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CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 1
Class Correspondence: [email protected]
Lynn Tanner, PT, Laura Gilchrist PT, PhD, Bonnie Carlson-Green PhD, LP, Nathan Gossai,
MD, Teresa Herriage, DNP, APRN, CNP, CPHON, Heather Johnson, PNP, Diane Lesmeister,
OTR/L, Monica Olsen, PT, DPT, Leah Podergois, CCC-SLP, Sharyl Samargia-Grivette, CCC-
SLP, PhD, Susan Sencer, MD
Lynn Tanner, PT [email protected]
Monica Olsen, PT, DPT
Page 3© 2021
Prospective Surveillance
Model
Surveillance
Adverse Event
Education
Early Detection
Rehabilitation
Wellness Promotion
Stout et al. 2012
Page 4© 2021
• Surveillance – assessing side effects along the cancer continuum of care
• Adverse event education – preventative education
• Early detection – identifying impairments/limitations/restriction early to treat
• Rehabilitation – intervention
• Wellness promotion – promoting a healthy lifestyle throughout treatment
Page 5© 2021
Surveillance
Reflexes
ROM
Strength
Gait
Balance
ADLs/IADLs
Education
Role of Rehab
Side effects
Prehab
Early Detection
Baseline assessment
Impairments Limitations at Cancer Dx.
Rehabilitation
Treat cancer-related and
developmental impairments
Wellness Promotion
Independence
Daily routine
Physical activity
Quality of life
Page 6© 2021
Surveillance
Ped-mTNS
ROM
Strength
Gait
Balance
Motor skills
ADLs/IADLs
Education
Role of Rehab
Scheduling
Side effects
Home exercise program
Early Detection
Ongoing assessment
Impairments measured
1x/mon
Limitations measured 1x/6
months
Rehabilitation
Treat cancer-related and
developmental impairments
and limitations
Wellness Promotion
Independence
Daily routine
Physical activity
Quality of life
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 2
Page 7© 2021
Surveillance
Ped-mTNS
ROM
Strength
Gait
Balance
Motor skills
ADLS/IADLs
Cognition
Communication
Education
Role of Rehab
Scheduling
Episodes of care
Late effects
Home exercise program
Early Detection
Late effects
Developmental Recovery
Rehabilitation
Treat cancer-related and
developmental impairments
and limitations
Wellness Promotion
Independence
Daily routine
Physical activity
Quality of life
Page 8© 2021
Surveillance
Ped-mTNS
ROM
Strength
Gait
Balance
Motor skills
ADLs/IADLs
Cognition
Communication
Education
Role of Rehab
Scheduling
Late effects
Home exercise program
Early Detection
Late effects
Developmental Recovery
Transition to Adulthood
Rehabilitation
Treat cancer-related and
developmental impairments
and limitations
Independent living
rehabilitation
Vocational rehabilitation
Wellness Promotion
Independence
Physical activity
Quality of life
Page 9© 2021
• Standardized measures and specific time points
• Educational handouts based on “light” color
• Sustained benefits on physical performance and physical activity level
Page 10© 2021
Diagnosis
Pain
ROM
Strength
Gait
Balance
Reflexes
Education
OP
4-8 wksPain
ROM
Strength
Gait
Ped-mTNS
Foot Posture
Gait endurance
Education
OP
2nd visit
Motor function
Home exercise program
Page 11© 2021
How are they feeling?
Activities
Enjoyed in the last week
Enjoyed prior to diagnosis
Both physical and not physical
Typical daily routine
School attendance
After school
Weekends
Environment Physical activities they
are good at
Physical activities they would like to
improve
Page 12© 2021
• Visual Analog Scale (VAS)
Age 13-21
• FACES scale
Age 5-12
• FLACC
Age 2 mos – 7 yr
• Younger children
• Ask caregivers about any concerns
of pain
• Behavior changes
• Pain in the last month
• Pain description
• Activities before, during, and after pain
• Medications
• Differentiate between pain and fatigue
• Assess relationship to chemotherapy
cycle
McGrath 2008 PedIMMPACT, Merkle 1997
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 3
Page 13© 2021
• Outcome measurement
– Goniometric measurement
– Technique extremely important
– Two-person measurement optimal to hold subtalar neutral position and avoid
measuring a pronated foot
Page 14© 2021
• Foot posture index (FPI-6)
–Scale measurement with standard criteria
–Manual available
• Hindfoot measurements– Bisect calcaneus with ankle dorsiflexed to O in prone and draw line
– In standing, measure the angle between vertical and calcaneal line
Page 15© 2021
• Decreased velocity
• Decreased step length
• Foot slap• Flat foot • Knee hyperextension
• Decreased step length
• Wide base of support
• Toe walking
• Steppage pattern
• Lateral lurch
Page 16© 2021
Computerized gait analysis
Observational gait analysis (OGA)
Water marks on paper
Measure/observe
Push-off
Initial contact
Step length
Base of support
Out-toeing/intoeing
Page 17© 2021
• Manual muscle tests– Difficult in children under 5
– Look at all muscle groups» toe extension/flexion strength
