Kari Anderson, OTR/L and Megan Webster, PT

Megan Webster, PT, Certified Personal Trainer, Certified Lymphedema Therapist

Karl Anderson, OTR/L, MOT

April 6th, 2013

Managing Cancer Related Fatigue

The National Comprehensive Cancer Network definition(NCCN):

• “A distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”

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What is cancer-related fatigue

National Cancer Institute: PDQ Fatigue. Bethesda, MD: National Cancer Institue. Available at:http://cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional. Accessed March 24, 2013

Acute Fatigue vs. Cancer-Related Fatigue

‘Healthy’ Fatigue• Acute

• Relieved by sleep and rest

• Has an identifiable cause

Cancer-related Fatigue•Chronic

•Not completely relieved by sleep and rest

•Severe

•Mechanism poorly understood

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• 70-100% of cancer patients are affected by CRF during treatment

• For 30% or more, it can linger long after treatment is completed

• Many people are fully functioning prior to cancer diagnosis

• Treatment leads to: Reduced strength and endurance, fatigue, cognitive impairments

and pain

Difficulty returning to previous activities and responsibilities

Prevalence

Cramp F, Danial J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database System Review. 2008:CD0061454

Fatigue Affects Quality of Life

Curt, GA, Breitbart, W. Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition. Oncologist. 2000;5(5):353-60.5

• Walking distances

• Cleaning the house

• General household chores

• Getting exercise

• Straightening up the house

• Lifting things

• Social activities with friends/family

• Climbing stairs

• Running errands

• Taking care/meeting needs of family

• Concentrating on things

• Preparing food

Daily activities affected included:

Fatigue affecting one’s occupation and the impact of cancer treatment on primary caregivers

Curt, GA, Breitbart, W. Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition. Oncologist. 2000;5(5):353-60.

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• Accepted fewer responsibilities

• Reduced work hours

• Took days off work

• Stopped working altogether

• Went on disability

• Used unpaid family and medical leave time

Cancer Related Fatigue

• Fatigue is a highly distressing symptom of cancer It negatively impacts:

• Physical performance

• Mood

• Social interaction

• Cognitive performance

• Sense of self

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Types of Cancer-Related Fatigue

Primary Fatigue• Fatigue that results from the result of a disease or medical condition.

• Fatigue that is related to your diagnosis

Cancer treatments contribute to primary fatigue• Chemotherapy

• Radiation

• Surgery

• Blood & Marrow Transplants(BMT)

National Cancer Institute: PDQ Fatigue. Bethesda, MD: National Cancer Institue. Available at:http://cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional. Accessed March 24, 2013

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Department of Occupational Therapy, University of Illinois-Chicago 2012

[Materials developed by Kara Stout]

Types of Cancer-Related FatigueSecondary Fatigue

-Fatigue that is a result of factors beyond your diagnosis

Contributors to secondary fatigue

•Poor sleep

•Physical de-conditioning

•Infection

•Medication side-effects

•Depression/anxiety

•Emotional distress/stress

•Nutrition

Types of Cancer-Related Fatigue

Cognitive/mental fatigue

-Fatigue that makes it difficult to concentrate or do activities that involve thinking

-Not always obvious, but it is real

Common descriptors

Department of Occupational Therapy, University of Illinois-Chicago 2012

[Materials developed by Kara Stout]10

•Sleepy brain

•In a fog: cloudy thinking

•Mind goes blank

•Haziness, dullness

•Total confusion

•Can not think straight

NCCN Interventions for FatigueOccupational TherapyEnergy Conservation

Set priorities

Pace/Delegate

Scheduling

Structured daily routine

Psychosocial interventions Educational and supportive

therapies

Physical TherapyActivity enhancement

Initiate endurance and resistance exercise

Referral to PT/OT/physical medicine

Nutrition consultation

Psychological consult

11 National Cancer Institute: PDQ Fatigue. Bethesda, MD: National Cancer Institue. Available at:http://cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional. Accessed March 24, 2013

Fairview Cancer Rehab Program

• Occupational and Physical Therapy Evaluations

Therapists have extensive training and experience with cancer survivors

In depth knowledge of medical records and able to adjust your treatments to your specific and current needs (i.e. lab values, precautions/contraindications)

