Services grew with word of mouth
When a St. Louis rehab facility expanded with a lymphedema program, physicians and patients quickly filled the facility and pressed for additional cancer rehab services.
SSM Rehab Outpatient Bellevue Clinic in St. Louis began its lymphedema program in the third quarter of 2000 with two physical therapists. By the fall of 2002, the program had grown to 73 patients and five therapists, says Sarah Stolker, MSPT, CLT-LANA, manager and market leader as well as program manager for cancer rehab services for SSM Rehab.
Lymphedema occurs with the accumulation of lymph tissue and swelling caused by inflammation. While congenital lymphedema is a hereditary disorder of chronic lymphatic obstruction and there are other causes of the condition, most cases of lymphedema are the result of surgical removal of lymph channels in mastectomy.
"We’re now trying to fill a void in the St. Louis area to be the resource for our past and current patients in lymphedema," Stolker says.
Community lectures get the word out
Stolker has helped to get the word out about the program through community lectures, such as visiting wellness programs and church groups. She explains to physicians, prospective patients, and others that lymphedema treatment is a complete decongestive therapy that involves manual lymph drainage through a superficial massage that stimulates the lymphatic system.
"I start with defining lymphedema and talk about current treatment approaches, prevention strategies, and goals of treatment," Stolker says. "We had a few breast cancer awareness days where I was invited to speak, and after meeting with physicians they would volunteer me to speak at these types of events."
Once the program began to treat patients, there was an increase in referrals from patients and their families, as well as from other clinics where lymphedema services were unavailable.
"The program grew, and that definitely necessitated an increase in staffing," Stolker says. "Then we started working on doing patient education for the treatment of cancer, the kinds of things I really thought were separate from lymphedema."
Soon it became clear that by focusing only on lymphedema, the program was missing an opportunity to provide even greater service to the area, because there are many patients who either may not have lymphedema or may have the condition in addition to other problems that could be resolved through cancer rehab.
Stolker started to look into cancer treatment-related fatigue, treatment after head and neck cancer, and rehab protocol after breast reconstruction. Here’s why and how these cancer services work in a rehab environment:
• Cancer fatigue.
"Once lymphedema opened the door, it showed me many other areas where cancer patients might benefit from our services," Stolker says.
For example, cancer fatigue affects nearly 70% of all cancer patients, Stolker explains. "It’s the result of a combination of things, like treatment itself, radiation, chemotherapy, and the stress of having cancer."
People with cancer have higher nutritional demands, and if they experience depression, then they may also have an appetite loss that means a decreased nutritional intake at a time when they need more calories and vitamins, she adds.
"Research does support exercise as an effective treatment for cancer patients who have fatigue, because exercise will increase physical energy, including energy for daily activities," Stolker says. "It decreases the heart rate, improves the quality of life, and provides a sense of well-being." So this is how cancer rehab services can provide marked benefits to cancer patients experiencing fatigue.
"The best training is interval training, short maximal regimens that allow for recovery between them so the patient doesn’t spend the afternoon in bed after a session," Stolker says. "And physical therapists can easily provide a springboard for patients to do this exercise in a controlled environment, monitoring them in the current medical situation, and kind of be their coach."
Physical therapy increases jaw function
• Head and neck cancer.
Typically, patients receiving head and neck cancer treatment will receive speech therapy, but physical therapy may not be ordered routinely, and this is where a cancer rehab program may help.
"Rehab therapy can make a big difference in range of motion," Stolker says. "There are often a lot of jaw restrictions, and therapy can increase jaw function and improve the fitting of a prosthesis for speech and swallowing."
If a patient’s nasal pharynx is removed or if the patient’s teeth are removed, then the patient will have altered speech and will have difficulty swallowing, all of which can be improved through therapy.
These same patients may also develop lymphedema, as there are 300 lymph nodes in the head and neck, creating ample opportunity for fluid to collect and cause facial swelling. So these patients also could be candidates for lymphedema treatment, Stolker says.
"Because these patients usually undergo radical neck dissection or modified neck dissection, they usually do have nerve damage of the spinal accessory nerve, and they actually get paralysis of the trapezius muscles," Stolker says. "The whole shoulder drops down, and it becomes very uncomfortable, causing shoulder pain."
Physical therapists can teach these patients exercises that will strengthen their other muscles around the shoulder muscle and help to prop it up, Stolker says.
New breast surgery eschews implants
• Breast reconstruction.
Stolker’s experience mirrors recent research showing that there’s a new trend of breast cancer patients opting for immediate breast reconstruction at the time of breast surgery.
"People are opting for these procedures that take part of their own bodies to reconstruct a breast, instead of using breast implants," Stolker says. "They do this because it decreases anesthesia risk by having only one surgery, and women have some fear of implants, which don’t look as natural as a reconstructed breast from your own tissue."
One type of this newer surgery involves breast reconstruction that uses abdominal musculature to reconstruct the breast. While this procedure has many advantages, there are drawbacks that bring rehab into the picture, Stolker notes. The surgery may result in abdominal hernia, abdominal weakness, back pain, and overall functional limitations, she says.
Also, these patients are advised to flex at the hips and lean forward for about a week to 10 days, both of which can exacerbate an existing back condition, Stolker adds.
"We really do find that rehab therapy can accelerate the patient’s return to function," Stolker says. "I’ve started to design a study with a local plastic surgeon on the benefits of rehab with these patients."
Part of cancer rehab treatment includes education on back safety and a slow introduction to truncal stabilization exercises.
"We take very careful steps to make sure that any abdominal strengthening that we do does not put patients at risk for abdominal hernias or any sort of back injuries," Stolker says.
"Also because of scar distribution, people can develop fluid trapping in the trunk, and so with lymphedema we can intervene there too," Stolker says.
• Lymphedema.
The cancer treatment program bases the lymphedema therapy on a technique first established in Germany in the 1980s, which is a combination of four techniques: skin care, manual lymph drainage, compressive bandaging, and exercise.
The lymphedema treatment typically is provided five days a week for two weeks, Stolker says. The first part of the treatment involves having therapists massage the area where fluid accumulates and stimulate the lymphatic system to drain.
Cancer patients who have lymphedema are at greater risk for infection. Because these patients have had lymph nodes removed and because lymphedema involves a protein-rich fluid, bacteria that penetrate the skin can proliferate rapidly, Stolker explains.
"So it’s not uncommon to see someone who has had several infections since the development of lymphedema," she says.
These patients will be prescribed antibiotics, but the decongestive therapy also can help reduce the patient’s infection rate. Patients also receive skin care treatment with a pH lotion to decrease the amount of bacteria on the skin’s surface, Stolker says.
The third part of the treatment involves applying a low-stretch bandage on the limb after the massage. This helps prevent the accumulation of fluid in the limb and facilitates the pumping out of additional fluid after exercise, Stolker says.
Last, therapists instruct patients about exercises that help them overcome any limitations they may have post-surgery and that help reduce fluid volume. These are light exercises performed in a specific sequence, Stolker says.
Need More Information?- Sarah Stolker, MSPT, CLT-LANA, Manager and Market Leader and Program Manager for Cancer Rehab Services, SSM Rehab Outpatient Bellevue Clinic, 1027 Bellevue Ave., Suite 15, St. Louis, MO 63117. Telephone: (314) 768-5375.
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