• Functional movement– Stairs - kids over 4 should alternate up/down
» with and without verbal cues
– Floor to stand through squatting or 1/2 kneel (2 yrs)
– Supine to sit (core weakness)
– Hopping (using plantarflexion or quads/hams)
– Heel walking
• Strength subtest of Bruininks-Oseretsky Test – Second Edition
Page 18© 2021
• Peripheral neuropathy
• Decreased ROM
• Vestibular impairment
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 4
Page 19© 2021
• Single leg stance
– eyes open or closed, hands on hips
• BOT-2 balance scale
• Stationary subscale PDMS II
• Others
– Pediatric balance scale
– mCTSIB
– BESS
– Dynamic Gait Index
Page 20© 2021
• Standardized testing
– Peabody Developmental Motor Scales, Second Edition
– BOT-2: Bruininks-Oseretsky Test of Motor Proficiency, Second Edition
• Others
– Bayley Scales of Infant Development – Third Edition
Page 21© 2021
• Screen grip/pinch
• Change in fine motor skills/ADLs/IADLs
• Refer to OT
Page 22© 2021
• Decreased during treatment and after treatment
• Can test using 6-minute walk test
• American Thoracic Society guidelines
• 50 ft walk way
• BP/HR pre and post if possible
• Objects to retrieve/drop if needed for young ages
• Age > 5 yo
• PACER
• Other
• Treadmill test, Cycle ergometer
Page 23© 2021
• PedsQL
• PROMIS scales
Page 24© 2021
Impairment level outcomes
1x/month
Motor function 1x/6 months
Neuropathy
1x/3 months during intense
treatment
1x/6 months during
maintenance
When clinically appropriate
New symptoms
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 5
Page 25© 2021
• CIPN assessment and intervention
• Trunk patterns
– May have asymmetry secondary to surgery or radiation
• Understand frequency of vincristine dosing
Page 26© 2021
• CIPN assessment and intervention
• Muscle atrophy and limb length discrepancies secondary to surgery and radiation
• Look at asymmetries secondary to tumor location and treatment
Page 27© 2021
• Deficits depend on stage and treatment
• Possible CIPN
• Time in treatment leads to extreme deconditioning in higher stage patients
• Can have surgical needs depending on tumor placement
• Possible vestibular component secondary to ototoxicity of treatment
Page 28© 2021
• Decreased ROM
• Decreased gait velocity
• Decreased muscle strength
• Decreased grip strength
• Functional Loss
• Gerber et al (2006) found these deficits in survivors 20 years post treatment
Page 29© 2021
• Surgeries are complicated
– Limb salvage
» Endoprosthesis (growing?)
» Cadaver graft
– Ampuation
» Rotationplasty
» Amputation
• Close communication with orthopedic surgeon
• Wbing precautions
• Incision healing
• Bone healing
• Specifics
• Advocate for need of rehab
• Focus on ROM, strength, symmetry, gait, and physical activity capabilities
Page 30© 2021
• Awareness of Immune-effector cell-associated neurotoxicity syndrome (ICANS)
– Encephalopathy
» But awake with decreased verbal and physical reponse
– Decreased level of consciousness
– Seizures
– Muscle spasms/weakness
– Hemiparesis or paraparesis with SEVERE cases
– Increased intracranial pressure or cerebral edema
– Aphasia
– Ataxia (Lee, 2019) (Firestein, 2020)
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 6
Page 31© 2021
• Cytokine Release Syndrome (CRS)
– Fevers, myalgias, headaches, chills, tachycardia
• Tumor Lysis syndrome
• Neurotoxicity from ICANS persist past symptoms of CRS
(Firestein, 2020)
Page 32© 2021
• ROM
• Strength
• Balance
• Endurance
– 6 MWT
– PROMIS fatigue scale short form
• Motor skills
– BOT-2
• QOL
(Lenker & Foley, 2019)
Page 34© 2021
• Treatment schedule
– Chemotherapy medications
– Radiation
– IP and OP admissions
– Distance to center
– Pre-medications
• Family readiness and coping
• Other services needed
– psychology
Page 36© 2021
Gait intervention
CIPN severity
Ankle ROM
Gait pattern
Strength
Treatment phase
Age/size of child
Activity level
Family readiness
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 7
Page 37© 2021
“Quiet walking”
“Squish the bugs walk”
Lengthen stride length
T-band just below knee for toe walking
Balance beam dorsiflexion freeze
Stride stance work
Treadmill training
Symmetry, quality with endurance
Inversion - look at toe extensors, circumduction
Out-toeing - foot compensation or WBOS
ORTHOTICS
Page 38© 2021
Historical interventions Historical results
Daily heelcord stretching -Loss of ankle ROM
-Midfoot collapse
-Hindfoot valgus
Off-the-shelf dorsiflexion stretching splints
night and sedentary time
-Maintains or slight increase in DF ROM
-Midfoot collapse
-Hindfoot valgus
Hinged AFOs worn daytime and/or nighttime
-Varied results in ankle DF ROM
-Collapsed midfoot
-Hindfoot valgus
Page 39© 2021
Orthotic DecisionAnkle ROM
• Baseline ROM
• Speed of loss• 5-10 degree
