CREATE Childhood Cancer Rehabilitation 11/5/2021

CREATETM Childhood Cancer Rehabilitation 11/5/2021

© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or

in part in any manner without the permission of the copyright owner 1

Class Correspondence: [email protected]

Lynn Tanner, PT, Laura Gilchrist PT, PhD, Bonnie Carlson-Green PhD, LP, Nathan Gossai,

MD, Teresa Herriage, DNP, APRN, CNP, CPHON, Heather Johnson, PNP, Diane Lesmeister,

OTR/L, Monica Olsen, PT, DPT, Leah Podergois, CCC-SLP, Sharyl Samargia-Grivette, CCC-

SLP, PhD, Susan Sencer, MD

Lynn Tanner, PT [email protected]

Monica Olsen, PT, DPT

Page 3© 2021

Prospective Surveillance

Model

Surveillance

Adverse Event

Education

Early Detection

Rehabilitation

Wellness Promotion

Stout et al. 2012

Page 4© 2021

• Surveillance – assessing side effects along the cancer continuum of care

• Adverse event education – preventative education

• Early detection – identifying impairments/limitations/restriction early to treat

• Rehabilitation – intervention

• Wellness promotion – promoting a healthy lifestyle throughout treatment

Page 5© 2021

Surveillance

Reflexes

ROM

Strength

Gait

Balance

ADLs/IADLs

Education

Role of Rehab

Side effects

Prehab

Early Detection

Baseline assessment

Impairments Limitations at Cancer Dx.

Rehabilitation

Treat cancer-related and

developmental impairments

Wellness Promotion

Independence

Daily routine

Physical activity

Quality of life

Page 6© 2021

Surveillance

Ped-mTNS

ROM

Strength

Gait

Balance

Motor skills

ADLs/IADLs

Education

Role of Rehab

Scheduling

Side effects

Home exercise program

Early Detection

Ongoing assessment

Impairments measured

1x/mon

Limitations measured 1x/6

months

Rehabilitation



and limitations

Wellness Promotion

Independence

Daily routine

Physical activity

Quality of life




Page 7© 2021

Surveillance

Ped-mTNS

ROM

Strength

Gait

Balance

Motor skills

ADLS/IADLs

Cognition

Communication

Education

Role of Rehab

Scheduling

Episodes of care

Late effects


Early Detection

Late effects

Developmental Recovery

Rehabilitation



and limitations

Wellness Promotion

Independence

Daily routine

Physical activity

Quality of life

Page 8© 2021

Surveillance

Ped-mTNS

ROM

Strength

Gait

Balance

Motor skills

ADLs/IADLs

Cognition

Communication

Education

Role of Rehab

Scheduling

Late effects


Early Detection

Late effects

Developmental Recovery

Transition to Adulthood

Rehabilitation



and limitations

Independent living

rehabilitation

Vocational rehabilitation

Wellness Promotion

Independence

Physical activity

Quality of life

Page 9© 2021

• Standardized measures and specific time points

• Educational handouts based on “light” color

• Sustained benefits on physical performance and physical activity level

Page 10© 2021

Diagnosis

Pain

ROM

Strength

Gait

Balance

Reflexes

Education

OP

4-8 wksPain

ROM

Strength

Gait

Ped-mTNS

Foot Posture

Gait endurance

Education

OP

2nd visit

Motor function


Page 11© 2021

How are they feeling?

Activities

Enjoyed in the last week

Enjoyed prior to diagnosis

Both physical and not physical

Typical daily routine

School attendance

After school

Weekends

Environment Physical activities they

are good at

Physical activities they would like to

improve

Page 12© 2021

• Visual Analog Scale (VAS)

Age 13-21

• FACES scale

Age 5-12

• FLACC

Age 2 mos – 7 yr

• Younger children

• Ask caregivers about any concerns

of pain

• Behavior changes

• Pain in the last month

• Pain description

• Activities before, during, and after pain

• Medications

• Differentiate between pain and fatigue

• Assess relationship to chemotherapy

cycle

McGrath 2008 PedIMMPACT, Merkle 1997




Page 13© 2021

• Outcome measurement

– Goniometric measurement

– Technique extremely important

– Two-person measurement optimal to hold subtalar neutral position and avoid

measuring a pronated foot

Page 14© 2021

• Foot posture index (FPI-6)

–Scale measurement with standard criteria

–Manual available

• Hindfoot measurements– Bisect calcaneus with ankle dorsiflexed to O in prone and draw line

– In standing, measure the angle between vertical and calcaneal line

Page 15© 2021

• Decreased velocity

• Decreased step length

• Foot slap• Flat foot • Knee hyperextension

• Decreased step length

• Wide base of support

• Toe walking

• Steppage pattern

• Lateral lurch

Page 16© 2021

Computerized gait analysis

Observational gait analysis (OGA)

