they may be able to grasp certain key words and successfully make guesses, as well as understand gesticulations, facial expressions, the tone of voice, and other situational clues. The efficiency of speech therapy is debated since most patients will have a degree of spontaneous improvement. Nonetheless, speech therapy is indicated, whenever available, not only for psychological support but also to provide the necessary stimulation for the patient to utilize his or her maximum speech ability, to adjust to new circumstances, and to instruct the family in proper communication with the patient by using short simple sentences at a normal voice volume, gestures and facial expressions, always with respect, optimism, patience, and encouragement. Dysarthria is a motor disturbance of speech, which implies weakness, slowness, or incoordination of the muscles that produce speech. Understanding written or spoken language is, therefore, never a problem. Articulation is usually the main problem, but speed, rhythm, sound, and intonation may also be disturbed. Mild dysarthria accom-
panies many brain cancers that involve cranial nerves and cerebrum and affect the facial musculature, but dysarthria is particularly prominent in brainstem tumors. Management, which is often successful, emphasizes teaching the patient to use the remaining speech muscles more effectively or to bypass the effects of disturbed function. First, the patient is guided in producing sounds, then words, and finally whole sentences. If speech still remains completely unintelligible, other communication methods are introduced, such as writing, typing, sign language, or pictures. Aprosopia is a little-known communication disorder that is seen with lesions of the nondominant right hemisphere.19 This condition relates to the inability to express and comprehend variations in pitch, rhythm, and stress, which give emotional meaning to speech. These patients may speak in a relatively flat voice and are often unable to recognize the emotional tones of speech, including the meaning of nonlanguage speech sounds, such as grunts or sighs. It is important for the clinician and the family to understand this deficit and to communicate with the patient strictly by words, since specific therapy does not exist. Considerable improvement usually occurs with time. Dysphagia, or impaired swallowing, is frequently seen in patients with brain cancer, especially when the brainstem is involved. In its most severe form, the patient may be totally unable to swallow, but in milder cases, there may only be difficulty with the swallowing of liquids. Aspiration with resulting pneumonia may occur, which demands careful evaluation of the condition and proper intervention. Serial radiographic swallowing studies should be done for proper monitoring of the condition until it is resolved or until other safer means of nutrition are established. A swallowing training program may be instituted by the speech or occupational therapist where the patient attempts to swallow food of different consistency using different techniques and positions. A nasogastric tube can be used for several weeks while waiting for spontaneous recovery, but a more persistent dysphagia warrants insertion of a gastrostomy tube for prolonged feeding. Neuropsychological changes may be prominent when cancer affects the cerebral hemispheres. Reduced memory and judgment frequently make successful rehabilitation impossible as the patient may be unable to remember instructions. Severe agitation may need treatment with a major tranquilizer, such as chlorpromazine or haloperidol. Visual perceptual deficits, caused by a central disturbance in organizing visual stimuli from the environment, frequently accompany right brain damage even when visual field and acuity are normal. These patients may experience difficulty in recognizing the three dimensions: depth and distances, the relationship of lines and objects, and vertical and horizontal lines. This may, in turn, affect different functions, including reading, understanding maps, recognizing familiar objects, and driving vehicles safely. Similarly, these patients may be unable to recognize the emotional significance of facial expressions, adding to the communication problems caused by the frequently accompanying aprosopia. There is a tendency to be impulsive and careless, to minimize or even ignore the problems in functioning, to make frequent mistakes, and often to neglect the left environment (anosognosia). Patients with lesions in the left hemisphere, on the other hand, usually act and learn slowly, make few mistakes, and are aware of their deficits, which frustrate them severely. In recent years, neuropsychological training programs designed to help patients overcome the visual, perceptual, and cognitive deficits have been reported as being successful.20 In addition, repeated neuropsychologic evaluations have been found to be sensitive indicators of recurrence.21 CANCER OF THE SPINE While primary tumors of the vertebrae (e.g., multiple myeloma) are uncommon, metastases to the spine are frequent. The spine is the most common site for skeletal metastases.22 At autopsy, 70% of patients who die from cancer demonstrate vertebral metastases,23 and more than 5% have evidence of metastatic compression of the spinal cord.24 This is usually an extradural anterior mass that involves bone. Intradural extramedullary tumors are usually histologically benign meningiomas or neurofibromas. Gliomas (i.e., ependymomas, astrocytomas, and medulloblastomas) are usually intramedullary, although occasionally they are also found in an extramedullary site. Although
the response to treatment is quite different for all of these histologically distant tumors, the neurologic symptoms, signs, and rehabilitation interventions are quite similar. Injury to the spinal cord and peripheral nerves is a recognized risk of therapeutic radiation that may not become manifest for many months, or even years.25 A transient radiation myelopathy primarily involving sensory neurons may occur in 10 to 15% of patients receiving mantle radiation for Hodgkin’s disease.26 This condition is usually associated only with sensory symptoms, such as paresthesias and Lhermitte’s sign, and resolves in 1 to 9 months.26 Delayed radiation myelopathy is an irreversible and progressive neurologic condition that may affect motor, sensory, and sphincter functions and has a reported incidence of 1 to 12%.27 CLINICAL PRESENTATION By far the most frequent presenting symptom of a tumor of the spine is pain. The pain may be localized, diffuse, or radicular in nature. It is characteristically made worse by activity and by straining. Different from more benign back pain, the pain caused by tumors tends to be persistent, to be present or even worse at night, and is not relieved by rest. Additional symptoms at presentation may be weakness of the legs, difficulty in walking, and urinary sphincteric problems leading to incontinence. Neurologic deficits may develop insidiously or occur suddenly, depending on the tumor’s rate of growth and location, or on the occurrence of a sudden pathologic fracture. Slowly progressive neurologic dysfunction is often seen with tumors of the lower spine that encroach on the cauda equina, whereas tumors of the thoracic spine may cause the sudden collapse of a vertebral body with direct compression of the spinal cord or of its blood supply. Although only half of all tumors of the spine are located in the thoracic region, these cause 70% of all spinal cord compressions that result in paraplegia. Such paraplegia may be neurologically complete, that is, with total paralysis and sensory loss below the level of the lesion. More frequently, however, the neurologic lesion is incomplete, with sensation and motor function preserved to varying degrees, as may be rated by the ASIA Impairment Scale,28 which is a modified version of the Frankel Scale.29,30 Impaired bladder and bowel control at first may present clinically as urinary urgency or hesitancy, but with progressive cord compression, urinary retention or bowel and bladder incontinence may occur. TREATMENT Proper rehabilitation management planning and intervention depend on an accurate diagnosis and staging of the tumor, just as does the medical and surgical management. Most patients with spinal metastases can and should be managed nonsurgically with radiation, chemotherapy, and orthotic stabilization of the spine, since it has been demonstrated that radiation alone provides results that are similar to those of surgery followed by radiation.31 In general, laminectomy with decompression has been found to be of limited use as compared with radiation, since the compressive lesion is usually located anteriorly to the cord, and the surgical procedure itself contributes to spinal instability. However, profound neurologic deficits, especially when occurring rapidly, may warrant surgical decompression, which preferably should be done by an anterior approach followed by surgical stabilization of the spine. Surgical decompression of the spinal cord is not very effective once the patient has become completely paraplegic. Surgical stabilization may often be indicated when gross spinal instability is present, as two of the three “columns” (anterior, middle, and posterior) of the spine have been destroyed by the tumor.32 The extent of surgical stabilization varies, depending on the patient’s anticipated life expectancy. Patients with short life expectancy (less than 1 year) benefit most from a relatively simple procedure employing methylmethacrylate, which allows immediate spinal stability and rapid mobilization of the patient, whereas patients with a more favorable prognosis may be better served by vertebrectomy, spinal instrumentation, and bony fusion in conjunction with methylmethacrylate.32 Spinal metastases and myelomatous lesions, even when accompanied by compression fractures and minor or modest spinal instability, can be successfully managed by spinal orthotic support and radiation. Both modalities may significantly decrease pain. Lesions in the cervical spine are most rigidly immobilized by a halo brace (Fig. 71.1) but also may be adequately supported by a SOMI brace (sternal-occipitalmandibular immobilizer) (Fig. 71.2). When such lesions are present in the upper thoracic spine, spinal orthoses may not be necessary, as this
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Figure 71.1. Halo-orthosis. (Reproduced with permission from Ragnarsson KT. Orthotics and shoes. In: Rehabilitation medicine: principles and practice. Joel A DeLisa, editor. Philadelphia: J.B. Lippincott; 1988).