loss
• Active and passive
• Goal: 10°ADFROM
Strength
• Ankle ≤ MMT 4
• Progression• Muscle
endurance
Gait
• Foot slap
• Early heel rise• Shortened step
length
• Toe walking
• Change over 6 MWT
Foot Posture
• Loss of arch
• Calcaneal valgus
• Out-toeing
• In-toeing
• Prevention
Treatment Cycle
• Early
• Middle
• End
• Neurotoxic agents
Age
• Age 2-4
• School age• Adolescent
• Adult
Season
• Compliance in hot weather
Page 40© 2021
Decreased ankle ROM
Muscle weakness
+/- Foot posture
Gait change
Early/Mid/Late
Treatment
2-Pull Solid AFO
Full day wear until ROM normal andheel-toe gait pattern typical
Page 41© 2021
Stable functional DFROM
DF muscle
weakness
Gait changes
Fatigue
+/-foot posture
Mid/late treatment
Energy Response/Articulated/Ca
rbon AFO
Page 42© 2021
Decreased ankle ROM
Foot posture changes
+/- Muscle weakness
Late/end treatment
Serial Casting
+/-Orthotics
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 8
Page 43© 2021
Foot posture changes
Good strength
Normal gait
Late/end treatment
SMO/FO
Page 44© 2021
Passive ankle dorsiflexion to 15Active ankle dorsiflexion to 10
30 min PT session without footslap
No toe walking
Minimal early heel rise
Heel walk 50 feet with minimal compensations
Decrease time in AFO’s
Start with 4-6 hours
per day outside
AFO’s
Continue night-time use
if doing so
Try to select time of day that child is active out of them
Option: Wear before and after school
Option: Wear during school and not on weekends
Attempt to wear them in the latter half of the day
Option: Wear during school only
Reassess after 1 month
Page 45© 2021 Page 46© 2021
“Quiet walking”
“Squish the bugs walk”
Lengthen stride length
Heel walking
Tip toe walking
Treadmill training
Inversion - look at toe extensors, circumduction
Out-toeing - foot compensation or WBOS
ORTHOTICS
Page 47© 2021
• Core strengthening
– Prone over ball, Yoga, Crab walk, prone extension
• Hip and peripheral LE strengthening
Page 48© 2021
• Gastrocsoleus stretches
• Hamstring stretches
• Yoga sequences
– Downward dog
– Modified downward dog
– Lizard
– Pigeon
• Modified long-sit
• Nerve flossing techniques
• Wedge standing
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 9
Page 49© 2021
Induction/delayed intensification hoping to maintain strength
Consolidation/Maintenance Increase strength
Page 50© 2021
• Functional tasks
» encourage independence
» Standing while playing, kneeling while playing
» Up/down pieces games to encourage floor to stand transitions
» Stairs/step stool
Page 51© 2021
• Core strengthening
– Yoga, Pilates, theraball, push-ups
• Hip strengthening
– Bridges with cars, side step with t-band, clam shells
• Quads/hams
– Floor to stand transitions, sit to stand 1 min, eccentric control
Page 52© 2021
• Peripheral strength
– Heel walking
– Tip toe statues
– Jumping high for push off
– Jumping down for eccentric control
– Toe grasping
– Foot “caves”
– Dorsiflexion tug-of-war
Page 53© 2021
• Single leg stance work– Step stance, kicking ball, soccer ball stop, Yoga, Wiifit, popping
bubbles with feet, etc
– watch foot position and hip lean
• Unstable surface – standing, tandem stance, single leg stance
• Eyes closed• Balance beam
– forward, backward, tandem
• Head turns, diagonal movements
Page 54© 2021
– Stairs– Floor to stand
» Squats - especially for young children - ?femoral anteversion risk» 1/2 kneel to stand - able to lead with either leg
– Jumping» 2 foot take off and landing» Distance and height for strength/power» Hopping - look at both legs» Plyometrics for older kids
– Running» Look at speed, symmetry
– Skipping, Galloping
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 10
Page 55© 2021
• Transcutaneous electrical nerve stimulation (TENS)
– Reduce pain by reducing cytokine release and increasing endogenous opiod and
serotonin release
– Stimulate large nerve fibers impacting pain receptors
• Heat, massage, exercise
– Increase perfusion and oxygenation to the area reducing inflammatory mediators
that cause cell dysfunction
• Low levels of evidence and mixed results
(Ogle et al, 2020)
Page 56© 2021
Planning Pacing
Prioritizing Positioning
Energy conservation
Page 57© 2021
Less Fatigue
Move as able using 4 Ps
Progressive strengtheningRest
Weakness
Fatigue
Page 58© 2021
• > 18 yo
– 150-300 minutes of moderate
physical activity
– 75-150 of vigorous activity
– Muscle strengthening 2 days/wk
• Goal of meeting physical activity
guidelines
– 60 minutes of moderate to
vigorous physical activity/day (6-
17)
– Muscle strengthening 3 days/wk
– Bone strengthening 3 days/ wk
Page 59© 2021
PA
Frequency
Intensity
Time
Type
– Family-centered care
– Ongoing conversation
– Creativity
– Acknowledgement of small gains
– Positive reinforcement
– CIPN and walking as exercise?