Water marks on paper

Measure/observe

Push-off

Initial contact

Step length

Base of support

Out-toeing/intoeing

Page 17© 2021

• Manual muscle tests– Difficult in children under 5

– Look at all muscle groups» toe extension/flexion strength

• Functional movement– Stairs - kids over 4 should alternate up/down

» with and without verbal cues

– Floor to stand through squatting or 1/2 kneel (2 yrs)

– Supine to sit (core weakness)

– Hopping (using plantarflexion or quads/hams)

– Heel walking

• Strength subtest of Bruininks-Oseretsky Test – Second Edition

Page 18© 2021

• Peripheral neuropathy

• Decreased ROM

• Vestibular impairment




Page 19© 2021

• Single leg stance

– eyes open or closed, hands on hips

• BOT-2 balance scale

• Stationary subscale PDMS II

• Others

– Pediatric balance scale

– mCTSIB

– BESS

– Dynamic Gait Index

Page 20© 2021

• Standardized testing

– Peabody Developmental Motor Scales, Second Edition

– BOT-2: Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

• Others

– Bayley Scales of Infant Development – Third Edition

Page 21© 2021

• Screen grip/pinch

• Change in fine motor skills/ADLs/IADLs

• Refer to OT

Page 22© 2021

• Decreased during treatment and after treatment

• Can test using 6-minute walk test

• American Thoracic Society guidelines

• 50 ft walk way

• BP/HR pre and post if possible

• Objects to retrieve/drop if needed for young ages

• Age > 5 yo

• PACER

• Other

• Treadmill test, Cycle ergometer

Page 23© 2021

• PedsQL

• PROMIS scales

Page 24© 2021

Impairment level outcomes

1x/month

Motor function 1x/6 months

Neuropathy

1x/3 months during intense

treatment

1x/6 months during

maintenance

When clinically appropriate

New symptoms




Page 25© 2021

• CIPN assessment and intervention

• Trunk patterns

– May have asymmetry secondary to surgery or radiation

• Understand frequency of vincristine dosing

Page 26© 2021

• CIPN assessment and intervention

• Muscle atrophy and limb length discrepancies secondary to surgery and radiation

• Look at asymmetries secondary to tumor location and treatment

Page 27© 2021

• Deficits depend on stage and treatment

• Possible CIPN

• Time in treatment leads to extreme deconditioning in higher stage patients

• Can have surgical needs depending on tumor placement

• Possible vestibular component secondary to ototoxicity of treatment

Page 28© 2021

• Decreased ROM

• Decreased gait velocity

• Decreased muscle strength

• Decreased grip strength

• Functional Loss

• Gerber et al (2006) found these deficits in survivors 20 years post treatment

Page 29© 2021

• Surgeries are complicated

– Limb salvage

» Endoprosthesis (growing?)

» Cadaver graft

– Ampuation

» Rotationplasty

» Amputation

• Close communication with orthopedic surgeon

• Wbing precautions

• Incision healing

• Bone healing

• Specifics

• Advocate for need of rehab

• Focus on ROM, strength, symmetry, gait, and physical activity capabilities

Page 30© 2021

• Awareness of Immune-effector cell-associated neurotoxicity syndrome (ICANS)

– Encephalopathy

» But awake with decreased verbal and physical reponse

– Decreased level of consciousness

– Seizures

– Muscle spasms/weakness

– Hemiparesis or paraparesis with SEVERE cases

– Increased intracranial pressure or cerebral edema

– Aphasia

– Ataxia (Lee, 2019) (Firestein, 2020)




Page 31© 2021

• Cytokine Release Syndrome (CRS)

– Fevers, myalgias, headaches, chills, tachycardia

• Tumor Lysis syndrome

• Neurotoxicity from ICANS persist past symptoms of CRS

(Firestein, 2020)

Page 32© 2021

• ROM

• Strength

• Balance

• Endurance

– 6 MWT

– PROMIS fatigue scale short form

• Motor skills

– BOT-2

• QOL

(Lenker & Foley, 2019)

Page 34© 2021

• Treatment schedule

– Chemotherapy medications

– Radiation

– IP and OP admissions

– Distance to center

– Pre-medications

• Family readiness and coping

• Other services needed

– psychology

Page 36© 2021

Gait intervention

CIPN severity

Ankle ROM

Gait pattern

Strength

Treatment phase

Age/size of child

Activity level

Family readiness




Page 37© 2021

“Quiet walking”

“Squish the bugs walk”

