REP 12 - Sometimes, You Don't Know What You Don't Know...
Our family is very fortunate to live in a small, tight knit, lake-side community in Quebec where everyone knows one another and cares for one another. Knowing that I work in Oncology, I‘ve been approached many times by family, friends and neighbors who pass by my dock and stop to seek professional advice on cancer –related problems.
- I feel tired all the time following my cancer treatment last year….Is that normal? Should I be concerned? Can exercise help?
- I seem to have lost a lot of muscle and strength lately even though my scans have been normal following cancer treatment. Should I join a gym and be training?
- I beat breast cancer but have recently developed low back pain at night. Do I need physio and can I drop by for you to give me some exercises to do?
In my willingness to help, I’m often tempted to give some generic advice and offer to do a casual consult even though a small voice at the back of my head says:
“ You may be out on the limb ….. do you have sufficient information to give advice or prescribe treatment…..you’re liable for your actions even though this is a casual consult! ”
I’m certain that many physiotherapists in our profession are in the same boat.
A case in point is the following. ….Recently, one of our neighbors pulled me aside at a cocktail party to chat about his father who had been newly diagnosed with a rare hematological cancer. His father was in process of being treated with experimental chemotherapy at one of our specialized Oncology Centers and staying with their family for the duration. He assured me that he was in good hands medically, but his son was very stressed and concerned about his father’s level of fatigue, weakness, shortness of breath, and inability to engage in his normal activities. His greatest wish was to be able to fish and play golf once again.
I commiserated with him and told him that I’d research the type of chemo his father was on and see if the side effects could be causing some of his functional disability. It was tempting to assure his son that these side effects of treatment are likely transient and that, in the interim, he might try to gradually increase his activity levels by joining a gym and exercising in small bouts until he feels better….Safe Generic Advice???
How wrong I would have been! Thankfully, I stopped in my tracks as a good Samaritan after his son sent me this information.
- The diagnosis was apparently advanced disease given the nature and indications for use of the type of chemotherapy prescribed. The treatment was only indicated for patients in whom all other types of chemo had failed or were contraindicated and designed to slow the disease process down…not cure it.
- His father had preexistent heart disease at age 73 for which he was extensively medicated.
- The chemo his father was receiving was highly cardiotoxic
- His heart rate at rest was 110 and skyrocketed as soon as he stood up. Shortness of breath was constant.
- His feet were constantly numb and he was losing his balance regularly and this was a common adverse reaction to the chemotherapy
Having received this information, I was certainly reluctant to intervene without consulting his medical team but nonetheless suggested that I do a formal consult. But my concerns about being “out of the medical loop” continued to haunt me.
Another case in point was that of a young neighbor (45years old) who had completed her chemotherapy 3 years ago and wanted to know if her recently developed thoracic and low back pain were just the result of a lack of exercise.
Once again, it would have been very easy to reassure her that “Exercise is Medicine” and that an increase in activities would help. How wrong I would have been once again!
Exercise is NOT an innocuous intervention in patients who have or have had cancer. Yes, numerous studies have shown that exercise increases function, survival and quality of life. But what they fail to point out is that these studies were done on highly selective populations where patients at risk where excluded!
The questions that we need to ask ourselves are whether or not we can educate, treat, or prescribe exercise safely at distance from the medical treatment team and without access to detailed patient files? The stage of disease and risks associated with treatment are often a moving target….particularly in case study #1….. and I would never have had sufficient information to provide a safe follow-up.
I believe that many physiotherapists find themselves in these awkward “casual consult “situations. In doing a screening consult, we often do not conduct a thorough clinical assessment but rather a quick few tests and basically treat the problem at face value……… Sore back? Exercise is best. Lost muscle?......build it up. Hands and feet are numb?.. Contrast baths may help!
Also, the fact that these patients fall outside of our usual practice settings, we commonly fail to open a home file and carefully record our findings on examination and the details of treatment or exercise prescribed.
Given the risks associated with cancer and its treatment the liability is significant. Patients on many different types of chemotherapy are essentially at risk for developmental myocardial infarct and/or pathological fractures related to treatment induced skeletal fragility. We need to have this basic knowledge in our clinical arsenal given the incidence (1 in 2 lifetime diagnosis in Canada) and prevalence of cancer in Canadian society at present.
What does a basic course in Oncology Rehab give you?
It provides clinicians with the general oncology background needed to assess and treat patients with present or past history of cancer and sets a framework for adapting their clinical skills to the management of cancer –related functional problems.
Cancer rehabilitation is not just a peripheral specialization any longer but rather relevant to ALL clinicians who work in Hospital, home care, or private clinic settings whenever they treat patients with a history of past or present diagnosis of cancer. The pathophysiology of cancer and impact of treatment (surgery, chemotherapy, radiation) on cardiovascular, musculoskeletal and neurological systems including the development of pain, fatigue, muscle wasting, articular and skeletal dysfunction is significant. Specific problems related to common disease sites including breast, prostate, colon, lung, and hematological malignancies need to be recognized and dealt with accordingly.
Education is the key to safe practice and practicing with sufficient information is the key to risk management.
We need to:
1. Recognize and understand the unique rehabilitation needs related to:
- Cancer diagnosis and treatment
- The specific effects of surgical, chemotherapeutic and radiation protocols on functional capacity including: generalized hematological and metabolic alterations, disease and treatment related muscular weakness, cancer pain, cancer fatigue, and neurological dysfunction
- Dysfunction commonly associated with specific cancers including: breast, lung, and hematological cancers.
2. Derive assessment protocols based upon:
- Outcome measures validated in the cancer population
- Clinical observations related to the common side effects of cancer
- Physical examination and functional testing appropriate to the disease trajectory
3. Derive intervention strategies based upon realistic goals and client-centered outcomes which may include not be limited to:
- Biophysical modalities
- Therapeutic exercise
- Manual therapy
- Functional activity training
The reflex of assuming that many of the treatment modalities in our clinical “bag of tricks” are contraindicated in patients with cancer is patently false and frankly doing patients a great disservice. We have any interventions that have been shown to be of great benefit to a wide variety of cancer patients with all disease stages. WE simply need to know
How to be in the know?
The oncology division has developed a Guide to Oncology Physiotherapy Resources which can be found in the Practice Resources section (for member’s only.)
What’s In the Guide?
- The focus is oncology physiotherapy, and not cancer in general.
- In addition to the general topic of oncology physiotherapy, specific cancers and areas of practice are included when available.
- The focus is on resources for physiotherapists to use in practice, and particularly the value of physiotherapy for people with cancer.
- All settings are included from acute care to rehab and outpatient, and home.
- While there is a focus on Canadian material, information from other English-speaking countries is included.
- There is a focus on English-language material; French-language and multilingual versions are noted when possible.
Priorities for the Oncology Division in 2019 include:
The first meeting of the National Education Committee was recently to begin the task of identifying core and more advanced competencies in Rehabilitation Oncology. The group has prioritized the task of creating an inventory of: Who's teaching? What's being taught? Weighting (elective versus core curriculum) and content differences between Universities? Content of courses being taught privately? As well as courses/lectures available on the Web. In the coming months, we plan to circulate a national survey which will serve as a basis for harmonizing education in rehabilitation oncology and help promote the need for all physiotherapists to have a basic knowledge of cancer and its impact on function and quality of life.
The Oncology Division Newsletters:
What the focus for 2018 -2019 is (e.g. review of specific cancer presentations and the role of PT)
To be in the know, join the Oncology Division
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