REHABILITATION OF ONCOLOGICAL PATIENTS

  1. Rehabilitation of oncological patients
  2. Rehabilitation of lymphedema

A. REHABILITATION OF ONCOLOGICAL PATIENTS

Patients will be evaluated by the rehabilitation doctor at Hospital Quirón in order to define the current deficiencies (such as pain, weakness, lymphedema, limited mobility, polyneuropathies, myopathies…) leading to the current disability. Patients will be prescribed a rehabilitation and physiotherapy programme with realistic objectives in accordance with the referral oncologist.

1. MOST FREQUENT ILLNESSES: by tumour, treatment or concomitant.

  1. Lymphedema
  2. Respiratory illness: atelectasis, pneumonia, superinfection, chronic obstructive pulmonary disease, emphysema, bronchiectasis, asthma… thoracic, abdominal, cardiovascular surgery, traumatisms.
  3. Circulatory illness.
  4. Rheumatological illness: arthrosis, osteoporosis, back pain, shoulder pain, inflammatory arthritis… Deformities: kyphosis, scoliosis, dystrophies…
  5. Traumatic illness: vertebral compression, hip fractures, proximal third humeral fractures, distal radial fractures.
  6. Myopathies. Neurological illness: cerebrovascular accident, polyneuropathies, spinal cord compression (vertebral fracture, epidural cuff).

2. INTERDISCIPLINARY TEAM

                                    

The interdisciplinary team, coordinated by the oncologist, will offer this specific therapeutic programme for specific deficiencies, during which frequent clinical control of the patient is maintained and therefore communication with the oncologist for information on the progress made, as well as for any intercurrent complication which may occur.

3. REHABILITATION PRESCRIPTION

Depending on the patient´s clinical situation (base illness, comorbidity, secondary effects of treatment received), they will benefit from rehabilitation treatment aimed at functional recovery or at improving their comfort and quality of life.

The rehabilitation will fit within one of the three phases described below, although a patient may go through several stages of the illness and modify the rehabilitation programme between:

3.1. Rehabilitation of patients CURRENTLY IN TREATMENT

Patients in chemotherapy treatment

The therapeutic objective is to prevent and treat symptoms, try to maintain the functionality of the patient, to resist chemotherapy treatment and ultimately, to improve quality of life at all times.

An attempt will be made to coordinate chemotherapy with an individualised rehabilitation programme to treat disorders that may occur such as generalised, localised fatigue; muscular atrophies; myopathies or polyneuropathies…

Objectives of RHB:

  • Respiratory exercise programme.
  • Maintaining total free joint movement; or treating if there is joint limitation, capsulitis, joint retraction…
  • Muscle strengthening.
  • Improving tolerance to stress.
  • Encourage the psychological benefit of the patient undergoing rehabilitation.

3.2. Post-TREATMENT Rehabilitation

After chemotherapy treatment the patient may be very week or have muscular atrophies or some osteoarticular or neurological complication specific to their illness or chemotherapy.

In this context, the patient may benefit from a general conditioning programme and functional readaptation to try and compensate for the side effects and sequelae of the applied treatment, and when possible, to try and recover their previous functional level or the maximum possible recovery for its sequelae.

3.3. Rehabilitation AFTER SURGERY

The objective of rehabilitation after surgery may be:

  • Prevention: e.g. following a breast tumorectomy or mastectomy rehabilitation is recommended to avoid limitation of shoulder mobility secondary to axillary scarring.
  • Treatment: e.g. lymphedema following an axillary clearance.

Under certain circumstances and in accordance with Oncology, patients suffering from lymphedema will be offered the opportunity of carrying out a maintenance programme with the possibility of repeating the treatment on an annual basis.

3.4. PALLIATIVE Rehabilitation

Patients without the possibility of curative treatment may present a combination of symptoms and deficiencies and are offered the following therapeutic programmes:

  • General maintenance: mobility of the four limbs; muscle strengthening exercises.
  • Programme of realistic functional objectives and as long as the situation allows it: e.g. if the patient wants to be able to eat by himself/herself; a bedridden patient that wants to sit in an armchair; moving to go to the bathroom…
  • Comfort. Relaxation.

4. ADVICE ON ORTHOSIS AND TECHNICAL SUPPORT

  • Pressotherapy clothing
  • Foot drop splints
  • Walker (wheels, articulated); crutches; wheelchairs.
  • Home respiratory physiotherapy devices, etc.

5. CIRCUIT OF ONCOLOGICAL PATIENTS TRIBUTARY OF REHABILITATION TREATMENT.

The rehabilitation will be carried out in the following units, coordinated by the oncologist according to the clinical situation of the patient. Rehabilitation is offered under the following regimes:

  1. Outpatient: as the majority of patients affected by lymphedema in the upper limbs; respiratory physiotherapy; other illnesses; traumatological, neurological…
  2. Hospital: rehabilitation to try to improve respiratory function, general autonomy; postoperative rehabilitation…
  3. Home: with the objective of functional recovery or comfort, depending on the progression on the disease.