Lengthen stride length

T-band just below knee for toe walking

Balance beam dorsiflexion freeze

Stride stance work

Treadmill training

Symmetry, quality with endurance

Inversion - look at toe extensors, circumduction

Out-toeing - foot compensation or WBOS

ORTHOTICS

Page 38© 2021

Historical interventions Historical results

Daily heelcord stretching -Loss of ankle ROM

-Midfoot collapse

-Hindfoot valgus

Off-the-shelf dorsiflexion stretching splints

night and sedentary time

-Maintains or slight increase in DF ROM

-Midfoot collapse

-Hindfoot valgus

Hinged AFOs worn daytime and/or nighttime

-Varied results in ankle DF ROM

-Collapsed midfoot

-Hindfoot valgus

Page 39© 2021

Orthotic DecisionAnkle ROM

• Baseline ROM

• Speed of loss• 5-10 degree

loss

• Active and passive

• Goal: 10°ADFROM

Strength

• Ankle ≤ MMT 4

• Progression• Muscle

endurance

Gait

• Foot slap

• Early heel rise• Shortened step

length

• Toe walking

• Change over 6 MWT

Foot Posture

• Loss of arch

• Calcaneal valgus

• Out-toeing

• In-toeing

• Prevention

Treatment Cycle

• Early

• Middle

• End

• Neurotoxic agents

Age

• Age 2-4

• School age• Adolescent

• Adult

Season

• Compliance in hot weather

Page 40© 2021

Decreased ankle ROM

Muscle weakness

+/- Foot posture

Gait change

Early/Mid/Late

Treatment

2-Pull Solid AFO

Full day wear until ROM normal andheel-toe gait pattern typical

Page 41© 2021

Stable functional DFROM

DF muscle

weakness

Gait changes

Fatigue

+/-foot posture

Mid/late treatment

Energy Response/Articulated/Ca

rbon AFO

Page 42© 2021

Decreased ankle ROM

Foot posture changes

+/- Muscle weakness

Late/end treatment

Serial Casting

+/-Orthotics




Page 43© 2021

Foot posture changes

Good strength

Normal gait

Late/end treatment

SMO/FO

Page 44© 2021

Passive ankle dorsiflexion to 15Active ankle dorsiflexion to 10

30 min PT session without footslap

No toe walking

Minimal early heel rise

Heel walk 50 feet with minimal compensations

Decrease time in AFO’s

Start with 4-6 hours

per day outside

AFO’s

Continue night-time use

if doing so

Try to select time of day that child is active out of them

Option: Wear before and after school

Option: Wear during school and not on weekends

Attempt to wear them in the latter half of the day

Option: Wear during school only

Reassess after 1 month

Page 45© 2021 Page 46© 2021

“Quiet walking”

“Squish the bugs walk”

Lengthen stride length

Heel walking

Tip toe walking

Treadmill training

Inversion - look at toe extensors, circumduction

Out-toeing - foot compensation or WBOS

ORTHOTICS

Page 47© 2021

• Core strengthening

– Prone over ball, Yoga, Crab walk, prone extension

• Hip and peripheral LE strengthening

Page 48© 2021

• Gastrocsoleus stretches

• Hamstring stretches

• Yoga sequences

– Downward dog

– Modified downward dog

– Lizard

– Pigeon

• Modified long-sit

• Nerve flossing techniques

• Wedge standing




Page 49© 2021

Induction/delayed intensification hoping to maintain strength

Consolidation/Maintenance Increase strength

Page 50© 2021

• Functional tasks

» encourage independence

» Standing while playing, kneeling while playing

» Up/down pieces games to encourage floor to stand transitions

» Stairs/step stool

Page 51© 2021

• Core strengthening

– Yoga, Pilates, theraball, push-ups

• Hip strengthening

– Bridges with cars, side step with t-band, clam shells

• Quads/hams

– Floor to stand transitions, sit to stand 1 min, eccentric control

Page 52© 2021

• Peripheral strength

– Heel walking

– Tip toe statues

– Jumping high for push off

– Jumping down for eccentric control

– Toe grasping

– Foot “caves”

– Dorsiflexion tug-of-war

Page 53© 2021

• Single leg stance work– Step stance, kicking ball, soccer ball stop, Yoga, Wiifit, popping

bubbles with feet, etc

– watch foot position and hip lean

• Unstable surface – standing, tandem stance, single leg stance

• Eyes closed• Balance beam

– forward, backward, tandem

• Head turns, diagonal movements

Page 54© 2021

– Stairs– Floor to stand

» Squats - especially for young children - ?femoral anteversion risk» 1/2 kneel to stand - able to lead with either leg

– Jumping» 2 foot take off and landing» Distance and height for strength/power» Hopping - look at both legs» Plyometrics for older kids