part of the spine is stabilized inherently by the rib cage. Lesions in the more mobile lower thoracic and lumbar spine are often associated with severe pain. An adjustable thoracolumbar sacral (TLS) orthosis (Fig. 71.3) with posterior stays may provide sufficient support for less severe lesions, decrease pain, and allow greater mobility. The soft anterior portion of the corset, the apron, should fit snugly over the entire abdomen for optimal support. Larger lesions and postoperative conditions may require fabrication of a custom-molded plastic TLS brace, a two-piece removable orthosis (Fig. 71.4) that firmly grabs the pelvis below and the chest above. When neurologic loss has occurred, the rehabilitation therapy must be carefully individualized, on the basis of the extent of the neurologic dysfunction, the medical/surgical condition, and the patient’s life expectancy. Spinal cord dysfunction with severe or complete paralysis and sensory loss, and perhaps bladder and bowel dysfunction, warrants a comprehensive but relatively short-term rehabilitation program involving as many members of the rehabilitation team as judged appropriate by the physiatrist. The rehabilitation programs should be designed to address each of the many clinical complications and conditions that may be seen in individuals with spinal cord dysfunction of traumatic origin (Table 71.6). Early intervention should include bedside physical and occupational therapy, establishment of bowel and bladder training programs, and the application of nursing principles to prevent complications, such as pressure sores and joint contractures, that increase morbidity, worsen the functional prognosis, and prolong the rehabilitation phase. Proper positioning of the patient in bed and turning at least every 2 hours is of paramount importance in this regard. The patient and family are given emotional support and are educated in the medical aspects of spinal cord dysfunction and man-
Figure 71.2. Sternal-occipital-mandibular immobilizer (SOMI orthosis). (Reproduced with permission from Ragnarsson KT. Orthotics and shoes. In: Rehabilitation medicine: principles and practice. Joel A. DeLisa,editor. Philadelphia: J.B. Lippincott; 1988).
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Figure 71.3. Thoraco-lumbo-sacral orthosis (TLSO, Knight-Taylor brace). (Reproduced with permission from Ragnarsson KT. Rehabilitation of patients with physical disabilities caused by tumors of the musculoskeletal system. In: Tumors of the musculoskeletal system. Michael M. Lewis, editor. New York: W.B. Saunders Co.; 1991).
agement. If the prognosis is poor (i.e., less than 6 months) the patient is instructed early in the ADL skills, which he or she can quickly learn to perform, and provided with the necessary assistive devices, such as a wheelchair, nursing supplies, and personal assistance. As soon as medically appropriate, discharge from the hospital to the home or a nursing facility can be accomplished. When life expectancy is greater and the general criteria for admission to the inpatient rehabilitation service are met, the patient may be transferred there for a more comprehensive and intensive rehabilitation program. CANCER OF THE HEAD AND NECK Definitive treatment of cancer that arises from the skin of the face and neck or tissues of the nose, mouth, throat, and larynx may result in impairments in cosmesis, oral communication, feeding, and respiration, as well as affect the senses of sight, hearing, taste, and smell. These functional deficits may have major psychological, social, and vocational consequences if not adequately addressed early and managed properly. Surgical excision and reconstruction are frequently followed by radiation, which by itself may produce clinical problems, including skin erythema, blistering and peeling, edema, delayed wound healing, muscle atrophy and fibrosis with reduced mobility, nerve damage with weak muscles and sensory deficits, dry mouth, and bad or lost taste. Sensory deficits and radiation-induced skin changes require careful grooming and hygiene to prevent further skin damage, by using nonirritating soaps and cosmetic products, an electric razor instead of a
blade, lukewarm water for washing, loose-fitting garments, and similar measures. Meticulous oral hygiene is essential, and the patient should frequently use diluted mouthwash with 3% hydrogen peroxide but avoid all irritating agents (i.e., alcohol, tobacco, and astringent toothpaste) and should limit denture wear. A sense of noxious taste and dry mouth may be reduced by the use of artificial saliva and by increasing fluid intake. Mobilizing exercises for the mouth, jaw, neck, and shoulders should be emphasized to prevent adhesions and contractures. Cosmetic defects of the face are primarily treated by surgical reconstruction, but different types of maxillofacial prostheses may be custom-made from plastic materials to closely match the facial contours and complexion. Surgical resection of cancer involving the mouth, pharynx, and larynx may result in impaired functions of chewing, swallowing, and speaking in different proportions. Following resection of the tongue and mandible, physical exercise of the residual muscles may improve chewing and swallowing, and special tubes or utensils may help to place the food into the pharynx or esophagus and thus ease the swallowing process. Defects in the palate may be corrected by a prosthetic device, an obturator, placed between the oral and nasal cavities. Total laryngectomy results in a complete loss of voice and a permanently open tracheostomy.33 Preoperatively, a speech pathologist should meet with the patient to explain ways to communicate postoperatively. Communication is initiated postoperatively by using writing materials, communication boards, or electronic typing gadgets, but as early as possible the patient is instructed in the use of an artificial electrolarynx. Here, a hand-held battery powered “diaphragm” is placed firmly against the neck to transmit sound waves through the tissues into the mouth, where it resonates and may be articulated with relative ease as comprehensible speech. Greater training, however, is required to become proficient in the so-called esophageal speech, which is generated by trapping air in the upper esophagus by the tongue and releasing it suddenly into the pharynx, thus producing a “burp-like” lowpitched sound that may be articulated into words. Other patients may prefer pharyngeal speech, which is produced by capturing air within the mouth or pharynx. In some cases, a tracheopharyngeal shunt may be surgically reconstructed to restore a more normal voice.34 Due to the open tracheostomy, the laryngectomized patient is unable to strain during lifting, pushing, or defecation, except by manually closing the stoma. The permanent tracheostomy requires not only good local care, but also inhalation of humidified air through a stoma cover made of a piece of gauze that acts as a sieve for dust and other foreign materials. Certain laryngeal cancers may be treated with partial resection of the larynx, that is, hemilaryngectomy or supraglottic laryngectomy. Hemilaryngectomy removes one vocal cord, while supraglottic resection removes the epiglottis. The former is associated with a voice change that may be improved with voice therapy, whereas the latter is associated with impaired deglutition, which is restored with appropriate therapy. Aspiration pneumonia is a possible complication of laryngeal dysfunction. In paralysis of a vocal cord, autologous cartilagenous transcervical implant can restore phonation and diminish aspiration. Radical neck dissection may involve the removal of several neck muscles and temporary or permanent damage of the spinal accessory nerve that supplies the sternocleidomastoid and the trapezius muscles. Table 71.6. Conditions and Complications Associated with Spinal Cord Dysfunction
Figure 71.4. Custom molded thoraco-lumbo-sacral orthosis (TLSO), a two-piece removable plastic orthosis (“body jacket”). (Reproduced with permission from Ragnarsson KT. Rehabilitation of patients with physical disabilities caused by tumors of the musculoskeletal system. In: Tumors of the musculoskeletal system. Michael M. Lewis, editor. New York: W.B. Saunders Co.; 1991).
