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Oncology Basics:

Creative Adaptations to Promote Activity for Patients with Cancer

Kelly Guich, MS, OTR/L, CEIM

June 1, 2013

© 2013 Memorial Sloan-Kettering Cancer Center All Rights Reserved.

This presenter has no conflict of interest to report regarding any commercial product/manufacturer that may be referenced during thisthat may be referenced during this presentation.

Objectives

Understand:

Practice framework and relevance of adaptations.

Unique OT needs of patients in the acute oncology and palliative care settings.

Barriers patients with cancer experience requiring creative interventions.

Areas of oncology that frequently require adaptations.

Examples of custom adaptations OT’s can fabricate for patients with cancer during all phases of treatment.

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Practice Framework

The Person-Environment-Occupation Model

Add ll 3 f t t t l ti Address all 3 factors to create a solution

Allows for implementation of care at different levels and in any context1

Practice Framework

The Occupational Therapy Intervention Process Model

Implementing adaptive occupations for

Compensation

Remediation2

Occupational Therapy in Oncology

The role of Occupational therapy in oncology is “to facilitate and enable an individual patient to achieve maximum functional pperformance, both physically and psychologically, in everyday living skills regardless of his or her life expectancy”2

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Occupational Therapy Approach in Oncology Care 3,4

Intervention methods to:

Remediate

Compensate

Adapt

Cancer or the treatments involved in one’s care may lead to changes in physical, cognitive, and emotional well-being 3

Research has shown:

Adequate post-operative adaptations will maximize long-

Impact of Cancer Treatment on Performance

term function

Rehabilitation can improve patient’s feelings of stability and activity levels”5,2

Problem-solving interventions might be needed to resolve obstacles to the proper management of cancer pain 6

Orthotic Fabrication 7,8,9

Orthopedic reconstructive surgeries for tumor removal

Plastics reconstruction for tumor removal and tissue transfers

Plastics reconstructive surgeries with free flaps

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Role of Fabricating Orthotics for Reconstructive Surgeries 7

Occupational Therapy is consulted for immobilization of the graft site

Plastic surgery and Orthopedic surgery work Plastic surgery and Orthopedic surgery work together with OT to determine appropriate positioning

Once integrity of the graft is proven, maintaining joint and muscle integrity becomes the priority

Goals of OT for Patients Requiring Custom Orthotics

Immobilization of the joint

Protection of the flap/circulatory system

BADL

Education

Optimal positioning

Forearm Supination Orthosis with Adapted Positioning

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Extensive Forearm Graft

Extensive Forearm Graft Orthosis

Lower Extremity Orthotics

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Adapting Multi-Podus Boots

Scrotal Edema 10,11

A variety of disorders may cause scrotal inflammation

Male patients become significantly uncomfortable, limiting functional activity

Goals of OT for Patients Experiencing Scrotal Edema

Creation of custom supports

Education

BADLBADL

Functional mobility

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General Custom Scrotal Support

Custom scrotal supports assist with decreasing edema gand increasing patient comfort with functional activities.

Unique Case: External Hemipelvectomy 12

Amputation of lower extremity at hip level

Multiple limitations

OT goals: Scrotal edema

management

Increasing OOB, mobility and BADL

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Role of OT in Adapting Durable Medical Equipment 13,14

Modifications for post-surgical patients: Provide optimal positioning and pressure relief

Increase comfort to promote healing and activity

Common modifications: Commodes, cushions, and wheelchairs

Patient and family education is essential for carryover

Orthopedic Surgeries Requiring Seating Adaptations

Hemipelvectomy

Sacrectomy Partial or complete removal

of the sacrum

Att h t t l b Attachments at lumbar

vertebra and ilium

OT goals: ADL modification

Balance

Cushioning needs

Image: Stubblefield MD, O’Dell MW, eds. Cancer Rehabilitation Principles and Practice. New York: Demos Medical; 2009.

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Adapted Cushions

Modified Wheelchair Leg Rest

Modified Wheelchair Leg Rest

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Other Unique Adaptations 15

Helping patients to live their days to the fullest while maintaining a sense of control and dignity are the primary contributions of occupational therapy in the management of cancer-related treatments 18

Uniqueness of the individual and their obstacle preventing activity or independence is priority

Always consider psychosocial needs

Barrier: Preventing Complications While Improving Mobility in Patients with Head

and Neck Cancer

Patients that undergo surgical interventions for tumor excisiontumor excision

Plastic surgery team requirements for the patient to remain in specific positions to promote healing 16

Solution: Head and Neck Support

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Barrier: Pediatric Patients with Ongoing Chemotherapy Treatments

Some patients will require MediPort placements for easeplacements for ease with multiple future treatments.