– Running» Look at speed, symmetry

– Skipping, Galloping




Page 55© 2021

• Transcutaneous electrical nerve stimulation (TENS)

– Reduce pain by reducing cytokine release and increasing endogenous opiod and

serotonin release

– Stimulate large nerve fibers impacting pain receptors

• Heat, massage, exercise

– Increase perfusion and oxygenation to the area reducing inflammatory mediators

that cause cell dysfunction

• Low levels of evidence and mixed results

(Ogle et al, 2020)

Page 56© 2021

Planning Pacing

Prioritizing Positioning

Energy conservation

Page 57© 2021

Less Fatigue

Move as able using 4 Ps

Progressive strengtheningRest

Weakness

Fatigue

Page 58© 2021

• > 18 yo

– 150-300 minutes of moderate

physical activity

– 75-150 of vigorous activity

– Muscle strengthening 2 days/wk

• Goal of meeting physical activity

guidelines

– 60 minutes of moderate to

vigorous physical activity/day (6-

17)

– Muscle strengthening 3 days/wk

– Bone strengthening 3 days/ wk

Page 59© 2021

PA

Frequency

Intensity

Time

Type

– Family-centered care

– Ongoing conversation

– Creativity

– Acknowledgement of small gains

– Positive reinforcement

– CIPN and walking as exercise?

– FITT principles

Monica Olsen, PT




Page 61© 2021

Line Role Considerations

Pulse oximeter; CR leads; BP cuff

Measure basic vital signs Ensure good signal strength, ask RN if disconnecting

Arterial Line Real-time blood pressure monitoring; blood draw for ABG analysis

Prevent prolonged activity with line above heart-level

PIV; Central line (Femoral, Internal Jugular)

Intravenous administration of fluids, medications

Board to stabilize as needed, check for hip flexion ROM restrictions if femoral line

PICC; Hickman/ Broviac; Ports

Fluids, medications, blood draws Tape/pin to gown so no tension on the line; No BP in arm with PICC

EVD (External ventricular drain)

Drains CSF from lateral ventricles into an external bag to relieve elevated ICP's

RN must clamp prior to mobilization; needs to be recalibrated prior to unclamping

NG/NJ and GT/GJ Provide hydration, nutrition, and

medication to GI tract; remove contents

from the stomach

Prone ok as tolerated, consider timing of

treatments around feed schedule Page 62© 2021

Consideration PT Frequency Example

Are there new significant functional impairments? Is PT necessary for safe d/c home?

1-2x/day Ex. Teen with a new brain tumor now s/p resection

Is there a significant risk for deconditioning and loss of skills without direct, skilled intervention?

5-6x/week Ex. Child demonstrating new-onset moderate-severe CIPN symptoms

Is there a risk for complications due to immobility?

3-4x/week Ex. Child with newly diagnosed ALL with difficulty walking d/t LE pain

Is there a risk for loss of skill due to prolonged hospitalization?

1-2x/week Ex. Teen with AML admitted for a month-long chemotherapy admission

Are there no concerns for new impairments or loss of skill at this time?

1-2 visits total Ex. New diagnosis without other current functional impairments

Page 63© 2021

• PICU

– PROM

– PRAFO's

– Positioning

– Early Mobility

Page 64© 2021

• Prolonged admissions

– Create PT/OT/SLP schedule; Child

Life Specialist can help

– Education on daily routine/ ADL's

– Rehab out of room as able (ask RN if

able to go to gym, outside, etc.)

• Out of bed mobility

– Playmat, Cube

Chair, Benches, Activity Trays,

Tricycle, Wagons

– Walking schedule

Clinical Pearl

From 1st admission, educate

patients/families that beds

are for sleeping/ resting only;

not eating, playing etc.

Page 65© 2021

Lynn Tanner, PT




Page 67© 2021

Surveillance

•Reflexes

•Sensation

•ROM

•Tone

•Movement disorder

•Vision

•Oculomotor

•Vestibular

•Cognition

•Communication

•Strength

•Gait

•Balance

•Motor function

•ADLs/IADLs

Education

•Role of Rehab

•Prehab

Early Detection

•Baseline assessment

•Impairments Limitations at Cancer Dx.