– FITT principles
Monica Olsen, PT
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 11
Page 61© 2021
Line Role Considerations
Pulse oximeter; CR leads; BP cuff
Measure basic vital signs Ensure good signal strength, ask RN if disconnecting
Arterial Line Real-time blood pressure monitoring; blood draw for ABG analysis
Prevent prolonged activity with line above heart-level
PIV; Central line (Femoral, Internal Jugular)
Intravenous administration of fluids, medications
Board to stabilize as needed, check for hip flexion ROM restrictions if femoral line
PICC; Hickman/ Broviac; Ports
Fluids, medications, blood draws Tape/pin to gown so no tension on the line; No BP in arm with PICC
EVD (External ventricular drain)
Drains CSF from lateral ventricles into an external bag to relieve elevated ICP's
RN must clamp prior to mobilization; needs to be recalibrated prior to unclamping
NG/NJ and GT/GJ Provide hydration, nutrition, and
medication to GI tract; remove contents
from the stomach
Prone ok as tolerated, consider timing of
treatments around feed schedule Page 62© 2021
Consideration PT Frequency Example
Are there new significant functional impairments? Is PT necessary for safe d/c home?
1-2x/day Ex. Teen with a new brain tumor now s/p resection
Is there a significant risk for deconditioning and loss of skills without direct, skilled intervention?
5-6x/week Ex. Child demonstrating new-onset moderate-severe CIPN symptoms
Is there a risk for complications due to immobility?
3-4x/week Ex. Child with newly diagnosed ALL with difficulty walking d/t LE pain
Is there a risk for loss of skill due to prolonged hospitalization?
1-2x/week Ex. Teen with AML admitted for a month-long chemotherapy admission
Are there no concerns for new impairments or loss of skill at this time?
1-2 visits total Ex. New diagnosis without other current functional impairments
Page 63© 2021
• PICU
– PROM
– PRAFO's
– Positioning
– Early Mobility
Page 64© 2021
• Prolonged admissions
– Create PT/OT/SLP schedule; Child
Life Specialist can help
– Education on daily routine/ ADL's
– Rehab out of room as able (ask RN if
able to go to gym, outside, etc.)
• Out of bed mobility
– Playmat, Cube
Chair, Benches, Activity Trays,
Tricycle, Wagons
– Walking schedule
Clinical Pearl
From 1st admission, educate
patients/families that beds
are for sleeping/ resting only;
not eating, playing etc.
Page 65© 2021
Lynn Tanner, PT
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 12
Page 67© 2021
Surveillance
•Reflexes
•Sensation
•ROM
•Tone
•Movement disorder
•Vision
•Oculomotor
•Vestibular
•Cognition
•Communication
•Strength
•Gait
•Balance
•Motor function
•ADLs/IADLs
Education
•Role of Rehab
•Prehab
Early Detection
•Baseline assessment
•Impairments Limitations at Cancer Dx.
