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Deborah Howell (Host): Welcome, we all know that patients with cancer need a lot of medical attention, but can these same patients also benefit from some sort of rehabilitation therapy? I’m Deborah Howell and our guest today is Keri Claybourn, a physical therapist at High Point Therapy at Deaconess Women’s Hospital. Welcome Keri.

Keri Claybourn (Guest): Thank you Deborah.

Host: First of all, I am deeply curious, how can therapy be helpful to cancer patients?

Keri: So I think it is often an under served referral that doesn’t always happen because patients are like what are you going to do for me in therapy, but there are so many different avenues that we can do. We can educate them often on things to be aware of. If they’ve had lymph nodes removed and radiation. We can help talk to them about lymphedema prevention and treatment for lymphedema if that develops. We can talk to them about energy conservation. We can discuss neuropathy and how we can help them to manage their neuropathy that often is a side effect following their chemotherapy treatments. We can also work on general strengthening endurance exercises, just getting them back to their prior level of function.

Host: And if you’re not a cancer patient, you might not be familiar with lymphedema and neuropathy, maybe you could tell us a little bit about both?

Keri: So lymphedema is something you can develop even if you’re a non-cancer patient, but cancer patients are at risk when they have had lymph nodes removed with their treatment and/or radiation. Radiation is the gift that keeps on giving, so edema shows the good skin cells as well as the cancer cells. What that is, is you can develop some chronic swelling that does not go away, so you’re looking at how can we manage the swelling for the rest of their lives? Oftentimes if you get it addressed in the beginning stages, then you can help manage it for the long term of their life. I wish there was a magic wand to fix it and that’s probably the most common question I hear, “So if I get this taken care of now, can it go away?” No, but if you get it managed now, and we can give you symptoms and things to look for, then we can address it before it ever becomes an issue. This is a different type of swelling than if you went and sprained your ankle. If you sprained your ankle, that’s just going to be fluid and water. This swelling actually has proteins in it and our body cannot absorb those proteins on their own, so they need help and treatment and something called complete decongestive therapy to help absorb those proteins so that they’re not dealing with this chronic swelling, which is good because if you stay swollen then that puts them at risk for cellulitis, infection, hospitalization, things like that. Neuropathy, what that is, is a lot of times people are more familiar with neuropathy if you’re dealing with a diabetic patient but it is actual damage in the peripheral nerve. Patients will complain of numbness and tingling. Most often in the cancer patients, it’s going to be tips of their fingers, tips of their toes. They’re going to have decreased sensation and it’s a very painful feeling because it’s a nerve pain. So there are some different types of therapy and education that we can do for those patients to help those to manage as well as safety measures to implement so that way they’re not risk of cutting themselves or stepping on something if they can’t feel.

Host: You know my husband is going through this very same thing, and he says in his feet it feels like absolutely a thousand little people in there with swords just stabbing his toes.

Keri: Yes, and it sounds almost exactly like most of the patients that I see and it’s very, very uncomfortable. Oftentimes, physicians will try different types of neuropathy medication, and sometimes that’s successful in helping, but then a lot of times, you know there isn’t a magic cure for it, but the thing that we need to work on is when that’s going on, they don’t want to move their feet, they don’t want to move their hands because it hurts, but we need to encourage movement and there’s different strengthening exercises, range of motion exercises, compression and different things like that, that we can recommend to help guide those patients.

Host: Great, now back to lymphedema for a moment, treatments and preventions?

Keri: Yes, so prevention, the big thing is a lot of patients will tell me, “I’ve never been told anything about it, and now here I am two years later,” – and let’s use a breast cancer patient for example, “and my arm’s swollen, why wasn’t I told this?” You know, we talk about often, where they told it but just with everything else going, it was the last thing that they were worried about at the time or were they really not told much, so we’re really working to try to implement more of a screening process. That would be the goal to have every patient at least have a session as being instructed of what they can do and what they should look for. So oftentimes at their initial evaluation, I give them a handout of okay, these are the symptoms so even if you don’t have any of this now, you can develop lymphedema at any time in your life. So you could be 30 years out from cancer and develop lymphedema, and so patients need to be aware of looking for is there heaviness in that extremity? Is it warm? Do I feel like – in the arm especially people will say they feel like there’s a wad of something in between their arms and their chest wall or they’ll notice their clothing fits tighter, and that would be the same with the legs too. So a lot of times the preventative stuff is just educating them on what to look for. We do give them handouts. We discuss flying. There’s research that supports the change in the air pressure, you should have a preventative garment. If their active, then we help them to get a preventative garment, so that way that helps to apply the compression before swelling ever is addressed. So there’s a lot of different things depending on what the activity level is for that person. Once somebody comes for actual treatment, it kind of depends on where they are at with things. What is recommended to do the complete decongestive process is you would do compression, which is using wraps, you would do something called manual lymphatic drainage, which would be moving the lymphatic fluid to the healthy lymph nodes that have not been affected, then you also have skin care which is number one. We need to make sure that you’re not having open cuts, you’re not having blood pressures done on that side, you’re not having needle sticks, anything that could compromise that skin being open because healing could be delayed if there’s lymphedema present, and then the last component is exercise and exercise is probably the biggest thing. Most cancer patients are like, “I feel terrible, why do you want me to exercise” but there’s so much research to support the benefits of that.