Loss of motor power Loss of sensation Pressure sores Urinary dysfunction Bowel dysfunction Sexual dysfunction Autonomic hyper-reflexia Pain Spasticity Joint contractures Heterotopic ossifications
Metabolic disturbances • Negative calcium balance • Negative nitrogen balance • Hormonal imbalance Circulatory disturbances • Orthostatic hypotension • Edema • Deep vein thrombophlebitis Respiratory disturbances Psychological problems Social problems Vocational problems
This is likely to result in gross asymmetry of the neck and shoulders, restriction of motion, overstretching of remaining muscles, and persistent pain if not treated early. During the rehabilitation of these patients, it is of primary importance to unload the shoulder immediately postoperatively, reduce shoulder and neck pain, and prevent stretch fibrosis of the trapezius and contracture of the unopposed pectoralis muscles, as well as to provide strengthening exercises for the residual muscles in the neck and shoulder girdle to compensate for lost muscles.35 The patient is instructed to maintain good posture, both while sitting and standing, and to pull back the shoulders frequently. Sleeping on the back is preferable, with proper support provided by pillows placed between the scapulae and under the posterior neck. Lying on the affected side is to be avoided, and when lying on the unaffected side, the affected arm should be slightly raised and supported on a pillow. Occasionally, it may be helpful to wear a sling, or even a shoulder orthosis, to compensate for trapezius paralysis. Therapeutic exercises are initially passive but gradually progress to active-assistive and eventually resistive exercises as tolerated by the patient. Strenuous physical activities, such as lifting, carrying, pulling, and pushing, should be avoided initially but may be resumed in the course of time as the physical condition improves. CANCER OF THE LUNG The physical disabilities associated with lung cancer and its treatment include respiratory insufficiency, shoulder pain and stiffness, scoliosis, and the remote effects of certain lung cancers that cause a neuromuscular disorder that becomes manifest as weakness and incoordination. However, the functional limitations associated with lung cancer frequently do not receive adequate attention and intervention because of the high mortality and short life expectancy associated with the disease. Reduced respiratory capacity after lung resection or pneumonectomy, especially when combined with pre-existing chronic obstructive pulmonary disease (COPD), may result in respiratory complications and insufficiency during both the postoperative period and the long-term follow-up. These may best be prevented by preoperatively teaching the patient deep-breathing exercises, segmental breathing, effective means of coughing, and the principles of postural drainage. On the first postoperative day, these activities are resumed with a physical or respiratory therapist to eliminate mucus, which otherwise might plug the bronchi and cause atelectasis and pneumonia. As the patient recuperates and becomes ambulatory, shoulder range-of-motion, general strengthening, and endurance exercises, as well as postural training, are added to the therapy program to increase strength and stamina and to prevent postthoracotomy scoliosis and scapulohumeral displacement.36 CANCER OF THE BREAST Breast cancer is usually treated with mastectomy or with lumpectomy followed by radiation, and often with chemotherapy. This treatment not only may result in considerable physical disability, but the woman’s self-image and emotional well-being may be adversely affected. The cosmetic impact of the loss of the breast, a symbol of femininity, is profound and adds to the emotional turmoil created by the cancer diagnosis and the uncertain prognosis of the disease. Radical mastectomy with removal of the pectoralis muscles, although now rarely performed, may cause shoulder weakness and, together with axillary node dissection, may produce swelling of the ipsilateral arm. Stiffness of the shoulder and hand may limit reach and manual dexterity. Fortunately, the recent trend of performing modified radical mastectomies or lumpectomies and routinely providing proper postoperative rehabilitation therapy has reduced the frequency and severity of these problems. Postoperative rehabilitation has three main goals: prevention of physical disability, restoration of cosmetic appearance, and psychosocial and vocational re-adjustment. Physical rehabilitation aims at improving muscle strength and mobility at the shoulder, minimizing arm swelling, and facilitating resumption of all functional activities—ADL, recreation, and work. Following radical mastectomy, the arm should be kept slightly elevated, with the shoulder abducted to 80 to 90 degrees and externally rotated, keeping the elbow free.37 The entire arm is compressed by a wellwrapped elastic Ace bandage, which is reapplied every 8 hours to reduce
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the swelling. Substantially less physical rehabilitation is necessary following modified radical mastectomy and axillary dissection, an operation that spares the pectoralis major and usually the pectoralis minor. Lumpectomy with axillary dissection requires even less physical and psychological rehabilitation, which may proceed at a more rapid pace. Depending on the extent of the mastectomy, physical exercises may be started within 2 to 5 days postoperatively. The nurse or therapist first instructs the patient in deep-breathing and relaxation exercises, and in how to move about in bed comfortably, and to get up and perform light self-care tasks using primarily the unaffected arm. Gentle exercises are started at this time, with the patient actively moving all the unaffected limbs, as well as the elbow, wrist, and hand on the affected side, and isometrically contracting the distal muscles (hand squeezing) while supine and with the affected arm elevated. When the drains have been removed from the surgical site, the exercises may become more demanding. The patient starts performing gentle active exercises of the affected shoulder while still in a supine position. Approximately 10 days postoperatively, when the sutures are removed, active or active-assistive shoulder exercises in the upright position are begun, that is, “wall climbing” exercises using the uninvolved arm or an overhead pulley system to ease the task. Upon discharge, the patient receives a series of exercises to perform at home to ensure that full shoulder mobility and maximum strength will be regained. Cosmetic restoration following mastectomy involves either surgical reconstruction of the breast or provision of a prosthesis. During the initial postmastectomy period, a temporary Dacron-filled prosthesis may be provided, but a more definitive prosthesis can be furnished when the surgical incision is well healed, usually 1 or 2 months following the surgery.38 Reconstruction is usually done several months after surgery, following the completion of chemotherapy and radiation, although immediate reconstruction at the same operation after mastectomy and axillary dissection has many advocates. Reconstruction is particularly indicated in younger women who have good life expectancy but whose self-image has suffered due to the mastectomy, although neither age nor an uncertain prognosis should be a contraindication to this procedure. Simple and temporary fillings of soft materials may be inserted into the brassiere initially for cosmetic effect, but a permanent prosthesis is ordered 2 to 3 months postoperatively, or after completion of the radiation therapy. Lymphedema of the arm after radical mastectomy is seen in approximately 10 to 15% of patients, although relatively mild or moderate arm swelling is much more common, especially in the early postoperative days. Lymphedema is less common after modified radical mastectomy, and rare after lumpectomy, even though both procedures do have axillary dissection. When lymphedema is severe, it may result in both a significant disability and a disfigurement. While surgical removal of lymph nodes and lymph vessels or their destruction by radiation undoubtedly is the major etiologic factor, a number of other contributing factors may play a role, including infection, inflammation, scar formation, obesity, thrombophlebitis, arm dominance, and habitual dependent position of the arm. The greatest incidence of lymphedema has been noted among those who received high-dose radiation or had a history of one or more infections.39 Prevention of lymphedema with proper postoperative care and initiation of an exercise program, as outlined above, is most important because treatment of persisting lymphedema is relatively ineffective. Such treatment usually involves different physical interventions: performing, several times a day, sets of isometric exercises of all the arm muscles while the arm is maintained in an elevated position, and using sequential pneumatic compression with a multi-compartmental inflatable sleeve.40 These modalities help to pump the fluid from the hand and distal arm toward the body. Many hours of pump use may be required each day to reduce the edema significantly. Compression therapy by manual massage of both the edematous41 and the contralateral arm42 has also been advocated but is considered by some to be time-consuming and inefficient.43 Between periods of use, the arm should be carefully wrapped with elastic bandages, and when maximum reduction of the edema has been obtained, a custom fitted elastic support sleeve should be fabricated and worn continuously. The entire limb should be guarded
