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What can I do for this patient?
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What can I do for this patient? - September 16, 2008 7:05:28 PM
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Kaden
Posts: 346
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50 year old male referred to physical therapy for hip pain. Current undergoing chemo for lung cancer that has metastisized to the bone including lower lumbar spine, and both hips.
Main complaint is pain and stiffness. I figure no mobs due to risk of pathologic fracture, but what about LE stretching. Seems this would put similar stresses across the joint.
Any thoughts?
How do folks handle communication with the patient and referring MD in cases like this.
I don't work with this population - really ever - so any advice would be appreciated.
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RE: What can I do for this patient? - September 16, 2008 7:40:56 PM
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SJBird55
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Why is there fear of fracture with mobilizing joints? First of all, what does the patient want? For pain control, the patient should probably be on heavy narcotics. Second of all, do you realize how much force goes through a joint during ambulation or from sit to stand or scooting in bed needing to perform bridging to scoot over? Do you really think that joint mobilization is going to come even close to those kinds of forces? (I'm referring to grade I-II) Do you know the location of the lesion?
If the patient didn't know the location of the lesion, I'd ask for both a report and for the diagnostic images so I could see the lesions for myself. I'd ask the patient direct questions about medications. I'd try to get a good picture of the pain intensity, frequency of the potentially altering intensities. I'd ask how often the patient is taking the prescribed pain medications. To control the pain associated with cancer, it isn't reasonable to have the "wait until the pain occurs" kind of approach. If the intensity seems to be high and doesn't seem to fluctuate much, I'd ask the patient if it would be okay to speak to whomever prescribes the pain medications to see if there is a better option.
Even though the gentleman is 50, I'd have him attempt to use a rolling walker. He may be able to reduce the stresses through the joints with the walker. He may be a candidate for a wheelchair.
If he wants to exercise, I'd suggest some type of non-weightbearing activity - like a recumbent bike OR exercise in an aquatic environment. Sure, I'd show him some common lumbar and lower extremity stretches. He should do them gentle and keep the intensity of the stretch at a mild intensity. If he starts to feel pain, he's gotta back off.
Everyone is different... the key is to learn what he wants. You aren't going to fix any problem. His function probably isn't going to improve. His prognosis might not be that great. Massage is helpful in the short-term - probably both physically speaking, but also mentally. Your role will probably be more palliative in nature. Ask him about how he tolerates chemo treatments. It's highly likely that he has a pattern of how well he's able to function based on his chemo days - fatigue might be an issue. You might have to work around his response to chemo... meaning, during the week he has chemo, he might only be able to really attend once that week for PT services. In this area, some chemo for lung cancer is oral - those patients also seem to have a pattern to their ability to function.
Would home services be a better option for him? I can't remember where you are located, Kaden... if his prognosis is really poor, what about hospice? Well... if he's doing chemo, I don't think he's a candidate for hospice... hospice does do a really good job of keeping pain controlled in a manner that the person is reasonably cognitively functioning (until the functional decline is really, really substantial).
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RE: What can I do for this patient? - September 16, 2008 8:46:43 PM
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blast7
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I find Oncologists to be very helpful and very effective in coordinating a patient's full plan of care so I would not hesitate to speak directly with the MD. You will gain much more info by talking to the MD than reading his/her notes.
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RE: What can I do for this patient? - September 18, 2008 1:14:42 AM
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Kaden
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Thanks for the advice. I have a call into the MD.
SJ,
My worry about fracture with joint mobs is from grade III/IV. I think he had some previous OA problems exacerbated by his bed rest from early treatments and does really present with a stiff hip needing mobs to gain motion.
What about stretching? It would seem to me these would be even more harmful b/c of the long axis to them. With mets to the lumbar spine and hip I am worried about stress to these areas caused by typical LE and lumbar stretches.
I will probably just stick with some AROM and focus on strengthening until I hear from the MD.
Thanks again for the advice.
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RE: What can I do for this patient? - September 18, 2008 7:41:18 AM
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buckeye
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Kaden - Your concerns are not totally unwarranted. Although fractures with moblizations or stretching are probably rare, I think there have been reported cases of femur fractures occurring with passive stretches. Some of your conversation may need to include explanation of potential risk and benefits of exercise/stretching. I am not aware of any statistics to give our patients on frequency of fractures with stretching/mobilization, so it may just be enough to say the risk is greater for this patient due to the cancer mets to the bone. SJBird has some good advice for you. Maybe treating without mobilization or aggressive stretching for a trial is a good idea. If no success in a reasonable period of time, then consider more aggressive treatment.
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RE: What can I do for this patient? - September 22, 2008 3:54:12 PM
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Kaden
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Okay, so I talked to the oncologist. He stated the patient was doing fairly well and even though some mets to the hip and lumbar spine should be fine for some gentle stretching and strengthening.
My question is...If you thought his hip pain was exacerbated by decreased articular mobility would you attmept grade III/IV mobs? Or would you start with gentle stretches first and intervene with joint mobs only if necessary.
There doesn't seem to be much difference in the force b/w the two (patient directed stretch versus mobs) but I feel hesitant to be the one putting those mob forces across the joint.
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RE: What can I do for this patient? - September 22, 2008 5:43:23 PM
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SJBird55
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Kaden why don't you start with Grade I/II... see how that is tolerated for a few minutes, then go for a grade III for a few minutes and then attempt a IV? I honestly wouldn't have quite the hesitation - just use common sense. If there is going to be a major problem, you're going to feel muscle guarding. Start gentle and progress if there isn't any guarding.
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RE: What can I do for this patient? - September 22, 2008 6:10:24 PM
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Kaden
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SJ,
Because that sounds like too much of a rationale based, logical progression :). Sometimes I like to make things difficult on myself by second guessing things, it keeps me on my feet and thinking.
Thanks for the advice.
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RE: What can I do for this patient? - September 22, 2008 8:05:48 PM
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SJBird55
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From: Michigan
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Keep us posted. I'm confident it'll go fine. Spend time talking to the patient about what the patient is perceiving as you do the manual interventions. Communicate to the patient what you don't want him to feel. Be cautiously confident in your handling. If an unexpected response begins to occur, just back off, reassess and rethink the game plan. For this guy, maybe even educating him on various resting positions might be helpful. On days when he's just not up to tolerating a very high activity level and finds himself on the couch or in bed (you get the point), you could suggest making sure he spends some time lying on his side with pillows appropriately used... or what about time in the prone position - how does he feel about that position - are there breathing issues or pain issues due to his chemo treatments that would prevent this positioning?
You're attempting to do your best to assist him in his unknown journey; I'm sure he'll recognize your dedication.
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RE: What can I do for this patient? - September 24, 2008 2:07:35 AM
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ianwvu
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From: Glendale, AZ
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I tend to be a little more cautious with these kind of patients. I also rationalize with the same line of "do you know how much load they place through these bones/joints when they are doing something as simple as ambulating... of course the XYZ mob will definitely be safe" when questioned by another therapist, so I definitely understand that point, but I would guess with a femur, if you are performing a distraction mobilization, you are placing an unaccustomed force on the femur, which as a long bone is mostly dealing with superior/inferior compressive forces, and not medial/lateral "bending" type force. I would assume as long as you position them properly, spread your force out over a large area with your hands, and get as proximal as you can, you could achieve a good amount of force without risking much.
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