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PT sessions

• Individualized exercise prescription

Aerobic and endurance training, strength training, ROM

Manual therapy for myofascial restrictions, joint mobilization, and to decrease pain

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American College of Sports Medicine Roundtable on Exercise Guidelines for

Cancer Survivors

Exercise during and after cancer treatment is safe and positively impacts:

• Aerobic capacity

• Quality of Life

• Body composition

• Fatigue

• Strength

• Function•Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, et al. American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Medicine & Science in Sports & Exercise. 2010;42(7): 1409-1426

OT sessions• Occupational Therapy:

Energy management training

• Planning for physical and “brain” rest break

• Pacing, delegating

Cognitive compensatory strategies

• Mapping strategies for organization of thoughts

• Problem-solving to beak down tasks into manageable parts

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The Fatigue Cycle

Department of Occupational Therapy, University of Illinois-Chicago 2012

[Materials developed by Kara Stout]16

How to Manage Fatigue (The Basics)

• Banking your energy = saving energy when you can

• Budgeting your energy = deciding how to spend your energy

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Banking and Budgeting your Energy

•The goal is to put energy in the bank by resting

•Deposit energy by resting to strengthen your account

•Save energy so you can do the things you want and need to do

•Always keep a little energy in the bank for emergencies or special occasions

•The goal is to spend energy on what is important to you

•It can be hard to decide how to use your energy

•Think about your activities and how much energy they require

Who is Fairview Cancer Rehab for?

• Significant fatigue, diminished energy, increased need to rest

• Diminished concentration or memory

• Difficulty completing daily tasks

• Anyone who previously exercised and has difficulty returning to work/leisure activities

• Anyone who has never exercised and doesn’t know where to begin

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Case Study

• 46 y.o. female

• Stage IIIc R breast cancer, 16 nodes positive

• R mastectomy and Ax LND, chemo/radiation

• All treatment finished 2008

• Osteopenia, hyperlidipemia, asthma, migraines

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Case Study Continued

Impairments• Cognitive and physical fatigue

• Cognitive changes with decreased short term memory

• Weakness:

-Decreased shoulder strength

-Decreased leg strength

-Decreased endurance on 6 min walk test

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Case Study Continued

Treatment: Occupational Therapy

Energy management training

Cognitive compensatory strategies

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Case Study Continued

Treatment: Physical Therapy

-Education on how to increase aerobic capacity without undue fatigue using bike and eliptical machines

-Training in slow progression in weight lifting to avoid lymphedema and undue muscle soreness.

-Myofascial release to R shoulder, upper ¼.

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Discharge Status Fatigue Scores

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Case Study Continued

Discharge Status Physical Functioning

• 6 minute walk test at 97% of norm

• Leg press increased from 80# to 120# (90%of norm)

• Able to vacuum, carry groceries

• Returned to health club for weight lifting and aerobic workouts 3x week.

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Borg’s Scale of Perceived Exertion

Borg RPE scale© Gunnar Borg, 1970, 1985, 1994, 1998

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What can you do today?Begin a walking program

•Start walking once each day for 3-5 minutes, at a perceived exertion of 11-13 (light to somewhat hard)

•Add 1-2 minutes every 3 days with a goal of 30 minutes most days of the week. As you increase the amount of time, gradually increase your pace so you are working at a “somewhat hard” pace with perceived exertion of 12-14

•When you feel like you need a nap, try a short walk

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What can you do today?

• Decrease unnecessary muscle tension

• Strengthen your legs

-Find a chair with arms and push it up against the wall. Using your arms as little as possible, see how many times you can go from sitting to standing in 30 seconds

-Repeat it every other day and keep track of improvement

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How to access services

Fairview Cancer Rehab

612-273-6228

&

Managing Cancer-Related Fatigue Group

612-672-7272

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Questions

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References• National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in

Oncology: Cancer-Related Fatigue. Version 1.2010. Rockledge, Pa: National Comprehensive Cancer Network, 2010.Available online. Last accessed March 26, 2013

• Cramp F, Danial J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database System Review. 2008:CD006145

• Curt, GA, Breitbart, W. Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition. Oncologist. 2000;5(5):353-60.

• National Cancer Institute: PDQ Fatigue. Bethesda, MD: National Cancer Institue. Available at:http://cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional. Accessed March 24, 2013

• Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, et al. American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Medicine & Science in Sports & Exercise. 2010;42(7): 1409-1426

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