Rehabilitation

•Treat cancer-related and developmental impairments

Wellness Promotion

•Independence

•Daily routine

•Physical activity

•Quality of life

Page 68© 2021

Surveillance

•Reflexes

•Sensation

•ROM

•Tone


•Vision

•Oculomotor

•Vestibular

•Swallowing

•Cognition

•Communication

•Strength

•Gait

•Balance

•Motor function

•ADLs/IADLS

Education

•Role of Rehab during IP and return to home

•Scheduling IP

•Surgical side effects

•Safety

•Transfers

•Feeding

•Swallowing

•Adaptive communication

•Daily exercise program

Early Detection

•Ongoing assessment

•Contractures

Rehabilitation

•Treat cancer-related and surgical impairments and limitations

•Focusing on skills and safety needed for return to home

•Equipment

Wellness Promotion

•Independence

•Daily routine


•Quality of life

Page 69© 2021

Surveillance

•Ped-mTNS

•Sensation

•ROM

•Tone


•Vision

•Oculomotor

•Swallowing

•Cognition

•Communication

•Strength

•Gait

•Balance

•Motor function

•ADLs/IADLs

Education

•Role of Rehab

•Scheduling

•Radiation/chemo side effects


Early Detection


•Fatigue

•Neuropathy

•Contractures

Rehabilitation

•Treat cancer-related and surgical impairments and limitations

Wellness Promotion

•Independence

•Daily routine


•Quality of life

Page 70© 2021

Surveillance

•Ped-mTNS

•Sensation

•ROM

•Tone


•Vision

•Oculomotor

•Swallowing

•Cognition

•Communication

•Strength

•Gait

•Balance

•Motor function

•ADLs/IADLs

Education

•Role of Rehab

•Scheduling

•Radiation/chemo side effects


Early Detection


•Fatigue

•Neuropathy

•Contractures

•Weakness

•Integumentary

Rehabilitation

•Treat cancer-related and treatment impairments and limitations

Wellness Promotion

•Independence

•Daily routine


•Quality of life

Page 71© 2021

• No increase in physical exertion for 4 weeks.

• No contact sports or jumping/running for at least 3 months.

• Can work on passive/active cervical ROM

• Can work on gait, gentle strengthening, walking, controlled balance training

Page 72© 2021

• Keep patient active if they have an EVD prior to or post craniotomy

– Ask if EVD can be clamped

• Cervical movement important post surgery

• Up in chair 24 hours post-op

• Gait belts important

• Multidisciplinary care

– Involve family and nursing in rehab

» Coordinate schedules – pain, self-care, sleep




Page 73© 2021

• Brain tumor patients often have rehabilitation services during hospital admission after

surgery

• Possible candidates for IP rehabilitation

– Pediatric inpatient rehab unit reported 8% of population were patients with brain

tumors in 7 years of data collection

Kim et al 2013

• Outpatient therapy during and after radiation/chemotherapy treatment

– Fatigue with radiation can be a factor

Page 74© 2021

• Occurs 24-100 hrs after surgery

• Mutism or speech disturbances

• Dysphagia

• Decreased motor function

• Cranial nerve palsies

• Emotional lability

• Recovery can take weeks to months

• Resource: www.posteriorfossa.org

Page 75© 2021

• Complexity and unique presentation

require thorough neuro exam

• Cranial nerve testing important,

especially in infratentorial tumors

Cognition

Cranial nerves

Motor

Sensory

Coordination

Gait

Mobility

Page 76© 2021

• Ask child to remember 3 words

– Have them repeat the 3 words right away

– Have them repeat the 3 words in 10 minutes

• Caregiver questions

– School performance

– Developmental milestones

• Language

– Aphasia

» Expressive (Broca’s)– frontal lobe – often with right sided weakness

» Receptive (Wernicke’s)– left Temporal/parietal

• Require referral to neuropsychologist

• OT/SLP can help with memory strategies

Page 77© 2021

• I – Olfactory

» Ask about smell – not common

• II – Optic

» Pupillary light reflex

Pupil constricts with light

» Tracking in less responsive

patients

» Visual fields

Page 78© 2021

• III – Oculomotor

– Controls most eye movement, eyelid, and constricts pupil

• IV – Trochlear

– Superior Oblique muscle

– Nucleus controls opposite eye

• VI – Abducens

– Abducts the eye

• Extraoculor motor exam

– Double “H” Vision test with hold at each end

• Paresis causes diplopia – double vision




Page 79© 2021

• V – Trigeminal

– Sensory to the forehead, cheek, and jaw

– Motor to the masseter and temporalis

• Test

– Clench jaw and palpate

– Light touch sensation

• VII – Facial

– Upper and lower facial muscles

» Eyebrow elevation

» Smile

Page 80© 2021

• VIII – Vestibulo-cochlear

– Hearing

» Finger rub test

– Vestibular

» VOR reflex

Head thrust, DVA

» Postural control

Romberg – eyes closed

Page 81© 2021

• IX – Glossopharyngeal and X – Vagus

– Problems with choking food?

