[aptaoncology] Re: [EXTERNAL] Re: Radiation and STM

From: claudia wiser <claudiawiser@xxxxxxxxxxx>
To: "aptaoncology@xxxxxxxxxxxxx" <aptaoncology@xxxxxxxxxxxxx>
Date: Sat, 5 Mar 2022 13:45:58 +0000

Thank you all for your input!

Claudia

On Mar 4, 2022, at 2:23 PM, Baker Jennifer <dmarc-noreply@xxxxxxxxxxxxx> wrote:

Hello,
I appreciate this discussion. I’m in a rural setting and have recently had my
first client referred for post radiation tightness and discomfort in the
axilla. She finished her radiation within the last 2 months.

I am looking for updated continuing education related to this topic. Any
recommendations?

Thank you.

Jenn

From: aptaoncology-bounce@xxxxxxxxxxxxx
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx] On Behalf Of Paula Stout
Sent: Friday, March 4, 2022 12:31 PM
To: aptaoncology@xxxxxxxxxxxxx
Subject: [aptaoncology] Re: [EXTERNAL] Re: Radiation and STM

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Hi, and Happy Friday to all!

I agree with Deb and Kristin regarding timeline of MFR and manual therapy, with
considering stages of tissue healing.

And I certainly incorporate manual therapy, including MFR as needed later on
(with late side effects).

Of course, we definitely should be seeing these patients AS they go through
radiotherapy (frequency dependent upon each patient’s presentation/specifics),
as we can mitigate some of the many side effects and educate throughout.

Thank you all for this discussion!

Best,
Paula

Paula K. Stout, PT, DPT, CLT-LANA
Board Certified Specialist in Oncologic Physical Therapy
(573) 450-8290<tel:(573)%20450-8290>
paulakayespt@xxxxxxxxx<mailto:paulakayespt@xxxxxxxxx>

Sent from my iPhone

On Mar 4, 2022, at 11:06 AM, Kristin Carroll
<kristin.carroll@xxxxxxxxxxxxxxxxxxxxxxxxx<mailto:kristin.carroll@xxxxxxxxxxxxxxxxxxxxxxxxx>>
wrote:

Love this discussion! This is one of my areas of passion and yes, Deb, would
agree with you! Managing impairment as they occur and working with all the body
systems to restore them even through active changes.
Here are a few good articles that align with our healing phases. In skin
breakdown it talks about that it takes about 4 weeks for the epidermis to break
down from RT interventions.
I wait about 3-4 weeks as well to do manual treatments as earlier can disrupt
this healing matrix!
Thanks team, for all you do for this oncology population!

The radiotherapeutic injury – a complex ‘wound’ - Radiotherapy and Oncology
(thegreenjournal.com)<https://www.thegreenjournal.com/article/S0167-8140(02)00060-9/fulltext>
Radiotherapy and wound healing: Principles, management and prospects (Review)
(spandidos-publications.com)<https://www.spandidos-publications.com/10.3892/or.2011.1319>

[cid:image001.jpg@01D82FD3.61A1D3B0]
Kristin M. Carroll, PT<https://survivorshipsolutions.com/p/kristin-carroll>
[cid:image005.png@01D82FD3.61A1D3B0]
<https://survivorshipsolutions.com/p/kristin-carroll>
Board-Certified Clinical Specialist in Oncologic Physical Therapy
Co-Founder / VP of Clinical Operations

"You are not merely here to make a living. You are here in order to enable the
world to live more amply, with greater vision, with a finer spirit of hope and
achievement. You are here to enrich the world.” – Woodrow Wilson

From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
<aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>>
On Behalf Of Deborah Doherty
Sent: Thursday, March 3, 2022 9:12 PM
To: aptaoncology@xxxxxxxxxxxxx<mailto:aptaoncology@xxxxxxxxxxxxx>
Subject: [aptaoncology] Re: [EXTERNAL] Re: Radiation and STM

What a rich discussion! Thank you all!
There is so much we still need to research to build best practice. My personal
philosophy of treatment is prevention when Rad Oncs will refer. Stretching and
strengthening throughout the radiation treatment can prevent the intensity of
the fibrosis and prevent functional deficits.  I have had success with doing
MFR throughout radiation from a distance. For breast and lung cancer, fascial
stretching of the chest area from the abdomen, back, neck and pelvis can
prevent and decrease the intensity of the fibrosis. My general rule is that the
MFR can be completed directly on the radiated tissues 3 weeks after the
completion of radiation. Of course, there are some people who still have skin
fragility at 3 weeks so may need more time.

I teach in a cadaver lab. Radiated tissue on a cadaver is very visible. We have
had several cadavers over the years that had chest radiation from breast cancer
and the tattoos for radiation are still visible.  The shrinkage of tissue and
lack of flexibility compared to the non-radiated side is obvious. It is
especially amazing how it affects the intercostals, pect major and minor.
Imagine the difficulty breathing.. I do hope that eventually more prevention
interventions can be implemented,
Deb

On Thu, Mar 3, 2022 at 8:40 PM Jordet, Irene
<Irene.Jordet@xxxxxxxxxxxxxx<mailto:Irene.Jordet@xxxxxxxxxxxxxx>> wrote:
I will look forward to your dissertation Renata.
Thus far I would say I have had good luck doing progressively heavier STM each
session followed by MLD and chip pad + compression.