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against even trivial trauma, which may be caused by constricting garments and excessive heat or exercise, to minimize swelling. Treatment with these physical modalities has been shown to benefit the majority of patients with postoperative lymphedema and is more effective than diuretics, salt-restriction diets, benzopyrones, or surgical procedures.42–44 Benzopyrone has been reported to cause a slow but safe reduction of high-protein lymphedema of the extremities by stimulating proteolysis by macrophages.45 CANCER OF THE GASTROINTESTINAL TRACT The cancer rehabilitation team is involved in the care of the patient who has cancer limited to the gastrointestinal tract when the definitive surgical treatment has resulted in an ostomy. The enterostomal therapist (ET nurse) plays a major role in helping the cancer patient with an ostomy (i.e., colostomy, ileostomy, or urostomy) to understand the principles of ostomy care, to learn the different aspects of ostomy management, and to adjust to the altered self-image. After surgery, the patient is placed on a diet of clear liquids, which is followed by full fluids, and later solid food. What constitutes a well-balanced diet and the importance of a high-fiber, low-fat diet are discussed. It is best to increase the diet’s fiber content gradually to avoid gas formation and bloating, by adding fruits, vegetables, and whole-grain food in slowly increasing amounts. COLOSTOMY The surgical treatment of cancer of the rectum usually mandates the creation of a colostomy, using the sigmoid colon. A cancer higher in the colon can frequently be resected and the bowel reconnected by anastomosis. Before undergoing a surgical procedure for cancer that will result in a colostomy, the surgeon needs to discuss the plans carefully with the patient. Subsequently, the ET nurse should meet with the patient and family members to explain in simple but clear terms the nature of the colostomy, for example, where the stoma will be located on the abdominal wall, how it will look, what coverings and collection appliances will be needed, how evacuation will occur, and so on. A positive attitude on the part of the medical and nursing staff is important at this time, although the patient’s fears and concerns regarding function, appearance, and sexual activity need to be acknowledged and discussed. Detailed and explicit explanations, particularly regarding the surgical procedure and subsequent care, should be based on a patient’s individual needs. Too much information that the patient is not ready to absorb may do little except increase anxiety. A visit by a person who is successfully managing his or her colostomy may be very helpful. Good preoperative preparation reduces the patient’s fears and builds confidence, both of which will facilitate postoperative rehabilitation. Postoperatively, protecting the skin and collecting the drainage should be the primary goals. This is accomplished by a properly fitted appliance. Modern appliances with protective skin barriers cut to fit the exact size of the stoma will avoid postoperative peristomal skin excoriation and keep the patient dry and odor-free. A person with a colostomy has a choice of allowing the bowels to function normally or to irrigate as a method of attempting to control bowel movements. Often, the bowel habits return to normal patterns, and a well-fitting appliance may be emptied or changed as needed. Proper fit of an appliance by an ET nurse allows the patient to make an informed choice, as the appliances are odor-proof and disposable, and have protective pectin skin barriers attached to keep the peristomal skin healthy and free of irritating discharge. The patient may choose to learn irrigation techniques, but these cannot always be taught in the hospital setting, given the current pressure for early discharge. Outpatient ET services and/or visiting nurses often teach or continue to teach irrigation in the home after discharge. The purpose of the irrigation is to establish a bowel routine, with the goal of evacuating only after the irrigation, rather than spontaneously or at inopportune moments. However, this is not always possible. Therefore, the patient should always be instructed in the care and use of a properly fitted appliance. This may help the patient to avoid the frustrations that usually are experienced when bowel discharge continues between the irrigations. Irrigation of the colostomy may be done
daily, every other day, or even every third day, at the time of the patient’s preference. Initially, a full hour should be allocated for the irrigation and evacuation, although later 30 minutes may suffice to complete the task. The first irrigation is an important event that requires both sensitivity and technical skills on the part of the ET nurse. The irrigation should be done in private, preferably with the patient sitting by the toilet on a comfortable soft chair. A lubricated cone is gently inserted into the stoma and 1 liter of lukewarm tap water is instilled over a period of approximately 10 minutes from an enema bag placed no higher than at shoulder level, similar to administering an enema. The water distends the bowel, causing peristalsis and expulsion of stool. Following evacuation, the skin is cleansed with warm water and patted dry. The pouch is re-applied. A family member may want instructions in colostomy care, both to understand the patient’s plight and to be able to assist or take over the care during periods of illness. The patient and the family are provided with information on the United Ostomy Association, and its local chapters and publications, as a resource for further information Numerous clinical problems may arise at any time after the creation of a colostomy. Constipation is often due to inadequate intake of fluids or dietary fiber but may be successfully managed by increasing dietary fiber and fluid intake. Diarrhea may be caused by different foods (spicy, greasy, or fried foods; certain vegetables, fruits, and juices) or anxiety but small amounts of liquid stools may indicate incomplete evacuation or the presence of impacted feces. Excessive gas formation also may result from the ingestion of certain foods (baked beans, onions, greasy food) or other factors which need to be identified and treated appropriately. Noxious odor may be increased by various foods and liquids (cabbage, eggs, onions, garlic, beer, coffee). Each person must experiment with different foods. What may adversely affect one person may not affect another. Deodorant tablets placed in the disposable colostomy pouch may help to diminish odors. Skin excoriation and maceration will usually respond to appropriate local care by gentle washing with soap and water and applying a properly fitted appliance. Skin infections may be caused by fungi or bacteria. Fungal infections should be treated with mycostatin (Nystatin) powder and bacterial infections by administering topical or, occasionally, oral antibiotics. Stomal bleeding in small amounts is usually of little concern, but if persistent, mixed with stools, or in large amounts, it will require proper diagnostic evaluation and intervention. Sexual