– Soft palate

• XI – Accessory

– Trapezius, Sternocleidomastoid

– Shoulder shrug

• XII – Hypoglossal

– Tongue protrusion

Page 82© 2021

• Often damaged by tumor location

• Ototoxicity from chemotherapy can cause hearing and vestibular impairments

• Awareness of impairments may assist intervention direction

• Vestibular rehab focuses on compensation of the oculomotor and neuromuscular system

to overcome balance deficits

Page 83© 2021

• Hypertonia caused by damage to the CNS by tumor location or hemorrhagic incident

during/after surgery

• Cerebeller tumors can cause low tone secondary to poor regulation of muscle tone

• Outcome

– Modified Ashworth Scale

Page 84© 2021

• Impairments depend on etiology

• Hypertonia

• Hip abduction/rotation/extension, knee extension, ankle dorsiflexion

• Shoulder abduction/flexion, elbow extension, wrist supination/extension and finger

extension/abduction


• Ankle dorsiflexion, knee extension

• Outcome measurement

• Goniometry




Page 85© 2021

• At risk for scoliosis/kyphosis secondary to radiation or asymmetrical motor control

• LE issues from peripheral neuropathy or motor control issues

• Work on strengthening and symmetry in functional skills

• Outcome measurements

– Foot Posture Index (FPI)

– Core strength

» Timed Prone V-up

» Timed plank

» Timed side-plank

Page 86© 2021

• Deconditioning

• Motor control dysfunction


Page 87© 2021

• Manual muscle testing

• Pronator drift test

– UEs flexed to 90 in supination with eyes closed – indicates UMN injury

• Dynamometry

• Functional strength skills

• BOT-2 Strength subtest

• Look for asymmetry!

Page 88© 2021

• Damage to cerebral cortex


• Point/dull testing, light touch,

joint position sense

• Can change rapidly or slowly

after surgery

Page 89© 2021

• Hemiparetic gait pattern

• Steppage gait

• Flat foot shuffling gait

• Foot slap gait

• Ataxic gait pattern (wide-based, variable, sways)

Page 90© 2021

• Tumor in motor cortex, cerebellum, disturbing ascending/descending tracts

(thalamus) or vestibular system (cranial nerve VIII or vestibular nuclei)


• Combination of central balance and peripheral balance deficits




Page 91© 2021

• Seen in children with cerebellar tumors

• Outcome measures

– International Cooperative Ataxia Rating Scale (ICARS)

» Posture and Gait disturbance

» Kinetic functions

» Speech disorders

» Oculomotor disorders

– Scale for the Assessment and Rating of Ataxia (SARA)

» 8 items only

– Brief Ataxia Rating Scale (BARS)

» 5 items

Page 92© 2021

• Heel to shin test

– Look at path and speed

• Finger to nose

– Older kids – eyes closed

• Alternating pronation/supination

• BOT-2 coordination subtest

Page 93© 2021

– Pediatric Berg Scale

– mCTSIB

– Community balance scale

– BOT-2 Balance scale

– Sitting balance

– Romberg - test of the dorsal columns

+ test means ataxia sensory in nature

- test means ataxia is cerebellar in nature

– Single leg stance

Page 94© 2021

• Caused by tumor location or surgical/hemorrhagic complication

• Motor control training

– Repetitive task specific training

• Constraint therapy for hemiplegic upper extremity

Page 95© 2021

• Canadian Occupational Performance Measure (COPM)

• Weefim

– Age 3-12 or patient with cognitive delay

• Functional Independence Measure

• Gross Motor Function Measure

– Tests up to developmental level of a 5 y.o.

– Developed for children with Cerebral Palsy

• Pediatric Evaluation of Disability Inventory (PEDI)

– Ages 0-7

• Timed Up and Go (TUG)

• Timed Up and Down Stairs test (TUDS)

• 6 minute walk test

Lynn Tanner, PT




Page 97© 2021

• Multidisciplinary pathway for children and adolescents post surgical resection of a

brain tumor

• Team of neurosurgery, oncology, nursing, and rehabilitation therapists developed

pathway

• Included

– Weaning sedation to improve participation in rehab

– Pain meds

– Removing foley 24 hrs post to reduce risk of infection

– OOB to chair POD #1 if possible

– Meals in chair POD #2

Page 98© 2021

Post – op Day 1 Post – op Day 2 Post – op Day 3 Post – op Day 4 Post – op Day 5 Post – op Day 6

Breakfast with head

of bed elevated

Time:________

Lunch with head of

bed elevated

Time:_________

Dinner sitting in chair

Time: _______

Bathing

Time:________

Physical Therapy

Evaluation

Time:________

Occupational

Therapy Evaluation

Time:________

_____Turn head to

look at people when

talking or listening

2/3 meals sitting in

chair

Breakfast

Time: _______

Lunch

Time: _______

Dinner

Time:_________

Bathing

Time:________

PT Time:_______

OT Time:_______

_____Bathroom on

the commode or

toilet

_____Work on

dressing, bathing

and eating with a

little help

_____Turn head to

look at people when



chair

Breakfast

Time: _______

Lunch

Time: _______

Dinner

Time:_________

Bathing

Time:________

PT Time:_______

OT Time:_______

Speech eval if

needed Time:______

_____Toileting and

daily hygiene in the

bathroom

Walk out of room 3

times throughout

day.

