i bc27f85be50b71b1 (109 page)

354 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Multiple Myeloma

Multiple myeloma is a malignancy of plasma cells, which are derived

from B-lymphocytes (B-cells), and are responsible for creating antibodies. The disease is characterized by the tumor's arising in the bone marrow of Aat bones and the infiltration of the myeloma cells into the bone and, eventually, other organs. These malignant cells produce a single

type of antibody that may increase the viscosity of the blood. Classically, the disease produces bone pain and decreased number of normal hematOlogic cells (e.g., red blood cells, white blood cells, and platelets).

The disease has a slow progression. Most persons affected with

multiple myeloma have an asymptOmatic period that can last lip to 20

years. I Bone pain, usually the first symptom, occurs when the

myeloma cells have destroyed bone. Lesions created in the bone by

the malignant cells can cause pathologic fractures, especially in the

vertebral bodies. As further bone is destroyed, calcium and phospho·

rus are released, causing renal stones and renal failure.I.2.7

Amyloidosis may occur in patients with multiple myeloma. Deposition of this glycoprotein in tissues may cause them to become hard and waxy.

Myeloma is treated with chemotherapy, biotherapy, radiation, and

bone marrow transplantation. No treatment is curative.

Clinical Tip

• People with advanced stages of multiple myeloma may

be dehydrated. Ensure proper hydration before any type of

intervention.

•

Activity clearance should be obtained from the physician before mobilizing anyone with bone lesions.

Head, Neck, and Facial Tumors

Head, neck, and facial cancers involve the paranasal sinuses, nasal

and oral cavities, salivary glands, pharynx, and larynx. Environmental factOrs and personal habits (e.g., tObacco use) are often closely associated with the development of cancer in this region. 29

Physical therapy intervention may be indicated after the treatment

of head, neck, and facial tumors. Surgical procedures include radical

neck dissection, laryngectomy, and reconstructive surgery. Radical

ONCOLOGY

355

neck dissections may include removal or partial removal of the larynx, tonsils, lip, tongue, thyroid gland, parotid gland, cervical muscularllre (including the Sternocleidomastoid, platysma, omohyoid, and floor of the mOllth), internal and external jugular veins, and lymph

nodes.'· Reconstructive surgery may include a skin flap, muscle flap,

or both to cover resected areas of the neck and face. The pectoralis or

trapezius muscle is used during muscle flap reconstructive procedures.

A facial prosthesis is sometimes used to help the patient attain adequate cosmesis and speech.

Clinical Tip

•

Postoperatively, impairment of the respirarory system

should be considered in patients with head, neck, and

facial tumors because of possible obstruction of the airway

or difficulty managing oral secretions. A common associated factor in patients with oral cancer is [he use of tobacco (both chewing and smoking); therefore, possible

underlying lung disease must also be considered. During

physical therapy assessment, the patient should be assessed

for adventitious breath sounds and effectiveness of airway

clearance. Oral secretions should be cleared effectively

before assessing breath sounds.

• Proper positioning is important to prevent aspiration

and excessive edema that may occur after surgery of the

face, neck, and head.

• Patients may also require a tracheostomy, artificial airway, or both to manage the airway and secretions.

• After a surgical procedure, the physician should determine activity and range-of-motion restrictions, especially after skin and muscle flap reconstructions. Physical therapy

treatment to restore posture and neck, shoulder, scapulothoracic, and temporomandibular motion is emphasized.

• When treating patients with head, neck, and facial cancers, it is important to consider the potential difficulties with speech, chewing, or swallowing and loss of sensations, including smell, taste, hearing, and sight.

•

Because the patient may have difficulty with communicating and swallowing, referring the patient to a speech

therapist and registered dietitian may be necessary.

356

AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Neurologic Cal/eers

Tumors of the nervous system can invade the brain, spinal cord, and

peripheral nerves. Brain tumors can occur in astrocytes (astrocytoma), meninges (meningeal sarcoma), and nerve cells (neuroblastoma), or they can be the result of cancer that has metastasized to the brain. 9 Symptoms related to cancers of the nervous system depend on

the size of the tumor and the area of the nervous system involved.

Neurologic symptoms can persist after tumor excision, owing to

destruction of neurologic tissues. Changes in neurologic status due to

compression of tissues within the nervous system can indicate further

spread of the tumor or may be related to edema of brain tissue.

Sequelae include cognitive deficits, skin changes, bowel and bladder

control problems, sexual dysfunction, and the need for assistive

devices and positioning devices. After resection of a brain tumor,

patients may demonstrate many other neurologic sequelae, including

hemiplegia and ataxia. Radiation therapy to structures of the nervous

system may also cause transient neurologic symptoms.

Clinical Tip

The therapist should assess the patient'S need for skin care,

splinting, positioning, assistance in activities of daily living, cognitive training, gait training, balance, assistive devices, and special equipment. See Chapter 4 for further

treatment considerations.

Skin Cancer

The physical therapist may identify suspicious lesions during examination or treatment, and these should be reported to the medical doctor. Suspicious lesions are characterized by (1) irregular or

asymmetric borders, (2) uneven coloring, (3) nodules or ulceration,

(4) bleeding or crusting, and (5) change in color, size, or thickness.

Cancers of the skin include basal cell cancer, squamous cell cancer,

malignant melanoma, and Kaposi's sarcoma. I

Basal cell carcinoma is the most common skin cancer. 9 It is usually

found in areas exposed to the sun, including the face, ears, neck,

scalp, shoulders, and back. Risk factors include chronic exposure to

ONCOLOGY

357

the sun, light eyes, and fair skin. Diagnosis is made with a biopsy or a

tissue sample. The following are five warning signs of basal cell carcinoma the physical therapist should look for when working with patients31:

• Open sore that bleeds, oozes, or crusts and remains open for 3

or morc weeks

•

Reddish parch or irritated area, which may Cfust, itch, or hurr

• Smoorh growth with 3n elevated, rolled border, and an indentation in the center; tiny vessels may develop on the surface

• Shiny bump or nodule that is pearly or translucent and is often

pink (can be tan, black, or brown in dark-haired individuals)

• Scar-like area that is white, yellow, or waxy, with poorly defined

borders and shiny, taut skin

Squamous cell cancer usually occurs in areas exposed to the sun or

ultraviolet radiation. Lesions may be elevated and appear scaly or

keratotic (horny growth).9 Squamous cell lesions can metastasize to

the lymph nodes, lungs, bone, and brain.

Malignant melanoma is a neoplasm that arises from the melanocytes. Risk factors include previous history or family history of melanoma, immunosuppression, and a history of blistering sunburns before age 20. Malignant melanoma can metastasize to the lymph

nodes, lung, brain, liver, bone, and other areas of the skin.9 Moles or

pigmented spots exhibiting the following signs (called the ABCD rule)

may indicate malignant melanoma9:

A Asymmetry

=

B

Irregular border

=

C Varied color

=

D Diameter of more than 6 mm

=

Clinical Tip

•

After resection of skin lesions, proper positioning is

important ro prevent skin breakdown.