REHABILITATION OF LYMPHEDEMA

Lymphedema is the accumulation of excess fluids in the body caused by the obstruction of lymphatic drainage mechanisms. Its treatment includes decongestion of reduced lymphatic pathways to reduce the size of the limb.

CLASSIFICATION

There are several classifications according to their aetiology, clinic, topography etc. The most commonly accepted aetiological classification is currently: (Jiménez Cossio, 1987):

  • Primary: spontaneous onset or following a trigger due to congenital absence of lymphatic tissue or abnormality in its development. It can be hereditary (Milroy’s disease) or non-hereditary (early or late).
  • Secondary: caused by obstruction or interruption of the lymphatic system. The most frequent cause is post-surgical, mastectomy in women, prostatectomy in men. Other causes are malignancies, phlebolymphedema and infections (filariasis).

The most frequent aetiology of lymphedema is secondary to the treatment of breast cancer.

INCIDENCE

It can appear at any time following surgical intervention, not only in the immediate postoperative period, but also years later.

The risk of developing lymphedema is directly related to surgical treatment but it increases when radiotherapy is joined with surgery. Its incidence varies from a third of breast cancer patients (Brorson) to an incidence of 20-25% (Campisi) which would increase to 35% when both techniques are used. Others speak of a range between 6% and 70% of mastectomised patients. Sentinel node biopsy would considerably reduce morbidity compared with axillary clearance. Exogenous factors that may influence its appearance, such as obesity, old age, sedentary lifestyle, inflammatory or infectious upper limb processes, inadequate surgery or lack of hygienic-dietary methods have also been suggested.

The period with the highest risk of the appearance of lymphedema is 6 months after intervention.

REHABILITATION TREATMENT OF LYMPHEDEMA

The treatment of lymphedema is symptomatic, individualised and long term. At the moment there is no curative treatment.

The objectives of lymphedema treatment are:

  • Decreasing volume
  • Reducing symptoms
  • Avoiding progression and complications.

Types of rehabilitation treatment

1. Methods of prevention, hygiene and lymphedema care

2. Kinesiotherapy and postural treatment of lymphedema

3. Manual Lymphatic Drainage

4. Low stretch bandages

5. Intermittent Sequential Pneumatic Pressure Therapy

There is currently not sufficient evidence to establish conclusions regarding the best physical treatment to be used in the treatment of lymphedema (Badger, Cochrane 2008).

Research studies agree on the importance of the beginning of early rehabilitation, as a functional recovery of the limb is achieved in the short term. A multidisciplinary lymphedema treatment programme is recommended.

2.1. Lymphedema prevention methods. Hygiene. Skincare. Recommendations.

  • Postural methods in the immediate post-operative period: drainage position (45º slope) of the corresponding limb in the immediate postsurgical period.
  • They are explained to the patient, who is given a sheet with the following recommendations (see annexe II).
  • Kinesiotherapy (daily exercises): the recommended exercises for lymphedema are explained to the patient, who is given a graphic diagram.

The skin is the entry point for multiple infections that can give rise to a bad evolution of lymphedema. The patient is given a series of recommendations:

1.      Use of topical agents

2.      Precaution at work and at home

3.      Recommendations regarding clothing, diet and personal care

4.      Medical standards

2.2. Manual lymphatic drainage (MLD)

This is a technique to help drain the accumulation of lymph from tissues through a lymphatic system that has become incompetent. Firstly, a series of light abrasions will be performed, followed by two manoeuvres: call or evacuation manoeuvre and reabsorption or capture manoeuvre. Lastly, manipulations will be executed that will differ depending on the body part to be treated.

MLD has not been proven superior to pressotherapy, but somewhat better than simple lymphatic drainage in improving discomfort and a sensation of heaviness, although not in reducing the volume.

2.3. Pressotherapy. Support stockings.

External compression increases interstitial hydrostatic pressure and reduces the tendency for edema formation. Elastic bandages are used during the time in which MLD is being carried out, and the use of bracelets (sleeves) and gloves are subsequently indicated.

2.4. Kinesiotherapy and postural treatment of lymphedema.

This consists of active aerobic mobility in 30 minute sessions. It is carried out daily with containment measures. Swimming and avoiding tiring exercises are also recommended. Respiratory exercises are also useful.

Best: PRESSOTHERAPY + COMPRESSION SLEEVES + EXERCISES (2-3 times a day for 30 mins)

  1. Manual Sociedad Española de Medicina Física y Rehabilitación (SERMEF) 2006 (Manual Spanish Society for Physical Medicine and Rehabilitation)
  2. Asociación Española Contra el Cáncer. (Spanish Association Against Cancer) https://www.aecc.es/Comunicacion/publicaciones/Documents/Guia_linfedema_2010.pdf

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