PROSTATE CANCER

NAME : RABI’ATUL ‘ADAWIYAH BINTI MD.YUSOFMATRIX :PH04120030SEM/YEAR :SEM6/YEAR3HOSPITAL : PROCARE NURSING HOMELP : MR.ADRIAN,MS.YOGES

ANATOMY AND PHYSIOLOGY

DEFINITIONProstate cancer occurs in the prostate gland, which is located just below a male's bladder and surrounds the top portion of the tube that drains urine from the bladder (urethra)

RISK FACTOR

• A family history of cancer

• Genes

• A previous cancer

• Diets and lifestyle

• Hormones - higher levels of testosterone

• Vasectomy – birth control

• prostatitis

AN

TEST AND DIAGNOSIS

Prostate-specific antigen (PSA)

CASE STUDY

DEMOGRAPHIC DATA

Name : Mr.LAge : 70 years oldGender : maleMRN : xxxxRace : ChineseDate of admission : 26/11/14Date of assessment : 6/3/2015Doctor’s Diagnosis : Prostate CA with multilevel cord compression and bone metastasisDoctor’s Management :conservative, refer physio

SUBJECTIVES

Chief complaint : pt c/o pain on tailbone.Pt unable to move both leg,lesssensation and have water retention.Present hx : pt was diagnosed with prostate cancer since June 2013.Pt was referred to HUKM Ortho Spine for instrumentation but counselled for RT d/t Pt have been paraplegic more than 1 month.Pt have completed palliative RT to spine C1-C3 20 GY/5#1 week,T11- L3 8 GY/1#/1day and fully completed RT on 21/11/2014.On 26/11/2014,pt was admitted to Procare Nursing Home for full medical and hospitalized care.Ptwas referred to physiotherapy for further management since then.Past hx : Pt was bathing,and suddenly feel both leg weakened.Ptclaims that he have to crawl out from toilet.Pt went to Hospital Seremban in Oct 2014,which at first was treated as GBS,but later confirmed as compression secondary to metastatic.Pt was transferred to HUKM Ortho Spine for instrumentation.General health : fatigue,rashes all over bodiesPmhx : NILFamily hx : NIL

Drug hx: Omeprazol 20 mg 1 OD(treat GERD) ,Gabapentin 300 mg 1 OD(treat epilepsy,analgesic),Prednisolone sirups1bd(anti-inflammatory),Bisacodyl 5mg 3 on(bowel) ,Bisacodyl suppository 1 pn,Clencanus 6000 1 mg 1OD,Morphine 5g 2 – sal 4 hourly,augmenbin 1bd,lozenge 1 dailyPersonal hx : married and have 4 childrenSocial hx :i. occupation: english teacherii. House : single storey,sitting toilet but pt is on

CBD.Pt is staying in nursing house currently.iii. Lifestyle : non-smoker,non alcoholic consumeriv. Hobby : gardening,carpentingPremobility : mobileDominant hand : Rt sideAllergy : NKDA

Doctor Investigation:(a)MRI Spine (5/11/2014)Compression in T6 & L1 with epidural soft tissue extension causing compression of cauda equinanerve roots at L1.destruction of C2 with epidural soft tissue causing focal and compression at cervicomedullary junction(b)CT Abdomen (29/11/2014)Prostatic mass with extensive local infiltration and bone metastasis.Bilateral non obstructive nephrolithiasis. Cholelithiasis.Multiple thyroid nodules

OBJECTIVES

GENERAL OBSERVATIONPt was on bed,half lying with bed head raised to 60°.Pt was positioned with pillow supported under head,Rt side trunk and between legs.CBD is on Rtside of bed.Pt is alert,able to obey command and cooperative.Body built : mesomorphicPosture :normalExternal appliances : wheelchair (recliner)Gait : pt unable to walk d/t paralysis

LOCAL OBSERVATIONBowel : diapersbladder : CBDMental impairment : NILCommunication impairment : NILVisual field deficit : NILHearing deficit : NILPerceptual status : normalPsychological status : depressionany structural deformity : foot drop,both feetBony prominence : NILSwelling : NILEdema : both hands and feet,pittingSpasm : NILTenderness : NILWarmness : on feetMuscle wasting : both UL and LLSkin :i. Type : dry,ii. Color : red spotted all over body d/t rashesiii. Wound/scar: scattered all over body d/t rashesPressure sore : KIV