dysfunction after abdominoperineal resection is common, not due to the colostomy per se but due to damage to the autonomic nerves in the pelvis sustained during extensive surgery. The altered self-image often associated with the colostomy can cause temporary sexual dysfunction. Men may become impotent and women anorgasmic, while sexual desire is not lessened.46 Sexual counseling for both partners, good communication, and the teaching of new techniques for mutual gratification can do much to restore successful sexual activity. The colostomy patient will normally experience a reactive depression or grief and subsequently go through the different stages of adaptation that are associated with any kind of major personal loss. The colostomy’s negative influence on the patient’s self-image is best counteracted by the physician and the ET nurse when they are able to make an accurate assessment of the patient’s complaints and condition, plan actions and interventions accordingly, and provide supportive counseling on an individual basis.47 ILEOSTOMY The principles and techniques of ileostomy care are similar to those of colostomy. The stools are of a loose consistency and drain continuously from the ileostomy. It is, therefore, necessary that the collecting pouch be worn at all times and that it be properly fitted by an ET nurse. Small bowel contents contain active digestive enzymes, which can cause severe peristomal skin excoriation if leakage occurs. The collecting pouch must be emptied as needed, usually every 3 to 6 hours, by releasing the clamp from the bottom of the pouch and emptying the contents directly into the toilet. Since the fluid loss through ileostomy is greater than with colostomy, fluid intake must be increased to prevent dehydration. There are no dietary restrictions except to avoid corn and peanuts, but the food should be eaten slowly and chewed well to prevent food blockage. A greater loss of electrolytes and certain vitamins, especially B12, may also be experienced, thus requiring regular
monitoring and supplementation. Certain coated medications and timerelease capsules may pass through the gut without being digested, a fact to be considered whenever physicians prescribe medications for individuals with ileostomy. In general, the psychosocial adjustment and rehabilitation outcome for an individual with ileostomy are similar to those after any surgery that requires alteration of elimination habits and results in living with a stoma. CANCER OF THE GENITOURINARY SYSTEM Invasive cancer of the bladder frequently requires radical cystectomy and the creation of a new outlet for urine. More than 40 years ago, Bricker developed the ileal conduit procedure by connecting the ureters to an isolated segment of ileum, which is surgically closed at one end but opens at the other as a stoma on the abdominal wall, allowing free elimination of the urine. This procedure has become the traditional form of long-term urinary diversion. The management principles of ileal conduit stoma care are similar to those of colostomy and ileostomy. Since urine flows continuously from the stoma, the collecting system must be well fitted and watertight to prevent leakage. The collecting pouch must have a drain valve for easy emptying and for connecting to a night-time urine collection bag. Skin or stoma problems from the urine are not uncommon and may be caused by alkaline urine. Many physicians prescribe vitamin C, 1,000 mg daily, to keep the urine slightly acid. The intake of 8 to 10 glasses of fluid daily is important. In recent years, the continent urostomy has gained considerable popularity when used with compliant patients. The Kock pouch and the Indiana pouch, with several modifications of both procedures, result in an internal reservoir.48–53 The patient inserts a catheter into the stoma every 4 to 6 hours to empty the internal pouch contents. This procedure eliminates the need for external devices. GENITAL CANCER Members of the cancer rehabilitation team may occasionally be asked to provide care for a patient with cancer involving the genital organs, or when the cancer and its treatment have caused sexual dysfunction. Rehabilitation interventions usually involve carefully planned reconstructive surgery and psychological and sexual counseling. The form of surgical reconstruction varies, depending on the type of the cancer and the extent of the surgical resection but also on the specific needs of the patient. The woman who has undergone radical gynecologic surgery with resection of the vagina may benefit from vaginal reconstruction that allows resumption of sexual intercourse.54 The man who is unable to achieve penile erection can be prescribed sildenafil, taught intrapenile injection of vasodilating drugs to cause erection when desired, or rarely nowadays have a penile prosthesis implanted.55 The choice of prosthesis is between semirigid silicone rod implants and a system of inflatable cylinders implanted into the shaft of the penis, with the scrotal pump and fluid reservoir placed in the abdominal wall.56–58 The implantation of the semirigid rod is a relatively simple surgical procedure with few mechanical problems, but the penis stays semierect permanently. The inflatable prosthesis provides a more normal appearance of the penis both when flaccid and erect, but mechanical problems with the system arise quite often. Cancer of the testes is usually treated with prompt surgical excision of one or both of the testicles, followed by radiation and/or chemotherapy. Surgical implantation of a prosthetic testicle at a later date may be gratifying for patients concerned about their appearance and self-image. Sexual rehabilitation obviously is not limited to those who have cancer affecting the genital organs, but should be available for anyone who experiences sexual dysfunction for physical or psychological reasons due to cancer and its treatment. Different members of the rehabilitation team collaborate in providing sexual counseling for patients with different forms of cancer, both on an individual basis and by organizing courses and seminars on the physiology and anatomy of sexual function, on human sexuality, and on ways of adjusting to sexual dysfunction. Male sexual impotence compounds the reactive depression associated with the diagnosis of cancer and adds to the stigma of any physical disability. This condition is frequently met with prejudice and poor understanding on the part of both the patient and his sexual partner. Sexual rehabilitation emphasizes that sexuality is considered part of the whole person and cannot be lost due to an illness or injury. Phys-
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ical disability, in contrast to a physical illness, does not decrease sexual drive, although it may affect sexual function both physically and psychologically. The anatomy and physiology of sexual function should be carefully explained to the disabled patient and his partner and general guidelines for success given. Good communication and strengthening of relationships between sexual partners are emphasized. The different physical aspects of sexual performance are explained in order to make expectations compatible with performance capability. For most cancer patients with a physical disability, impairment of mobility, sensation, continence, and erection should not interfere with building a solid personal relationship, with having sensitivity to the partner’s desires, or with being able to please and enjoy. Sexual rehabilitation is built on the concept that if sexual comfort is taught, sexual competence may result.59 Manual and oral sexual acts may be appropriate for both sexes. No treatment or rehabilitation of the patient with cancer can be considered complete until the clinician has adequately addressed the impact of the condition on sexual function. Sexual health cannot be separated from total health. The extra time spent considering sexual adequacy and providing guidelines for help can benefit the patient for years. CANCER OF THE LIMBS Primary malignant tumors of the limbs require surgical treatment. The main surgical goal is to remove the tumor, either by an excision with wide margins through a site well clear of any malignant growth, or by a radical removal of the entire bone or the compartment afflicted by the tumor. A subsequent surgical goal is to reconstruct the resulting defect for optimal function and cosmesis. Although