Volume 3/Issue 9 - September 2023 - Ribbons Physical Therapy

October is Breast Cancer Awareness Month

Each year in the United States, about 264,000 women get breast cancer and 42,000 women die from the disease. Men also get breast cancer, but it is not very common. Most breast cancers are found in women who are 50 years old or older, but breast cancer also affects younger women. ¹1 in 8 women in the United States will be diagnosed with breast cancer in their lifetime. But there is hope. When caught in its earliest, localized stages, the 5-year relative survival rate is 99%. Advances in early detection and treatment methods have significantly increased breast cancer survival rates in recent years, and there are currently over 3.8 million breast cancer survivors in the United States. Awareness of the facts and statistics surrounding breast cancer in the United States is key in empowering individuals to make informed decisions about their health.²

¹Division of Cancer Prevention and Control, Centers for Disease Control and Prevention
²National Breast Cancer Foundation, Inc.

Common Cancer diagnoses that can cause pelvic floor dysfunction:

Breast cancer and its therapies are one of the most common causes of upper extremity lymphedema. Multiple studies show:

1 in 5 breast cancer survivors will develop lymphedema
Lymphedema most often presents within 6-9 months after surgery, but can develop many years later
Risk factors including:
- Invasive cancer diagnosis
- Dissection/disruptions of axillary lymph nodes
- Radiation Therapy
- Local Infection
- Obesity

Other Symptoms That May be Experienced by Breast Cancer Patients

Loss of Shoulder ROM (Range Of Motion)
CIPN (Chemo Induced Peripheral Neuropathy)
CICI or RICD (Chemo Induced Cognitive Impairment “Chemo Brain”/Radiation Induced Cognitive Decline “Rad Brain”)
Radiation Fibrosis
Osteoporosis/Osteopenia
Patients undergoing hormone therapy may experience incontinence or urgency, dyspareunia

Early Detection and Intervention Is Key to Managing the Effects of Lymphedema

Referral to a Certified Lymphedema Therapist (CLT) at the earliest stage of treatment is essential to manage the disease before serious complications occur. This year, NCCN (National Comprehensive Cancer Network) included early intervention as part of its 2023 Survivorship guideline updates. The guideline states:

If possible, limb measurement of both sides should be performed as a baseline for survivors with treatment-related or individual risk factors, preferably by a trained lymphedema specialist.
Survivors should undergo baseline and ongoing periodic evaluation for the development or exacerbation of lymphedema.

Ribbons PT has instituted a program for surgeons that follows NCCN guidelines by establishing baseline measurements and assessment prior to surgery, one-month post-op, and quarterly for one year. In addition to monitoring for early signs of lymphedema, these quarterly interactions with your patients give us an opportunity to address other deficits such as shoulder (ROM) range of motion and any other deficits that may hinder recovery.

Ribbons PT Launches Thoracic/Pulmonary Pre-habilitation Program for Lung Cancer Surgery Patients

Lung cancer is the second most common cancer diagnosis in the US and the number one cancer killer among American women & men. Lung cancer, surgery, chemotherapy, and radiation therapy all have deleterious effects on function and present a symptom burden that may be more significant than among other solid tumor patient populations. Side effects and impairments associated with lung cancer can include Dyspnea, coughing, decreased appetite, pain/worsening pain, reduced functional capacity, psychological distress, fatigue, impaired balance, depression, anxiety, decreased HRQOL, Polyneuropathy, and post-thoracotomy pain syndrome.

40 to 50 percent of Small Cell Lung Cancer (SCLC) patients will develop brain metastases (BM). Low dose radiation to the whole brain may be used to prevent the spread of lung cancer to the brain. Side effects from whole brain radiation include deficits with short term memory, attention deficits, and word finding.
Non-Small Cell Lung Cancer (NSCLC) is the most common lung cancer diagnosis. About 25 percent are early-stage operable at diagnosis.
Up to two thirds of LCS (Lung Cancer Survivors) have metastases at diagnosis (6 percent five-year survival rate).
Five-year survival rates are improving, which means more importance should be placed on long-term morbidity & QoL.

As lung cancer diagnosis & long-term survival rates improve, long term function & QoL is becoming a greater concern.

Prehab for Lung Cancer Patient Population

Many patients with lung cancer are not appropriate for surgery and may be ineligible due to functional capacity (increased mortality risk). Poor exercise capacity predisposes patients to other comorbidities, decreased QOL, and potentially early mortality. The median survival rate for inoperable lung cancer is 8-10 months. 5-year survival rate 7 percent. This is why QoL is so important to these patients, which we can assist to improve.