_____ _____

_____

_____Turn head to

look at people when



chair

Breakfast

Time: _______

Lunch

Time: _______

Dinner

Time:_________

Bathing

Time:________

PT Time:_______

OT Time:_______

_____ Gather

materials and

complete daily

hygiene in bathroom

with minimal help

Walk out of room 3

times throughout day

with stairs.

_____ _____

_____

_____ Pick up things

from floor like socks

or shoes


chair

Breakfast

Time: _______

Lunch

Time: _______

Dinner

Time:_________

Bathing

Time:________

PT Time:_______

OT Time:_______

_____30 min of

activity out of bed

without rest

Walk out of room 3

times increasing

speed, walking on

line, start/stop

balance

_____ _____

_____


chair

Breakfast

Time: _______

Lunch

Time: _______

Dinner

Time:_________

Bathing

Time:________

PT Time:_______

OT Time:_______

_____40 min of

activity out of bed

without rest

Walk out of room 3

times increasing

speed, walking on

line, start/stop

balance

_____ _____

_____

_____ Get up from

the floor without help

Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal:

Page 99© 2021

• Medulloblastoma dx at age 13

• Presenting sx:

– 1.5 yr of progressive clumbsiness

– Decreased school performance

– Declining speech

Page 100© 2021

• Treatment

–Complete resection

–Proton radiation (6 wks) in other state

»2-3 weeks IP

–3 months of chemotherapy (vincristine, cyclophosomide,

cisplatin)

Page 101© 2021

• Current

– ataxia

– muscle weakness

– disconjugate gaze (post corrective

surgery)

– chemotherapy-induced ovarian

failure

– left CN VI paresis

– expressive language disorder

– motor speech disorder

– voice disturbance

• Post-op

– severe posterior fossa cerebellar

mutism syndrome (>1 day after

surgery)

– cranial nerve VI weakness

– left facial weakness

– right hemiparesis

– swallowing dysfunction

– severe ataxia

Page 102© 2021

• Mod A x 2 for supine to/from sit

• Mod A to sit at EOB

• PROM WNL x left cervical rotation

PT Assessment – POD #1

• Max A x 1 roll and supine to sit

• Stand pivot tx Mod A x 2

• Right weaker than left

• Cervical AROM

POD # 2

• Sit to/from stand Min A

• 3 steps fwd/bkwd Mod A

• Sit Min A

• Uses hand squeeze and thumbs up

POD #3




Page 103© 2021

• Decreased arousal

• Max A supine to sit

• Max A pivot transfer with

• Max A for head control

POD #4

• Mod A supine to sit

• Mod to Max A sit to stand and stand pivot (more with fatigue

• Amb 7 ft with Mod A

• Poor head control

POD #5

• Bed mobility with v.c.

• Sit with CGA to Min A

• Amb with walker 85’ max with Min to Mod A at trunk and v.c. to steering, R hand on walker

• Right AFO

• Left knee hyperextension

POD #19

DC to proton

Page 104© 2021

• Gait – Min A with walker w/o AFO x 500ft

• Fwd WS

• High steppage• Circumduction

• VERY IMPULSIVE

4 months post

• Gait – same as above with Min A pushing WC5 months

post

Page 105© 2021

• Patches one eye

• Goal: walk again

• Ankle DF 5-8 degrees

• Sits with left lateral trunk flexion with Ues raises for 90 sec max with trunk sway (moderate)

• Stands with CGA with bil knee hyperextension 90 sec max

• Supine to sit I

• Sit to/from stand CGA

• Heel to shin test positive for mild ataxia left greater than right

• Sensory testing WNL x of left great toe

• Disconjugate gaze

• Horizontal nystagmus

• Amb with Min to Mod A at left UE preferred, FWW with Min A

OP PT eval

6 mos post

Page 106© 2021

• Gentle prolonged stretching/positioning

• Knee immobilizers for hamstrings

• Serial casting/orthotics for ankle contractures

• Wrist/hand splinting

• Work closely with physiatrist for medical interventions and feedback on function

Page 107© 2021

• Strengthening

• Strengthen using synergy and out of synergy if decreased motor control

• Strengthen gravity assisted, gravity eliminated, anti-gravity

• Repetition in functional activities with assistance for quality of movement

Page 108© 2021

• Partial weight bearing treadmill training

• Robotic-assist gait training

– Significant improvement in GMFM scores and gait spatio-temporal parameters as well as hip kinematics in children with acquired brain injury