limb amputation has been practised for centuries, in recent years, limb salvage by extended local or regional excision and reconstruction has been the principal goal. The survival and disease-free survival after both types of surgical approaches are similar and have been vastly improved in recent years by the use of chemotherapy, radiation, or both. The return to optimal function can best be assured by a multi-disciplinary rehabilitation team approach that includes the surgeon, the medical and radiation oncologists, the physiatrist, and all the members of the rehabilitation team.60 Skeletal metastases are more common than primary bone tumors.61 Metastases to the limb bones are less common than those to the spine. While some patients may complain of localized pain, others are essentially asymptomatic until a pathologic fracture occurs. Such fractures occur in approximately 10 to 15% of patients who have radiographic evidence of skeletal metastasis. Pathologic fractures are most debilitating and often result in diminished survival for otherwise stable patients.22 At particular risk are women with metastatic breast cancer, patients with advanced metastatic disease, and those with a large single lytic lesion eroding the bony cortex.62 Active rehabilitation and physical mobilization do not seem to increase the fracture risk significantly. When prognosis suggests many months of anticipated function, prophylactic surgery for impending fracture of the femoral neck or shaft often diminishes the total disability consequent to pathologic fracture and more difficult surgical repair. Prophylactic surgery is otherwise generally not warranted but radiation may have some effect in reducing pain and limiting tumor growth.63 If pathologic fracture occurs, open surgical treatment with adequate internal fixation and conjunctive use of methylmethacrylate may be employed successfully to relieve pain, restore mobility, ease nursing care, and provide psychological reassurance.64 Postoperative immobilization should be brief, and aggressive physical therapy should be started early to return the patient swiftly to previous function, as well as to minimize hospitalization. PREOPERATIVE REHABILITATION Rehabilitation care should start immediately after the diagnosis of primary cancer of a limb is established, regardless of whether amputation or limb-sparing surgery is planned for cancer removal, or whether chemotherapy and radiation are to be instituted pre- or postoperatively. The implications of surgery and the postoperative course should be discussed at this time with the patient and family. Simultaneously, an appropriate physical exercise program should begin. These interventions during the emotionally stressful preoperative days may ease the patient’s adjustment and reac-
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tion to the postoperative course. Emotional support is best given by recognizing the patient’s fear and anxiety and by providing in a positive way some practical information and explicit factual instructions that can be easily understood and followed. While it is important that the positive aspects of the surgical treatment be explained (i.e., that it is a swift, life-saving technique, and that modern technology and training allow significant restoration of function), it is best for the physician to resist overly optimistic predictions and to discourage unrealistic hopes until postoperative rehabilitation success has been ensured. On the other hand, pessimistic statements as to what the patient will never be able to do are needless and are usually inaccurate. A time frame is provided for postoperative rehabilitation efforts and possible return to various functional activities, taking into consideration the extent of reconstruction, level of amputation, general physical and mental status, age, athletic ability, and lifestyle. Peer counseling by a successful rehabilitated amputee may further help the patient to anticipate postoperative events and function. When amputation or limb-sparing surgery is planned, the exact level of amputation and the surgical approach should be thoughtfully chosen, taking into account not only the location and type of cancer but also the probability of good wound healing and the successful fitting of a prosthesis, when required. It may be helpful for the surgeon to consult with the physiatrist and prosthetist for this purpose. Preoperatively, strengthening exercises should be started for muscles in the uninvolved extremities and the trunk, as well as for muscles to be spared in the affected limb. Specifically, the patient should learn to perform isometric exercises for the quadriceps and gluteal muscles. Strengthening exercises for the unaffected limbs should focus specifically on shoulder depressors and elbow extensors, which are critical for ambulation with crutches or walkers. Trunk-strengthening and balancing exercises may further ensure postoperative ambulation success. Ambulation with a walker or a pair of crutches, non–weight bearing on the affected limb, should be practised preoperatively while the patient has no fear of falling because of lack of limb support and is not impaired by incisional pain, medications, or postoperative complications. Such preoperative therapy not only will help the patient succeed swiftly in postoperative ambulation and self-care activities, but a quick restoration of function will ease the emotional adjustment to the disability, whether it be amputation or limb sparing with an internal prosthesis. LIMB AMPUTATION Limb amputation for cancer at one time was discouraged, as the prevailing opinion was that poor life expectancy did not justify the expense of surgery and prosthetic fitting. However, the 5-year survival for patients who have undergone amputations for limb cancer (49%) compares favorably with the survival of patients with amputations for limb ischemia,65 and the functional skills of cancer amputees are reportedly better than the skills of those patients who have had amputations for other reasons.66 Until recently, amputations for cancer were done in a radical fashion and left little, if any, residual limb, except when amputating for very distal limb tumors, since the basic clinical rule was to amputate proximally to the joint immediately above the tumor site. Lower-limb amputations for cancer involving the knee joint or thigh thus were frequently performed by a hip disarticulation or hemipelvectomy, and upper-limb amputations by shoulder disarticulation or interscapulothoracic (forequarter) amputations. These radical limb operations were believed to be mandatory due to the high risk of metastasis, especially metastasis to the lungs. Modern diagnostic techniques now can demonstrate the presence or absence of metastases with a high degree of accuracy. According to a recent survey, since the use of adjuvant chemotherapy, sarcomatous metastases are not as common as was previously thought.67 Thus, less extensive amputation techniques can now be employed, such as cross-bone amputations with 3 to 4 inches of normal bone left as the margin. Greater residual limb length thus results, and functional outcome is better for most patients. Accordingly, primary cancer in the distal femur now permits an amputation through the proximal femur, a cancer in the proximal tibia permits amputation in the mid or distal femur, and cancer in the distal tibia allows a below-