Rehabilitation
•Treat cancer-related and developmental impairments
Wellness Promotion
•Independence
•Daily routine
•Physical activity
•Quality of life
Page 68© 2021
Surveillance
•Reflexes
•Sensation
•ROM
•Tone
•Movement disorder
•Vision
•Oculomotor
•Vestibular
•Swallowing
•Cognition
•Communication
•Strength
•Gait
•Balance
•Motor function
•ADLs/IADLS
Education
•Role of Rehab during IP and return to home
•Scheduling IP
•Surgical side effects
•Safety
•Transfers
•Feeding
•Swallowing
•Adaptive communication
•Daily exercise program
Early Detection
•Ongoing assessment
•Contractures
Rehabilitation
•Treat cancer-related and surgical impairments and limitations
•Focusing on skills and safety needed for return to home
•Equipment
Wellness Promotion
•Independence
•Daily routine
•Physical activity
•Quality of life
Page 69© 2021
Surveillance
•Ped-mTNS
•Sensation
•ROM
•Tone
•Movement disorder
•Vision
•Oculomotor
•Swallowing
•Cognition
•Communication
•Strength
•Gait
•Balance
•Motor function
•ADLs/IADLs
Education
•Role of Rehab
•Scheduling
•Radiation/chemo side effects
•Daily exercise program
Early Detection
•Ongoing assessment
•Fatigue
•Neuropathy
•Contractures
Rehabilitation
•Treat cancer-related and surgical impairments and limitations
Wellness Promotion
•Independence
•Daily routine
•Physical activity
•Quality of life
Page 70© 2021
Surveillance
•Ped-mTNS
•Sensation
•ROM
•Tone
•Movement disorder
•Vision
•Oculomotor
•Swallowing
•Cognition
•Communication
•Strength
•Gait
•Balance
•Motor function
•ADLs/IADLs
Education
•Role of Rehab
•Scheduling
•Radiation/chemo side effects
•Daily exercise program
Early Detection
•Ongoing assessment
•Fatigue
•Neuropathy
•Contractures
•Weakness
•Integumentary
Rehabilitation
•Treat cancer-related and treatment impairments and limitations
Wellness Promotion
•Independence
•Daily routine
•Physical activity
•Quality of life
Page 71© 2021
• No increase in physical exertion for 4 weeks.
• No contact sports or jumping/running for at least 3 months.
• Can work on passive/active cervical ROM
• Can work on gait, gentle strengthening, walking, controlled balance training
Page 72© 2021
• Keep patient active if they have an EVD prior to or post craniotomy
– Ask if EVD can be clamped
• Cervical movement important post surgery
• Up in chair 24 hours post-op
• Gait belts important
• Multidisciplinary care
– Involve family and nursing in rehab
» Coordinate schedules – pain, self-care, sleep
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 13
Page 73© 2021
• Brain tumor patients often have rehabilitation services during hospital admission after
surgery
• Possible candidates for IP rehabilitation
– Pediatric inpatient rehab unit reported 8% of population were patients with brain
tumors in 7 years of data collection
Kim et al 2013
• Outpatient therapy during and after radiation/chemotherapy treatment
– Fatigue with radiation can be a factor
Page 74© 2021
• Occurs 24-100 hrs after surgery
• Mutism or speech disturbances
• Dysphagia
• Decreased motor function
• Cranial nerve palsies
• Emotional lability
• Recovery can take weeks to months
• Resource: www.posteriorfossa.org
Page 75© 2021
• Complexity and unique presentation
require thorough neuro exam
• Cranial nerve testing important,
especially in infratentorial tumors
Cognition
Cranial nerves
Motor
Sensory
Coordination
Gait
Mobility
Page 76© 2021
• Ask child to remember 3 words
– Have them repeat the 3 words right away
– Have them repeat the 3 words in 10 minutes
• Caregiver questions
– School performance
– Developmental milestones
• Language
– Aphasia
» Expressive (Broca’s)– frontal lobe – often with right sided weakness
» Receptive (Wernicke’s)– left Temporal/parietal
• Require referral to neuropsychologist
• OT/SLP can help with memory strategies
Page 77© 2021
• I – Olfactory
» Ask about smell – not common
• II – Optic
» Pupillary light reflex
Pupil constricts with light
» Tracking in less responsive
patients
» Visual fields
Page 78© 2021
• III – Oculomotor
– Controls most eye movement, eyelid, and constricts pupil
• IV – Trochlear
– Superior Oblique muscle
– Nucleus controls opposite eye
• VI – Abducens
– Abducts the eye
• Extraoculor motor exam
– Double “H” Vision test with hold at each end
• Paresis causes diplopia – double vision
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 14
Page 79© 2021
• V – Trigeminal
– Sensory to the forehead, cheek, and jaw
– Motor to the masseter and temporalis
• Test
– Clench jaw and palpate
– Light touch sensation
• VII – Facial
– Upper and lower facial muscles
» Eyebrow elevation
» Smile
Page 80© 2021
• VIII – Vestibulo-cochlear
– Hearing
» Finger rub test
– Vestibular
» VOR reflex
Head thrust, DVA
» Postural control
Romberg – eyes closed
Page 81© 2021
• IX – Glossopharyngeal and X – Vagus
– Problems with choking food?