Peak oxygen consumption is a strong predictor of long-term survival for NSCLC survivors. Providers may have concern with pre-op pulmonary rehab due to potential for delaying curative lung cancer resection (48 days seems to be magic number). However, although a 40week pre-habilitative program is optimal, even a 1 week prehab program with respiratory muscle training, cardiovascular exercise, education, & bronchodilators PRN has been shown to improve dyspnea, predicted post-op mortality, and complications and performance status.³ Prehab protocol includes:

Moderate endurance & resistance training
Breathing exercises
Aerobic exercises combined with at home breathing exercises with incentive spirometer:
30 sustained inspirations at 80% max vital capacity (6 cycles, 5 reps each, 1 minute rest between cycles)³

Primary Outcomes

Loss of Shoulder ROM (Range Of Motion)
CIPN (Chemo Induced Peripheral Neuropathy)
CICI or RICD (Chemo Induced Cognitive Impairment “Chemo Brain”/Radiation Induced Cognitive Decline “Rad Brain”)
Radiation Fibrosis
Osteoporosis/Osteopenia
Patients undergoing hormone therapy may experience incontinence or urgency, dyspareunia

³ Arbane G, Tropman D, Jackson D, Garrod R. Evaluation of an early exercise intervention after thoracotomy for non-small cell lung cancer (NSCLC), affection on quality of life, muscle strength and exercise tolerance: randomized controlled trial. Lung Cancer 2011;71(2):220-34. Jones LW, Eves ND, Waner E, Joy AA. Exercise therapy across the lung cancer continuum. Curr Oncology Rep. Jul 2009; 11(4):255-262. Brunelli A, Charloux A, Bollinger CT, et al. The European Respiratory Society and European Society of Thoracic Surgeons clinical guidelines for evaluating fitness for radical treatment (surgery and chemoradiotherapy) in p patients with lung cancer. Eur J Cardiothorac Surg. Jul 2009;36(1):181-184.
⁴ Sebio Garcia R, Yáñez Brage MI, Giménez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: A systematic review and meta-analysis. Interactive cardiovascular and thoracic surgery. 2016;23(3):486-497.
⁵ Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: systematic review and meta-analysis. R. Sebio García, et al

Sheree Obtains Oncologic Board Certification!

Sheree King, President/owner of Ribbons Physical Therapy, LLC, who is a Certified Lymphedema Physical Therapist, has been dedicated to the lymphedema/cancer patient population for nearly 20 years and is the region’s only LANA (Lymphology Academy North America) Certified Lymphedema Therapist, is now one of only three therapists in the State of Tennessee that is a Board-Certified Oncologic Specialist! In addition to developing case studies with actual patients, and extensive course work, Sheree also underwent a 7-hour exam to obtain board certification. Sheree had to demonstrate proficiency in recognizing and safely treating patients effected by the latest therapies offered by medical and radiation oncology, safely manage medically complex patients, and provide meaningful tools for measurable outcomes. She leads a team of Certified Lymphedema Physical and Occupational Therapists at her locations in Kingsport and Johnson City and has been integral with the area’s oncology programs to provide treatments unique to the cancer and lymphedema patient populations. In addition, Ribbons PT provides many programs that meets National Comprehensive Cancer Network (NCCN) guidelines as well as requirements set forth by Commission On Cancer (CoC) for oncology programs to maintain CoC certification. Ribbons Physical Therapy LLC is the only outpatient rehabilitation clinic in the East Tennessee region that is exclusively treating cancer survivors and lymphedema patients.

Congratulations Sheree!

Ribbons Physical Therapy Becomes Clinical Education Site for Milligan University’s Occupational Therapy Program

Starting in 2024, Milligan OT students can choose Ribbons PT as one of their Level 1 clinical rotation observation sites to learn first-hand how our Certified Lymphedema Therapists care for patients suffering from lymphedema and/or the effects of cancer and treatment side effects. In addition, this month our very own Mary Beth Street, OTR/L, CLT and Milligan Alumna is lecturing to the student cohort on lymphedema treatment and the unique requirements for treating patients suffering from cancer.

Earlier this year, Milligan University awarded the very first “Ribbons Physical Therapy Occupational Therapy Early Acceptance” Scholarship. The recipient is Sara Beth Dillard. Sara was accepted into the program while a Junior in undergraduate school and will be starting Milligan’s Occupational Therapy program in 2024. We are so grateful for the support of providers in our community, which allows us the opportunity to give back to the community in different ways. By helping support and develop future therapists we are ensuring that our passion to care for cancer and lymphedema patients will be carried forward for years to come.