Host: It just gets everything moving, everything circulating.

Keri: It does [laughter], it does and with the lymphedema, then you have the muscle pump action. So you want to make sure they’re exercising with compression on because that’ll help to move the fluid out. So if someone comes in for an evaluation I’m going to be looking at, are they a person that needs to be wrapped, where they would be coming in and getting bandages put on them? Are they a person that just needs the manual lymphatic drainage? Are they a person that needs both? They’re going to be most successful if they get those 4 components, but sometimes that’s not always necessary. There are oftentimes I never have to wrap someone because I can just do the manual lymphatic drainage. I can teach them how to do it or I can teach a family member and now there are some great products on the market, and the way of Flexitouch pumps that do the manual lymphatic drainage for the patients and allow them to be more compliant with that too.

Host: That is awesome.

Keri: Yes, we’ve come a long way.

Host: And Keri, what is the neuropathy treatment?

Keri: So the neuropathy treatments, once again lots of patient education, handouts that we have that want to make sure to tell patients to use gloves if they’re doing gardening, yardwork, the same with their feet – making sure they have shoes on because they’re going to have limited sensation. The other things that we do is compression and it’s actually really helpful for neuropathy. So if you get a patient, which often will have lymphedema and neuropathy, then compression’s going to be beneficial for both of them, but oftentimes I will guide patients in getting – they don’t have any lymphedema going on, getting some sort of compression socks, even a low grade compression, that will feel good on their feet or compression gloves. We help them to order those and get those addressed to help with that return and that feedback. The other thing is moving. So for the hands, we do a lot of putty exercises, range of motion exercises, fine motor exercises like where you would put little beads and putty and have them pick those out, buttoning things. What I’m most often told from my patients is, “I don’t want to move because it hurts so much,” so we have to encourage them to move in a positive way. For feet, we’re looking at shoe wear, making sure they have proper shoes. We also use an exercise, it sounds so silly but you put a towel on the ground, you put your bear foot on it, and you actually try to crunch the towel with your toe, so that way you’re working the intrinsic muscles of the feet. Often what you’ll also see with the chemotherapy induced neuropathy is sometimes patients will have absent reflexes in their ankles and they’ll start developing dropped foot so we’re looking at strengthening their ankles, strengthening their balance, so that they’re not going to be at a fall risk.

Host: Wow, you’re not kidding. It is the gift that keeps on giving isn’t it?

Keri: It is the gift that keeps on giving.

Host: Are there some postsurgical treatments for some of the patients you see?

Keri: Absolutely, for example, breast cancer patients – I’ll use that because that’s probably the most common that is referred. So a lot of times those patients have a lumpectomy and/or a mastectomy, they will develop some range of motion restrictions in their arms. Also into the chest they’ll have some pulling and something that develops called cording. My best way of describing cording is it’s almost like little guitar strings that will go down inside of the arm to the elbow, sometimes all the way to the wrist, and definitely into the chest wall. So our biggest thing for that is we get them going with a structured exercise program for range of motion, but then we’re able to come in here and do some myofascial releases onto those muscles. Often they’re tight in their pecs and then their scapular muscles are weakened and kind of stretched out because of the type of surgeries they have and then also radiation will make them tighter. I kind of like to describe radiation to my patients as that shrink wrap where you would put the blow dryer on and it would just kind of tighten down on things. Radiation tends to do that to the areas so we really need to get things moving and we need to teach them how they can do that at home. That includes not only instructing the patient themselves but also any caregivers or family members. Now if we’re discussing vulvar cancers, head and neck cancers, any of that, same thing, we’ll do range of motion exercises for them, we’ll help them with scar management. We will work on adjusting any problems that they may have that they’re encountering following their treatment.

Host: Well this is some really, really good information Keri. I am off to buy some compression socks for my husband and a towel. He’s going to do his toe exercises later today [laughter].

Keri: Yes.

Host: We want to thank you for explaining some of the rehabilitation options to help cancer patients get back to their best lives. Thank you so much for being with us.

Keri: Well thank you so much for having me.

Host: This is Deaconess, the Women’s Hospital, a place for all your life. For more information, please contact us at deaconess.com/highpoint or call 812-842-2820. This is Deborah Howell. Thanks for listening and have yourself a great day.