– Soft palate
• XI – Accessory
– Trapezius, Sternocleidomastoid
– Shoulder shrug
• XII – Hypoglossal
– Tongue protrusion
Page 82© 2021
• Often damaged by tumor location
• Ototoxicity from chemotherapy can cause hearing and vestibular impairments
• Awareness of impairments may assist intervention direction
• Vestibular rehab focuses on compensation of the oculomotor and neuromuscular system
to overcome balance deficits
Page 83© 2021
• Hypertonia caused by damage to the CNS by tumor location or hemorrhagic incident
during/after surgery
• Cerebeller tumors can cause low tone secondary to poor regulation of muscle tone
• Outcome
– Modified Ashworth Scale
Page 84© 2021
• Impairments depend on etiology
• Hypertonia
• Hip abduction/rotation/extension, knee extension, ankle dorsiflexion
• Shoulder abduction/flexion, elbow extension, wrist supination/extension and finger
extension/abduction
• Peripheral neuropathy
• Ankle dorsiflexion, knee extension
• Outcome measurement
• Goniometry
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 15
Page 85© 2021
• At risk for scoliosis/kyphosis secondary to radiation or asymmetrical motor control
• LE issues from peripheral neuropathy or motor control issues
• Work on strengthening and symmetry in functional skills
• Outcome measurements
– Foot Posture Index (FPI)
– Core strength
» Timed Prone V-up
» Timed plank
» Timed side-plank
Page 86© 2021
• Deconditioning
• Motor control dysfunction
• Peripheral neuropathy
Page 87© 2021
• Manual muscle testing
• Pronator drift test
– UEs flexed to 90 in supination with eyes closed – indicates UMN injury
• Dynamometry
• Functional strength skills
• BOT-2 Strength subtest
• Look for asymmetry!
Page 88© 2021
• Damage to cerebral cortex
• Peripheral neuropathy
• Point/dull testing, light touch,
joint position sense
• Can change rapidly or slowly
after surgery
Page 89© 2021
• Hemiparetic gait pattern
• Steppage gait
• Flat foot shuffling gait
• Foot slap gait
• Ataxic gait pattern (wide-based, variable, sways)
Page 90© 2021
• Tumor in motor cortex, cerebellum, disturbing ascending/descending tracts
(thalamus) or vestibular system (cranial nerve VIII or vestibular nuclei)
• Peripheral neuropathy
• Combination of central balance and peripheral balance deficits
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Page 91© 2021
• Seen in children with cerebellar tumors
• Outcome measures
– International Cooperative Ataxia Rating Scale (ICARS)
» Posture and Gait disturbance
» Kinetic functions
» Speech disorders
» Oculomotor disorders
– Scale for the Assessment and Rating of Ataxia (SARA)
» 8 items only
– Brief Ataxia Rating Scale (BARS)
» 5 items
Page 92© 2021
• Heel to shin test
– Look at path and speed
• Finger to nose
– Older kids – eyes closed
• Alternating pronation/supination
• BOT-2 coordination subtest
Page 93© 2021
– Pediatric Berg Scale
– mCTSIB
– Community balance scale
– BOT-2 Balance scale
– Sitting balance
– Romberg - test of the dorsal columns
+ test means ataxia sensory in nature
- test means ataxia is cerebellar in nature
– Single leg stance
Page 94© 2021
• Caused by tumor location or surgical/hemorrhagic complication
• Motor control training
– Repetitive task specific training
• Constraint therapy for hemiplegic upper extremity
Page 95© 2021
• Canadian Occupational Performance Measure (COPM)
• Weefim
– Age 3-12 or patient with cognitive delay
• Functional Independence Measure
• Gross Motor Function Measure
– Tests up to developmental level of a 5 y.o.
– Developed for children with Cerebral Palsy
• Pediatric Evaluation of Disability Inventory (PEDI)
– Ages 0-7
• Timed Up and Go (TUG)
• Timed Up and Down Stairs test (TUDS)
• 6 minute walk test
Lynn Tanner, PT
CREATETM Childhood Cancer Rehabilitation 11/5/2021
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in part in any manner without the permission of the copyright owner 17
Page 97© 2021
• Multidisciplinary pathway for children and adolescents post surgical resection of a
brain tumor
• Team of neurosurgery, oncology, nursing, and rehabilitation therapists developed
pathway
• Included
– Weaning sedation to improve participation in rehab
– Pain meds
– Removing foley 24 hrs post to reduce risk of infection
– OOB to chair POD #1 if possible
– Meals in chair POD #2
Page 98© 2021
Post – op Day 1 Post – op Day 2 Post – op Day 3 Post – op Day 4 Post – op Day 5 Post – op Day 6
Breakfast with head
of bed elevated
Time:________
Lunch with head of
bed elevated
Time:_________
Dinner sitting in chair
Time: _______
Bathing
Time:________
Physical Therapy
Evaluation
Time:________
Occupational
Therapy Evaluation
Time:________
_____Turn head to
look at people when
talking or listening
2/3 meals sitting in
chair
Breakfast
Time: _______
Lunch
Time: _______
Dinner
Time:_________
Bathing
Time:________
PT Time:_______
OT Time:_______
_____Bathroom on
the commode or
toilet
_____Work on
dressing, bathing
and eating with a
little help
_____Turn head to
look at people when
talking or listening
3/3 meals sitting in
chair
Breakfast
Time: _______
Lunch
Time: _______
Dinner
Time:_________
Bathing
Time:________
PT Time:_______
OT Time:_______
Speech eval if
needed Time:______
_____Toileting and
daily hygiene in the
bathroom
Walk out of room 3
times throughout
day.