Other complications :(i) Painful shoulder : NIL(ii) Subluxed shoulder : NILPAIN ASSESSMENTVAS Scale 0 1 3 4 5 7 8 9 10Area of pain: tailboneType of pain : achingAggravating fx : excessive movement of LL during positioningEasing fx : rest,turn to 1 side of bodyOnset : on and offDuration (i)am : on and

(ii)pm: offIrritability rate : medium

2 6

CHEST ASSESSMENTOn Auscultation - KIV

On chest expansionUpper lobeMiddle lobe KIVLower lobe On vocal fremitus Upper lobe Middle lobe KIVLower lobeBreathing pattern : diagphragmaticCough : KIV

REFLEXES

Superficial reflex

i. Abdominal reflex : KIV

ii. Cremaster reflex : KIV

iii. Babinski sign : (Rt) Absent (Lt) Absent

Deep Tendon reflex Rt Lt

Bicep

Tricep normal normal

Supinator

Knee absent absent

Ankle

SENSORY ASSESSMENT

SHARP AND BLUNT(Rt) (Lt)

LIGHT TOUCH(Rt) (Lt)

PAIN(Rt) (Lt)

PROPRIOCEPTION(Rt) (Lt)

C5

C6 intact intact intact intact

C7

L2

L3

L4 absent absent impaired impaired

L5

SI

RANGE OF MOTIONUPPER LIMB Rt Lt

SHOULDER

ELBOW AFROM AFROM

WRIST

LOWER LIMB

HIP

KNEE PFROM PFROM

ANKLE

MUSCLE TONE

Rt Lt

UPPER LIMB NORMAL NORMAL

LOWER LIMB FLACCID FLACCID

JOINT CONTROL

UPPER LIMB Rt Lt

SHOULDER

ELBOW good good

WRIST

LOWER LIMB

HIP

KNEE poor poor

ANKLE

TRUNK - POORPELVIC - POOR

COORDINATION

• UPPER LIMB

Finger to nose to therapist hand - good

• LOWER LIMB

Heel to shin

Unable to perform d/t pt paraplegic

BALANCE

Sitting• Static poor • Dynamic Standing• Static unable to assess d/t• Dynamic pt unable to stand Joint proprioceptionUL - normalLL - impaired

BED MOBILITY• Transfer bed chair (maximum dependant)• Transfer w/c toilet (maximum dependent,

pt is on CBD,and weardiapers)

• Shifting ability (maximum assistance)• Supine side lying (independent with moderate

assistant)• Side lying sitting (maximum dependant)• Sitting standing (maximum dependant)• Sitting (maximum dependant)• Standing (maximum dependant)• Ambulation (maximum dependent)

4 43 34 43 33 3

0 00 01 10 0

2 2

0 0

18 + 18 = 3638 + 38 = 76

38 + 38 = 76

RESULTS (A) complete: no motor or sensory function is

preserved in the sacral segments S4-S5

(B)incomplete: sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5

(C)incomplete: motor functional is preserved below the neurological level, and most key muscles below the neurological level have a muscle grade <3

(D)incomplete: motor function is preserved below the neurological level, and most key muscles below the neurological level have a muscle grade of ≤3

(E) normal: motor and sensory function in normal

6

27

1

1

1

6 7

61

7

RESULTS

Possible scores range from 18 to 126, with higher scores indicating more independency.• Self care item = 27/49• Sphincter control = 2 / 14• Mobility items = 4 / 28• Locomotion = 3 / 21• Communication items = 34 / 35• Psychosocial Adjudgement = 19 / 21• Cognitive function = 35 / 35

Total score = 124 / 203(dependent)

ANALYSIS

1) Pain on sacral region d/t bone metastasis 2) Edema on UL and LL d/t poor blood circulation3) Reduce LL muscle tone d/t muscle imbalance4) Muscle imbalance d/t poor motor recruitment5) Poor balance d/t poor LL joint control6) Poor LL joint control d/t muscle imbalance7) Poor bed mobility d/t poor joint control8) Reduce sensation on LL d/t poor sensory integration9) Absent babinski sign d/t LMNL10) Absent LL deep tendon reflex d/t LMNL11) Foot drop deformity d/t muscle imbalance

SHORT TERM GOALS1) To reduce pain within 1/522) To reduce edema within 1/523) To normalized muscle tone within 16/524) To improve muscle imbalance within 12/525) To improve balance within 16/526) To improve joint control within 16/527) To improve bed mobility within 18/528) To improve sensory integration within 18/52