knee amputation (BKA). Analogous amputation levels may be appropriately considered for cancer of the upper limbs. While maximum preservation of limb length compatible with eradication of the cancer is desirable, certain amputation levels may result in residual limbs that are difficult to fit and, therefore, best avoided, such as the hind foot, the distal third of the leg, and the femoral supracondylar region. It is critical to preserve the knee joint, if possible, to ensure smoothness of gait, lower energy cost, and better function. Whenever possible, 12 to 18 cm of tibia should be retained for optimal prosthetic fitting, but even a very short BKA that retains the tibial tubercle will preserve knee extension by the quadriceps muscle, and preservation of the knee joint will provide the needed position sense. This amputation level is, therefore, better than amputating above the knee. When the fibula is retained, it should be cut slightly shorter than the tibia. Disarticulation at the knee is also preferable to above-knee amputation (AKA), as it provides a wide weight-bearing surface, long lever arm, and proprioception. Unfortunately, this level often cannot be chosen due to intra-articular spread of cancer located in the mid or proximal tibia. It is preferable to have the AKA stump as long as possible to preserve maximal adduction power. Prosthetic knee joints can accommodate any length of femur. A residual femoral length that is less than 8 cm from the greater trochanter to the tip functions poorly. As a rule, hip disarticulation is preferred to an amputation level above the lesser trochanter. Hip disarticulation and hemipelvectomy need reconstruction with a long posterior flap in order to create a proper sitting area on the prosthesis.68 When provided with a wellfitting plastic laminated socket and an endoskeletal modular-design prosthesis, persons with hip disarticulation are able to stand, walk, and sit quite comfortably. Hemicorporectomy (translumbar amputation) has been performed on rare occasions on patients with widespread cancer of the pelvis, but without metastases elsewhere. This procedure is a challenging alternative to the nonsurgical approach and has been shown to have a good rehabilitation outcome.69 Cancers in the upper limbs unfortunately are primarily found in the proximal humerus and require shoulder disarticulation or interscapulothoracic amputation. Here, it is important to retain quality skin and maximum muscle mass for padding the shoulder, but retention of the humeral head, if possible, will result in better prosthetic fitting. Successful prosthetic use depends to a large extent on proper surgical techniques of amputation.70 It is not adequate only to provide a long residual limb, although this is important for both leverage and large total contact area for weight bearing. Optimally, the residual limb should be firm and tapered or cylindrical in shape, with all bone ends well padded. The skin must have good innervation and vascular supply and not be adherent to bone or have sensitive scars. Postoperative care should ensure optimal wound healing, minimize limb swelling, prevent joint contractures, and improve muscle strength and function. Application of appropriate dressing and external pressure on the residual limb is very important.71 Wrapping with the customary elastic bandages must be done skillfully with frequent re-applications to maintain maximum sustained pressure and to avoid a tourniquet effect. Different forms of semirigid dressings have been used, such as Unna paste dressings, custom-made elastic “stump” socks, plastic films, and inflatable air splints, each of which has different advantages and disadvantages. Inflatable and removable air splints, recently popularized, are made of clear plastic and have a zipper, which allows easy inspection, attachments, and removal. An elastic plaster bandage may be applied to the residual limb immediately after the amputation. This immediate postsurgical fitting is a rigid form of dressing that can effectively reduce edema and postoperative pain. A prosthetic pylon and foot can be attached directly to the plaster to allow standing within 2 days postoperatively. Initially, only minimal weight bearing is allowed, but progressive ambulation is continued and full weight bearing may be possible in 3 to 4 weeks.72 Several disadvantages of this technique have made it difficult to implement. A removable rigid dressing provides for easier inspection of the residual limb, dressing change, and adjustment for progressive shrinkage and may even allow attachment of a temporary adjustable prosthesis.73,74 POSTOPERATIVE EXERCISE PROGRAM Physical and occupational therapy should be initiated within 2 days after the amputation. The pre-
operative exercise program is resumed for muscle strengthening and joint mobilization. Knee flexion contractures may easily develop after BKA, whereas hip flexion and abduction contractures are frequently seen with short AKA. Mobilization is started at the bedside, but within a few days, the patient is taken by wheelchair to the therapy area, and ambulation in parallel bars or with a walker is started. The skillful amputee is subsequently provided with a pair of crutches; however, when prosthetic fitting has been completed, a single cane will usually suffice. Different types of ready-made or prefabricated temporary prosthetic devices exist for the earliest ambulation efforts, but a custom-fitted provisional prosthesis should be provided as soon as the surgical incision has healed. The amputee, however, may be discharged from the hospital even without a prosthesis, if the patient is ambulating safely with assistive gait devices and is independent in ADL. Transfer to the inpatient rehabilitation unit for more intensive therapy may be advisable at any time before these two goals are reached if the amputee is otherwise medically stable. PRESCRIPTION OF AN ARTIFICIAL LIMB The physician needs to consider multiple factors when prescribing a limb prosthesis. The amputation level and limb condition clearly are of primary importance, but prosthetic candidacy may be affected by numerous other factors, including associated medical conditions, other physical disabilities, life expectancy, muscle strength and coordination, stamina, various psychological factors (i.e., motivation, emotional adjustment, and cognition), and individual lifestyle factors (i.e., age, weight, family support, recreational interest, environment, and type of work). The extent of prosthetic usage is to some degree predictable, since each symptomatic medical problem adversely affects functional prognosis. The ability of the patient to ambulate with a walker or a pair of crutches, but without a prosthesis, strongly suggests prosthetic candidacy. After carefully considering these different factors, the physiatrist may have to choose between a prosthesis that provides relatively greater safety with stability and one with greater function and mobility, between durability and low prosthetic weight, besides considering differences in cost and cosmesis. When new or advanced designs are chosen, the skill and expertise of the prosthetist are crucial factors, and the prosthetist must be easily accessible to the patient as well. Most prostheses are currently fabricated from metals and plastics. The customary below-knee (BK) prosthesis consists of a socket, shank, and ankle-foot components, as well as a suspension system. The socket usually has a patellar tendon-bearing (PTB) design and total contact with the residual limb for maximum pressure distribution. Soft liners inside the socket add comfort by absorbing shocks. Several layers of socks may need to be worn to accommodate a shrinking residual limb. The shank is either of an endoskeletal design with an internal metal pylon or an exoskeletal structure made from laminated plastic. The solid ankle cushioned heel (SACH) foot is simple, durable, lightweight, and cosmetic and is still most commonly prescribed despite the arrival of a variety of new energy-storing prosthetic feet, such as the Seattle and the FLEX feet designs. The prosthesis is usually attached to the residual limb by a supracondylar cuff, although several other alternatives exist. The above knee (AK) amputee traditionally obtains a prosthesis with a rigid quadrilateral socket and a posterior ischial seat for additional weight bearing. More modern socket designs promise greater comfort in sitting and better control during ambulation.75 The popular single-axis knee joint with constant friction is simple and durable, whereas the more costly and complex polycentric or hydraulic knee units can provide better function for young, physically active amputees. Stability of the knee joint during stance may be increased by posterior placement of the knee axis, but for maximum safety, manual or automatic knee locks may be added. The AK prosthesis optimally is suspended by total suction, or by partial suction and a Silesian bandage or a pelvic band. An endoskeletal pylon connects the knee unit above to the prosthetic foot below. After a hip disarticulation, the amputee receives the Canadian-type prosthesis, which has a plastic laminated socket encircling the pelvis. This provides a resting surface for the ischial tuberosity for weight bearing. With proper molding, it is suspended from the iliac crest. A similar prosthesis is worn after hemipelvectomy, with the rib cage providing the weight-bearing surface.