_____ _____
_____
_____Turn head to
look at people when
talking or listening
3/3 meals sitting in
chair
Breakfast
Time: _______
Lunch
Time: _______
Dinner
Time:_________
Bathing
Time:________
PT Time:_______
OT Time:_______
_____ Gather
materials and
complete daily
hygiene in bathroom
with minimal help
Walk out of room 3
times throughout day
with stairs.
_____ _____
_____
_____ Pick up things
from floor like socks
or shoes
3/3 meals sitting in
chair
Breakfast
Time: _______
Lunch
Time: _______
Dinner
Time:_________
Bathing
Time:________
PT Time:_______
OT Time:_______
_____30 min of
activity out of bed
without rest
Walk out of room 3
times increasing
speed, walking on
line, start/stop
balance
_____ _____
_____
3/3 meals sitting in
chair
Breakfast
Time: _______
Lunch
Time: _______
Dinner
Time:_________
Bathing
Time:________
PT Time:_______
OT Time:_______
_____40 min of
activity out of bed
without rest
Walk out of room 3
times increasing
speed, walking on
line, start/stop
balance
_____ _____
_____
_____ Get up from
the floor without help
Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal: Caregiver/pt. goal:
Page 99© 2021
• Medulloblastoma dx at age 13
• Presenting sx:
– 1.5 yr of progressive clumbsiness
– Decreased school performance
– Declining speech
Page 100© 2021
• Treatment
–Complete resection
–Proton radiation (6 wks) in other state
»2-3 weeks IP
–3 months of chemotherapy (vincristine, cyclophosomide,
cisplatin)
Page 101© 2021
• Current
– ataxia
– muscle weakness
– disconjugate gaze (post corrective
surgery)
– chemotherapy-induced ovarian
failure
– left CN VI paresis
– expressive language disorder
– motor speech disorder
– voice disturbance
• Post-op
– severe posterior fossa cerebellar
mutism syndrome (>1 day after
surgery)
– cranial nerve VI weakness
– left facial weakness
– right hemiparesis
– swallowing dysfunction
– severe ataxia
Page 102© 2021
• Mod A x 2 for supine to/from sit
• Mod A to sit at EOB
• PROM WNL x left cervical rotation
PT Assessment – POD #1
• Max A x 1 roll and supine to sit
• Stand pivot tx Mod A x 2
• Right weaker than left
• Cervical AROM
POD # 2
• Sit to/from stand Min A
• 3 steps fwd/bkwd Mod A
• Sit Min A
• Uses hand squeeze and thumbs up
POD #3
CREATETM Childhood Cancer Rehabilitation 11/5/2021
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in part in any manner without the permission of the copyright owner 18
Page 103© 2021
• Decreased arousal
• Max A supine to sit
• Max A pivot transfer with
• Max A for head control
POD #4
• Mod A supine to sit
• Mod to Max A sit to stand and stand pivot (more with fatigue
• Amb 7 ft with Mod A
• Poor head control
POD #5
• Bed mobility with v.c.
• Sit with CGA to Min A
• Amb with walker 85’ max with Min to Mod A at trunk and v.c. to steering, R hand on walker
• Right AFO
• Left knee hyperextension
POD #19
DC to proton
Page 104© 2021
• Gait – Min A with walker w/o AFO x 500ft
• Fwd WS
• High steppage• Circumduction
• VERY IMPULSIVE
4 months post
• Gait – same as above with Min A pushing WC5 months
post
Page 105© 2021
• Patches one eye
• Goal: walk again
• Ankle DF 5-8 degrees
• Sits with left lateral trunk flexion with Ues raises for 90 sec max with trunk sway (moderate)
• Stands with CGA with bil knee hyperextension 90 sec max
• Supine to sit I
• Sit to/from stand CGA
• Heel to shin test positive for mild ataxia left greater than right
• Sensory testing WNL x of left great toe
• Disconjugate gaze
• Horizontal nystagmus
• Amb with Min to Mod A at left UE preferred, FWW with Min A
OP PT eval
6 mos post
Page 106© 2021
• Gentle prolonged stretching/positioning
• Knee immobilizers for hamstrings
• Serial casting/orthotics for ankle contractures
• Wrist/hand splinting
• Work closely with physiatrist for medical interventions and feedback on function
Page 107© 2021
• Strengthening
• Strengthen using synergy and out of synergy if decreased motor control
• Strengthen gravity assisted, gravity eliminated, anti-gravity
• Repetition in functional activities with assistance for quality of movement
Page 108© 2021
• Partial weight bearing treadmill training
• Robotic-assist gait training
– Significant improvement in GMFM scores and gait spatio-temporal parameters as well as hip kinematics in children with acquired brain injury
» 30% of patients had a CNS tumor
• Beretta et al. 2015
• Gait training in the aquatic environment