LONG TERM GOALS1) To maximize ADL functions as normal as before within

8/122) To reduce dependency in functional activity within 8/123) To prevent pressure sore within 6/52

PLAN OF TREATMENT

1) Passive movement

2) Passive stretch

3) Joint proprioception training

4) Circulation exercise

5) Active resisted exercise for UL

6) Positioning

INTERVENTION1) Passive movementOn half lying,bed head is set to 35°, i. Hip flexion extension both side 5 repetition x 3 sets x both sidesii. Hip abduction adduction 5 repetition x 3 sets x both sidesiii. Hip internal rotation external rotation 5 repetition x 3 sets x both sidesiv. Knee flexion extension 5 repetition x 3 sets x both sides v. Ankle dorsilexion plantarflexion 5 repetition x 3 sets x both sides 2) Passive stretchOn half lying,bed head is set to 35°,gastrocnemius stretch,15 sec hold x 3 repetitions x 1 sets3) Joint proprioception trainingOn half lying,bed head is set to 35°,knee flexion, press on bed 30 seconds x 3 sets x both sides4) Circulation exerciseOn half lying,bed head is set to 35°,hand clench,10 repetitions x 3 sets x both sides5) Active resisted exerciseOn half lying,bed head is set to 35°,i. Shoulder flexion extension 10 repetitions x 1 sets x both sides within ½ ROMii. Shoulder abduction adduction 5 repetitions x 1 sets x both sides within ½ ROMiii. Elbow flexion extension 10 repetitions x 1 sets x both sides 6) PositioningPt is turns to Lt side ly,1 pillow is placed under head.1pillow is place vertically under Rt side trunk and pelvic.1 pillow is place in between legs and knees are slightly bend.Bedhead raised to 60°.

PATIENTS EDUCATIONS1) Continue exercise as taught:i. Circulation exercise - hand clench,10 repetitions x 3 sets x

both sides x 2 times per dayii. Active exercise for a) Shoulder flexion extension 5 repetitions x 1 sets x

both sides x 2times per dayb) Elbow flexion extension 10 repetitions x 1 sets x

both sides x 2 times per day2) Should change positions every 2 hours to avoid bed sores

and reduce pain such asi. turn from Rt Lt side lyii. Ly sitting3)Advice pt to try to do everyday activity (especially UL) without help,such as feeding,combing,put on shirt etc

EVALUATIONPt was cooperative and able to obey command.Pt was able to follow treatment.During active resisted shoulder exercise,pt c/o easily tired.Pt able to resists only ½ of ROMDuring passive movement of Lt side hip flexion,pt c/o pain on tailbone.

REVIEWTo review pt in next visit.To assess chest expansion in next visit.To continue exercise as previous if pt able to tolerate with exercise in next visit.Treatment to add in next visit:i. Elevation for 15 minutesii. Passive movement – ankle circulation

FOLLOW UP

S/B PHYSIODate of assessment : 9/3/2015S - pt c/o pain on tailbone and water retention on feet become worst.O - Pt was on bed,coughing.Pt was on half lying with bed head raised to 60°.Pt was positioned with pillow supported under head,Lt side trunk and between legs.CBD is on Lt side of bed.Pt is alert,able to obey command and cooperative- VAS Scale remain same- °swelling- edema,pitting/hands and feet.- °spasm- °tenderness- Dry skin, red spotted all over body

CHEST ASSESSMENTOn Auscultation

mild crepitation on bilateral lowerlobe d/t sputum retentionnormal A/E

On chest expansionUpper lobeMiddle lobe good,symmetricalLower lobe On vocal fremitus Upper lobe Middle lobe normalLower lobeBreathing pattern : diagphragmaticCough : effective,but not productive,reduce cough effortSputum : NIL

• ROM

• MUSCLE TONE

• JOINT CONTROL

TRUNK CONTROL - POOR

PELVIC CONTROL - POOR

Rt Lt

UPPER LIMB AFROM AFROM

LOWER LIMB PFROM PFROM

Rt Lt

UPPER LIMB NORMAL NORMAL

LOWER LIMB FLACCID FLACCID

• MUSCLE POWERRt Lt

C5 4/5 4/5

C6 3/5 3/5

C7 4/5 4/5

C8 3/5 3/5

T1 3/5 3/5

L2

L3 0/5 0/5

L4

L5 1/5 1/5

S1 0/5 0/5

BALANCE

Sitting

• Static poor

• Dynamic

Standing

• Static unable to assess d/t

• Dynamic pt unable to stand

BED MOBILITY

• Transfer bed chair (maximum dependant)• Transfer w/c toilet (maximum dependent,

pt is on CBD,and weardiapers)