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Cancer in the upper limb frequently requires shoulder disarticulation or interscapular thoracic amputation, both of which make fitting the patient with a functional body-powered prosthesis difficult or impossible. Myoelectrically controlled and externally powered prostheses may provide some gross function, but such prostheses are relatively expensive, are heavy, and require repair more often than body-powered prostheses. In recent years, prosthetic techniques for all types of amputations have advanced significantly, especially with respect to evaluation methods, socket design, ankle-foot components, and cosmesis.76 PROSTHETIC FITTING AND TRAINING Before completion of the prosthesis, the amputee needs to visit the prosthetist several times to ensure optimal fit, function, and comfort. When fabrication has been completed, the prescribing physician checks the prosthesis for fit and comfort, socket stability, joint motions, appearance, and function. The lower-limb amputee receives gait training, with or without gait aids, depending on motor skills, instructions in attachment and removal techniques, and exercises to increase muscle strength, joint range of motion, balance, and posture. The upper-limb amputee learns to open and close the terminal device, position the arm, manipulate objects, and perform self-care tasks. Initially, a prosthesis may not be worn comfortably for more than 15 to 30 minutes at a time. The amputee thus requires frequent rest periods and short therapy sessions. After each wear, the skin of the residual limb must be examined for signs of excessive pressure or poor socket fit. At the beginning of prosthetic wear, confrontational situations may develop between the amputee and the health professional, especially when the patient’s expectations do not match the actual situation. New and increased demands may produce discomfort at the prosthesis–user interface and in other body parts. Disappointment with the final appearance, weight, ease of wear, level of comfort, and functional limitations of the prosthesis is common. The health professional needs to understand the adjustment process and assist the amputee by paying attention to legitimate complaints, providing encouragement, and making judicious adjustment to the prosthesis. Poor communication may force the amputee to obtain a new, but often no better, prosthesis elsewhere. Various deviations of gait occur with lower-limb prosthetic use due to problems with the residual limb, inadequate prosthetic fit, psychological reactions, and improper training. These need to be carefully analyzed and proper intervention offered. Lower-limb amputees ambulate at greater energy costs than do nondisabled persons.77,78 The BK amputee expends 23 to 68% more energy per unit distance than does an able-bodied person, and the AK amputee expends 52 to 124% more.79 However, to save energy, most amputees decrease their speed of ambulation, which is approximately 2.0 to 2.5 mph for BK and 1.0 to 1.5 mph for AK amputees, as compared with a normal speed of 3 to 4 mph for nondisabled persons. The lower energy cost and greater speed of ambulation for the BK amputee clearly show the importance of sparing the knee joint whenever possible. Patients with hip disarticulation or hemipelvectomy ambulate with lower energy expenditure if they use axillary crutches without a prosthesis, as compared with prosthetic use.79 Various clinical problems may occur as the result of the amputation and consequent prosthetic wear, including pain, skin lesions, swelling, joint contractures, and mental depression. Most amputees experience phantom sensation, which is a painless awareness of the amputated part. In contrast, phantom pain may be described as burning, crushing, cramping, or shooting sensations in the amputated phantom limb. The reported incidence of phantom pain has varied between 10 and 85%.80 This variation may be due to differences in classification of the types of pain,81 the fear of presumed mental illness if a phantom pain is reported,80 and the time delay since surgery.82 The pain may be aggravated by limb contact and different physical activities, but the exact cause remains unknown, as no detectable pathology or premorbid emotional problems are usually discovered. Phantom pain83 may be preventable or effectively managed by careful preoperative explanations of the nature of the phantom phenomenon, good surgical techniques, regular examinations postoperatively, and frequent manual handling and good care of the stump, as well as by
984 SECTION 21 / Principles of Rehabilitation Medicine
effective treatment of stump infections and early provision of a functional prosthesis. Definitive treatment, however, is difficult, but symptoms usually improve when a relatively normal situation has been restored. Other beneficial interventions include desensitization by frequent self-inspection and manipulation of the residual limb, application of superficial heat or cold, deep heating with diathermy, massage, vibration, TENS, imaginary exercises of the phantom limb, active exercises of the entire body, local anesthesia, and psychological interventions. Analgesic medications are relatively ineffective, but agents acting on the central nervous system may be helpful. Actual and localized pain in the residual limb occurs frequently after amputation for various pathologic reasons, such as infection, scar adhesion, muscle spasm, or poor socket fit. Skin reactions occur frequently under the prosthesis and require meticulous care. The limb should be gently washed with soap and water and thoroughly dried each evening rather than in the morning. The prosthetic socket should be cleansed with a moist soapy cloth, and socks should be washed immediately after removal and thoroughly dried before they are worn again. The residual limb should be kept dry and free of trauma to prevent maceration. Talcum powder is often used to keep the skin dry and smooth, but cocoa butter may be applied to lubricate the scar. During early prosthetic wear, the amputee may frequently experience skin maceration, abrasions, blisters, and infections of hair follicles and sweat glands, each of which requires specific treatment. Open, draining, or painful skin lesions require discontinuation of prosthetic wear until healing has occurred. Gradually, the skin will toughen with regular prosthetic use, and skin problems become fewer in the course of time. Reactive depression and grieving the limb loss may be anticipated, but these reactions are compounded by the cancer’s uncertain prognosis. Early restoration of function and psychological support provided by the entire health care team may be the best intervention, although psychiatric treatment may occasionally be indicated. LIMB-SPARING SURGICAL RECONSTRUCTION Local resection of cancer with limb-sparing reconstruction may result in survival, diseasefree survival equal to that for amputation, and function which is superior.84,85 Amputation, however, is still a primary treatment for many limb tumors since it may, at times, be impossible to perform a proper resection while preserving key nerves and vessels and to reconstruct a functional limb. Limb-sparing reconstructive surgery obviously is an attractive alternative to amputation for both cosmetic and emotional reasons, but it should only be undertaken if it will restore better and longer-lasting function than amputation with subsequent prosthetic fitting.86 Depending on the location and size of the tumor, it may be a difficult procedure where muscles, bone, and even joints are removed with the tumor. The cancerous bone may be replaced by transplanting a fresh frozen cadaveric bone allograft or an autologous graft, but more commonly by installing a synthetic metallic prosthetic implant.87–89 An expandable and adjustable prosthesis may now be installed in growing children, who formerly were felt to fare better with amputation.90 Just as when amputation is planned, all patients should be carefully told preoperatively what degree of function to expect after the limb-sparing operation. Rehabilitation interventions preferably should begin preoperatively when physical and/or occupational therapists should first teach the patient the muscle-strengthening, range-of-motion, and ambulation exercises that will be resumed postoperatively. Following lowerlimb-sparing surgery, the patient may begin exercising the uninvolved limbs on the first postoperative day but the initiation, pace, and intensity of exercises and the amount of weight bearing for the affected limb depend on the exact mode of reconstruction and the postoperative course. In general, continuous passive motion (CPM), active-assistive exercises, and weight bearing as tolerated may be allowed 6 to 10 days postoperatively, if no surgical complications occur and no specific contraindications exist. During rehabilitation and a 2.5-year follow-up of 17 children who underwent resection of malignant bone tumors in the lower limbs with insertion of expandable prostheses, 7 of these children walked without any assistive devices, but 10 required knee orthoses, crutches, or both for ambulation.29 Following upper-
limb–saving surgery, active hand and isometric shoulder muscle exercises are started on the first postoperative day, but if humeral resection is performed, active elbow and shoulder exercises should not begin for 2 or 8 weeks postoperatively, depending on whether a metallic implant or allo-/autografts, respectively, are used. It is thus of primary importance that the rehabilitation staff know exactly which muscles, nerves, and bones were resected, and what the reconstruction entailed, to plan a safe and effective rehabilitation program. Training in ADL is initiated approximately 1 week postoperatively. Prior to discharge, a decision is made as to whether the patient requires a permanent orthosis or other assistive devices to compensate for lost function. Following discharge, most patients are referred for continued therapy and are given specific instructions for exercise and other activities at home. CONCLUSION Management of cancer appropriately focuses on prevention, early diagnosis, and cure, but following effective treatment, most cancer patients experience some physical impairment that results in a physical disability or a handicap. As the prognosis for most types of cancers improves, it becomes more important to ensure that all cancer patients regain maximum function in the broadest sense to ensure return to all former roles. Multi-disciplinary rehabilitation, therefore, is an integral part of the total management of the cancer patient. The exact functional deficits need to be identified for each patient and proper rehabilitation interventions started promptly or at the same time as other treatments. REFERENCES 1. 2. 3. 4. 5. 6. 7.
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