• Functional electrical stimulation
• Focus on symmetry, stride length, weight shift, etc
• Consider vision/vestibular changes
– Gait with head turns
– Gait in crowded hall
• Orthotic considerations
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 19
Page 109© 2021
• Tumor in motor cortex, cerebellum, disturbing ascending/descending tracts
(thalamus) or vestibular system (cranial nerve VIII or vestibular nuclei)
• Peripheral neuropathy
• Combination of central balance and peripheral balance deficits
Page 110© 2021
0
5
10
15
20
25
30
35
40
45
Se
co
nd
s
2x/wkPT
1x/moPT
2x/wkPT
Min A
1-3/x1SBA
4/x1-5/x1
CGA
7/x1-1/x1
SBA3/x2
Page 111© 2021
0
50
100
150
200
250
300
350
1/12/20x1 2/9/20x1 3/12/20x1 4/6/20x1 5/14/20x1 7/23/20x1 9/22/20x1 1/28/20x2 3/17/20x2
2x/wk PT 1/20x1-5/20x1 and 1/20x2-3/20x2
Max A Mod A Min A CGA
Page 112© 2021
• Integrate rhythm challenges into motor activities
• Opposing UE/LE movements
– Swinging arms in gait
– Throwing/catching
– Dribbling
– Jumping jacks
– Stride jumps
– Skipping
Page 113© 2021
• Consider vision/vestibular/neuromuscular impairments
• Monitor asymmetry
• Progress difficulty by taking away use of one system (unsteady surface, eyes closed)
• Challenge balance during gait
– Head turns, perturbations, crowded hall, change in surfaces
Page 114© 2021
• Blocked practice of functional activity
• Circuit training-smart phone applications
• Use of Wii and Kinect
• Sport directed drills
• Obstacle Courses
• Treadmill
• Swimming
• Explore new community activities
• Step trackers
CREATETM Childhood Cancer Rehabilitation 11/5/2021
© Children's Minnesota, 2021. No part of this material, CREATE course handouts, may be reproduced in whole or
in part in any manner without the permission of the copyright owner 20
Lynn Tanner, PT
Page 116© 2021
Surveillance
•Ped-mTNS
•Sensation
•ROM
•Tone
•Movement disorder
•Vision
•Oculomotor
•Swallowing
•Cognition
•Communication
•Strength
•Gait
•Balance
•Motor function
•ADLs/IADLs
Education
•Role of Rehab
•Episodes of care
•Scheduling
•Community/school rehabilitation and collaboration
•Late effects
•Home exercise program
Early Detection
•Ongoing assessment
•Late effects
•Fatigue
•Neuropathy
•Contractures
•Posture
•Pain
Rehabilitation
•Treat cancer-related and treatment impairments and limitations
Wellness Promotion
•Independence
•Daily routine
•Physical activity
•Quality of life
Page 117© 2021
• Teenager treated for Medulloblastoma during early elementary school.
• Neuro-onc follow up clinic
– Family concerns
» Limited physical activity
» School avoidance
» Managing stairs at school
» Decreased IADL independence
» Fatigue with writing
» Limited keyboarding
» Desire to drive
Page 118© 2021
Surveillance
•Ped-mTNS
•Sensation
•ROM
•Tone
•Movement disorder
•Vision
•Oculomotor
•Swallowing
•Cognition
•Communication
•Strength
•Gait
•Balance
•Motor function
•ADLs/IADLs
Education
•Role of Rehab
•Episodes of care
•Scheduling
•Community/school rehabilitation and collaboration
•Late effects
•Home exercise program
Early Detection
•Ongoing assessment
•Late effects
•Fatigue
•Neuropathy
•Contractures
•Posture
•Pain
•Transition to adulthood
Rehabilitation
•Treat cancer-related late effects and limitations
•Episodes of care
•Career planning
•Vocational rehab
•Independent living
Wellness Promotion
•Independence
•Physical activity
•Quality of life
Page 119© 2021
• Pain onset
– New activities
– Growth
• Ankle contractures with growth
• Posture Assessment
• Strength gains
• Endurance needs
Page 120© 2021
• Rate of development kept up with age
• Reassessment of motor skills required
CREATETM Childhood Cancer Rehabilitation 11/5/2021
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in part in any manner without the permission of the copyright owner 21
Page 121© 2021
• Physical Activity level
– Continue to educate over time
» Changing interests
• Transition education
– School transition
– High school transition
– College transition
– Independent living/career transition
Page 122© 2021
• Independent living
– Safety
– Home adaptations
– Assistance
• Employment
– Physical needs for wanted career
– Career training through school program
Page 123© 2021
• OT
• SLP
• Neuropsychology
• Psychology
• Driving Assessment
• Orthopedic evaluation
– Scoliosis
• Etc.
Page 124© 2021
• When to return to PT
– Pain > 2 weeks
– New symptom onset
– Frustration with wanted skill
• Episodes of care