• Shifting ability (maximum assistance)• Supine side lying (independent with moderate• assistant)• Side lying sitting (maximum dependant)• Sitting standing (maximum dependant)• Sitting (maximum dependant)• Standing (maximum dependant)• Ambulation (maximum dependent)

ANALYSIS1) Pain on sacral region d/t bone metastasis

2) Mild crepitation on bibasal d/t sputum retention

3) Sputum retention d/t reduce airway clearance

4) Edema on UL and LL d/t poor blood circulation

5) Reduce LL muscle tone d/t muscle imbalance

6) Reduce muscle power d/t poor motor recruitment

7) Poor balance d/t poor LL joint control

8) Poor LL joint control d/t muscle imbalance

9) Poor bed mobility d/t poor joint control

10) Reduce sensation on LL d/t poor sensory integration

SHORT TERM GOALS• To reduce pain within 1/52• To reduce sputum retention within 1/52• To reduce edema within 1/52• To normalized muscle tone within 16/52• To improve muscle imbalance within 12/52• To improve balance within 16/52• To improve joint control within 16/52• To improve bed mobility within 18/52• To improve sensory integration within 18/52

LONG TERM GOALS• To maximize ADL functions as normal as before within 8/12• To reduce dependency in functional activity within 8/12• To prevent pressure sore within 6/52

PLAN OF TREATMENT

1) Passive movement

2) Passive stretch

3) Joint proprioception training

4) TME

5) Circulation exercise

6) Elevation

7) Active exercise for UL

8) Positioning

INTERVENTION

1)Passive movementOn half lying,bed head is set to 35°, Hip flexion extension both side 5 repetition x 3 sets x both sidesHip abduction adduction 5 repetition x 3 sets x both sidesHip internal rotation external rotation 5 repetition x 3 sets x both sidesKnee flexion extension 5 repetition x 3 sets x both sides Ankle dorsilexion plantarflexion 5 repetition x 3 sets x both sides

2)Passive stretchOn half lying,bed head is set to 35°,gastrocnemius stretch,15 sec hold x 3 repetitions x 1 sets

3)Joint proprioception trainingOn half lying,bed head is set to 35°,knee flexion, press on bed 30 seconds x 3 sets x both sides

4)Thoracic Mobility ExerciseOn half lying,bed head is set to 35°,TME 3 sec hold breath x 3 repetitions x 5ets

5)Circulation exerciseOn half lying,bed head is set to 35°,i. hand clench,10 repetitions x 3 sets x both sidesii. Passive ankle circulation 5 repetition x 3 sets x both sides

6)ElevationOn supine,legs are raises onto 3 pillow x 15 minutes

7)Active exercise On supine, i. Shoulder flexion extension 5 repetitions x 1 sets x both sidesii. Elbow flexion extension 10 repetitions x 1 sets x both sides

PATIENT’S EDUCATION1)Continue exercise as taught:

a)Thoracic Mobility ExerciseOn half lying,bed head is set to 35°,TME 3 sec hold breath x 3 repetitions x 3 sets x 2times per day

b)Circulation exercisehand clench,10 repetitions x 3 sets x both sides x 2 times per day

c)Active exercise Shoulder flexion extension 5 repetitions x 1 sets x both sides x 2times per dayElbow flexion extension 10 repetitions x 1 sets x both sides x 2 times per day

2)ElevationsAt least 10 minutes,per day

3)Advice pt to expectorate sputum

4) Should change positions every 2 hours to avoid bed sores and reduce pain such asi. turn from Rt Lt side lyii. Ly sitting

EVALUATION

Pt was able to obey command but not so cooperative.Ptrefuse to do previous exercise taught.Pt claimed that he was unable to lift his shoulder above head d/t fatigue.

During TME,pt Rt shoulder need to be assissted.

After 2nd set of TME,pt cough but no sputum.

Pt claimed that elevation and ankle circulation exercise improve his feet edema but,after 10 minutes,he c/o pain on anterior Lt thigh.

REVIEW

Review pt in next visit.To proceed same treatment in next visit.

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• http://www.mayoclinic.org/diseases-conditions/prostate-cancer/basics/definition/con-20029597

• http://www.cancerresearchuk.org/about-cancer/type/prostate-cancer/about/prostate-cancer-risks-and-causes