Image: MSKCC 2013

Solution: Protective Chest Plates

Barrier: Incontinence & Self Catheterization

Numerous diagnoses may cause incontinence

May increase family burden and decrease patient independence

Altered self image

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Solution: Self Catheterization Mirror

Barrier: Altered Body Image After Surgerical Procedures

Some surgeries may result in a change in the structure and visual appearance of the body

Psychological affects on body image can influence self esteem, functional activity, independence, and work/social involvement

Solution: Cosmetic Adaptation

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Barrier: Protecting Surgical Sites

Surgeries may require multiple operations over an extended period of time

Healing of the first surgery is essential before the next surgery can take place

OT’s consulted to assist in assuring protection of the surgical site while awaiting the next operation

Solution: Protective Orthotic

Documentation and Billing

Custom Orthoses

L Code Splint/Orthosis

L0100 Cranial helmet

L3906 Custom wrist splint

L3702 Elbow splint

Adaptations without L-codes Orthotic fit and train (i.e. pediatric chest plate)

Self care/BADL (i.e. scrotal support)

Evaluation

L3913 Hand/finger splint

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Conclusion Cancer treatments can significantly affect an individual’s

performance in daily activities or restrict the ways in which they are able to move

Creative custom designs or adaptations to existing resources are required in acute care to improve patient’s participation in occupations

OTs in oncology are challenged to create unique splints and positioning devices to maintain specific precautions set by the surgeons post operatively

OT practitioners provide holistic comprehensive interventions and adaptations that focus on a patient’s goals and ability to successfully participate in their lifestyle choices and improve quality of life during and well beyond their Cancer experience

Thank you

References1. Jones, Stubblefield, M. (2004). The role of knee immobilizers in cancer patients with femoral neuropathy. Archives of Physical

Medicine & Rehabilitation. Feb; 85 (2): 303-7.

2. Hughes, CW., Godden, D., Perkins CS. (2003). "Splinting the radial forearm free flap donor site." British Journal of Oral & Maxillofacial Surgery. Jun; 41(3): 193.

3. American Occupational Therapy Association. (2011). The role of occupational therapy in oncology. Retrieved from www.aota.org/Practitioners/PracticeAreas/MentalHealth/Fact-Sheets/OT-Role-

4. Penfold, Sarah, L. (1996). The role of the Occupational Therapist in Oncology. Cancer Treatment Reviews , 22, 75-81.

5. Kielhofner, G. (1998) Model of Human Occupational Therapy and Application. Baltimore: Williams and Wilkins, pp. 232-241.

6. Law, M. (1996). The person-environment-occupation model: A transactive approach to occupational performance. No. 63).

7. Caulfield, RH., Maleki-Tabrizi, A., Birch, J., Ramakrishnan, V.(2008). "A Novel splinting technique to protect free flaps in major limb trauma." The Journal of Trauma. Mar; 64 (3) E:44-6.

8. Saint-Cyr, M. and Langstein, H. N. (2006), Reconstruction of the hand and upper extremity after tumor resection. J. Surg. Oncol., 94: 490–503. doi: 10.1002/jso.20486

9. Selber, JC., Treadway, C., Lopez, A., Lewis, VO., Chang, DW. (2011). "The use of free flap for limb salvage in children with tumors of the extremities " The Journal of Pediatric Surgery April;46(4):736-44tumors of the extremities. The Journal of Pediatric Surgery. April;46(4):736-44.

10. Brooks JD. Anatomy of the lower urinary tract and male genitalia. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell's Urology. 8th edition. Philadelphia: Saunders; 2002: 41-80

11. Conn, H. (1972). Unilateral edema and jaundice after portacaval anastomosis. Annals of Internal medicine, 76, 459-461.

12. Stubblefield MD, O’Dell MW, eds. Cancer Rehabilitation Principles and Practice. New York: Demos Medical; 2009

13. Stewart, A. (1994) Empowerment and enablement: occupational therapy , 2001. BI: Journal of Occupational Therapy. 57 (7): 248-254.

14. Vallerand, A. H., Templin, T., Hasenau, S. M., & Riley-Doucet, C. (2007). Factors that affect functional status in patients withcancer-related pain. Pain, 132(1-2), 82-90. doi: 10.1016/j.pain.2007.01.029

15. Llyod, C. (1989) Maximizing occupational role performance with the terminally ill patients. BE Journal of Occupational Therapy: 52: 227-230.

16. Sardesai, MG., Fung, K., Yoo, JH., Bakker, H. (2008). "Donor-site morbidity following radial forearm free tissue transfer in head and neck surgery." The Journal of Otolaryngology of Head and Neck Surgery. Jun;37(3):411-6.

© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.