» 30% of patients had a CNS tumor

• Beretta et al. 2015

• Gait training in the aquatic environment

• Functional electrical stimulation

• Focus on symmetry, stride length, weight shift, etc

• Consider vision/vestibular changes

– Gait with head turns

– Gait in crowded hall

• Orthotic considerations




Page 109© 2021

• Tumor in motor cortex, cerebellum, disturbing ascending/descending tracts

(thalamus) or vestibular system (cranial nerve VIII or vestibular nuclei)


• Combination of central balance and peripheral balance deficits

Page 110© 2021

0

5

10

15

20

25

30

35

40

45

Se

co

nd

s

2x/wkPT

1x/moPT

2x/wkPT

Min A

1-3/x1SBA

4/x1-5/x1

CGA

7/x1-1/x1

SBA3/x2

Page 111© 2021

0

50

100

150

200

250

300

350

1/12/20x1 2/9/20x1 3/12/20x1 4/6/20x1 5/14/20x1 7/23/20x1 9/22/20x1 1/28/20x2 3/17/20x2

2x/wk PT 1/20x1-5/20x1 and 1/20x2-3/20x2

Max A Mod A Min A CGA

Page 112© 2021

• Integrate rhythm challenges into motor activities

• Opposing UE/LE movements

– Swinging arms in gait

– Throwing/catching

– Dribbling

– Jumping jacks

– Stride jumps

– Skipping

Page 113© 2021

• Consider vision/vestibular/neuromuscular impairments

• Monitor asymmetry

• Progress difficulty by taking away use of one system (unsteady surface, eyes closed)

• Challenge balance during gait

– Head turns, perturbations, crowded hall, change in surfaces

Page 114© 2021

• Blocked practice of functional activity

• Circuit training-smart phone applications

• Use of Wii and Kinect

• Sport directed drills

• Obstacle Courses

• Treadmill

• Swimming

• Explore new community activities

• Step trackers




Lynn Tanner, PT

Page 116© 2021

Surveillance

•Ped-mTNS

•Sensation

•ROM

•Tone


•Vision

•Oculomotor

•Swallowing

•Cognition

•Communication

•Strength

•Gait

•Balance

•Motor function

•ADLs/IADLs

Education

•Role of Rehab

•Episodes of care

•Scheduling

•Community/school rehabilitation and collaboration

•Late effects

•Home exercise program

Early Detection


•Late effects

•Fatigue

•Neuropathy

•Contractures

•Posture

•Pain

Rehabilitation

•Treat cancer-related and treatment impairments and limitations

Wellness Promotion

•Independence

•Daily routine


•Quality of life

Page 117© 2021

• Teenager treated for Medulloblastoma during early elementary school.

• Neuro-onc follow up clinic

– Family concerns

» Limited physical activity

» School avoidance

» Managing stairs at school

» Decreased IADL independence

» Fatigue with writing

» Limited keyboarding

» Desire to drive

Page 118© 2021

Surveillance

•Ped-mTNS

•Sensation

•ROM

•Tone


•Vision

•Oculomotor

•Swallowing

•Cognition

•Communication

•Strength

•Gait

•Balance

•Motor function

•ADLs/IADLs

Education

•Role of Rehab

•Episodes of care

•Scheduling

•Community/school rehabilitation and collaboration

•Late effects

•Home exercise program

Early Detection


•Late effects

•Fatigue

•Neuropathy

•Contractures

•Posture

•Pain

•Transition to adulthood

Rehabilitation

•Treat cancer-related late effects and limitations

•Episodes of care

•Career planning

•Vocational rehab

•Independent living

Wellness Promotion

•Independence


•Quality of life

Page 119© 2021

• Pain onset

– New activities

– Growth

• Ankle contractures with growth

• Posture Assessment

• Strength gains

• Endurance needs

Page 120© 2021

• Rate of development kept up with age

• Reassessment of motor skills required




Page 121© 2021

• Physical Activity level

– Continue to educate over time

» Changing interests

• Transition education

– School transition

– High school transition

– College transition

– Independent living/career transition

Page 122© 2021

• Independent living

– Safety

– Home adaptations

– Assistance

• Employment

– Physical needs for wanted career

– Career training through school program

Page 123© 2021

• OT

• SLP

• Neuropsychology

• Psychology

• Driving Assessment

• Orthopedic evaluation

– Scoliosis

• Etc.

Page 124© 2021

• When to return to PT

– Pain > 2 weeks

– New symptom onset

– Frustration with wanted skill

• Episodes of care

Documents

CREATE Childhood Cancer Rehabilitation 11/5/2021