From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
<aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>>
On Behalf Of Renata Braudy
Sent: Thursday, March 3, 2022 2:49 PM
To: aptaoncology@xxxxxxxxxxxxx<mailto:aptaoncology@xxxxxxxxxxxxx>
Subject: [EXTERNAL] [aptaoncology] Re: Radiation and STM

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Hi all-

I have grappled with this question about radiation for years .. and actually am
studying it as part of my PhD Dissertation. More to come on that next year ....

What we do know is that radiation can increase collagen deposition. It can
contribute to fibrosis, atrophy, loss of elasticity, weakness, shortening, and
contracture. Some of this may be due to direct damage to the tissues within the
field, but radiation may also affect nerves and blood flow, causing indirect
damage to tissues also. These two articles have been helpful to me. However, we
still don't know what to do about it. Also more to come in the future hopefully
:)

Straub JM, New J, Hamilton CD, Lominska C, Shnayder Y, Thomas SM.
Radiation-induced fibrosis: mechanisms and implications for therapy. J Cancer
Res Clin Oncol. 2015;141(11):1985-1994. doi:10.1007/s00432-015-1974-6

Stubblefield MD. Radiation fibrosis syndrome: Neuromuscular and musculoskeletal
complications in cancer survivors. PM R. 2011;3(11):1041-1054.
doi:10.1016/j.pmrj.2011.08.535

Renata

Renata Braudy, PT, MS, MA, OCS, CLT
PhD Candidate, University of Minnesota
M Health Fairview Physical Therapist
Minneapolis, MN

On Thu, Mar 3, 2022 at 4:29 PM Canaday, Cheryl A
<Cheryl.Canaday@xxxxxxxxxx<mailto:Cheryl.Canaday@xxxxxxxxxx>> wrote:
Thank you for your thoughtful response.

Cheryl Canaday, PT, DPT, CLT-LANA
Physical Therapist, Certified Lymphedema Therapist
Baptist Health South Campus ǀ Rehabilitation Services
Phone: 904-271-6575 ǀ Fax: 904-271-6678 ǀ
Cheryl.canaday@xxxxxxxxxx<mailto:Cheryl.canaday@xxxxxxxxxx>

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From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>]
On Behalf Of Steve Wechsler
Sent: Thursday, March 3, 2022 2:33 PM
To: aptaoncology@xxxxxxxxxxxxx<mailto:aptaoncology@xxxxxxxxxxxxx>
Subject: [aptaoncology] Re: Radiation and STM

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Claudia, I think your strategy is justified. I would suggest that it's our
responsibility to promote tissue healing while optimizing function... This
feels like one of those oncology rehab-specific clinical decision making
moments where we understand that things are going to get worse before they get
better due to treatment effects. While a patient is actively undergoing XRT, I
usually limit manual interventions within the radiation field (as you describe)
and transition to AROM (to patient's tolerance) and think about what I can do
in adjacent regions (deep breathing to facilitate rib cage expansion, pec
lengthening if skin is less/not irritated there, scap stabilization
strengthening)... I may set a goal with the patient about maintaining a certain
ROM rather than pushing to get more during this phase.

I think it's also a great opportunity to educate the patient about what they
can expect including signs/symptoms of worsening skin irritation that they can
look for (so when they're stretching at home and inevitably pushing themselves
further than you might, they know when they're going too far)... Educating them
about how taking a step back in our therapy intensity may be necessary to
prevent 2 steps back if we cause worse skin breakdown with aggressive
STM/movement... we may be the first provider to educate them on what's to come
- not an easy conversation but important!

To Cheryl's question - I do tend to have a heavy hand but I would say my rule
of thumb is still to think about promoting tissue healing even in the chronic
stage. So if things get "hot" and stay hot after STM... maybe that was too
much. If you're getting results (greater soft tissue mobility, ROM, less pain)
without s/s of increased inflammation... maybe that's the sweet spot! Different
for each patient.

Steve

On Thu, Mar 3, 2022 at 2:08 PM Perry Ashley
<dmarc-noreply@xxxxxxxxxxxxx<mailto:dmarc-noreply@xxxxxxxxxxxxx>> wrote:
That's a good question.  I have done a lot of research to try and find the
answer to this.  I even sat down with a Rad Onc to have a discussion of tissue
properties, combed through his text books to see how the cellular matrix is
effected but didn't find a lot of concrete advice.  I would be interested to
hear if anyone has a clear answer.

That being said, what I did find is the cellular matrix is essentially dried
out with high levels of cytokines for at least 3 months.  I asked the Physicist
how long these elevated cytokine levels last and his exact words " no one
really knows. "

I usually err on the side of caution as to not cause more inflammation
furthering scar tissue in the long run, but it does kill me not to be able to
get in aggressively right away.

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From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>]
On Behalf Of Canaday, Cheryl A
Sent: Thursday, March 03, 2022 1:10 PM
To: APTAOncology@xxxxxxxxxxxxx<mailto:APTAOncology@xxxxxxxxxxxxx>
Subject: [aptaoncology] Re: Radiation and STM

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To add to that question, I would also like to know what is the best practice
for STM over radiated field after many years where there is significant
radiation fibrosis

Cheryl Canaday, PT, DPT, CLT-LANA
Physical Therapist, Certified Lymphedema Therapist
Baptist Health South Campus ǀ Rehabilitation Services
Phone: 904-271-6575 ǀ Fax: 904-271-6678 ǀ
Cheryl.canaday@xxxxxxxxxx<mailto:Cheryl.canaday@xxxxxxxxxx>

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From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>]
On Behalf Of claudia wiser
Sent: Thursday, March 3, 2022 1:04 PM
To: APTAOncology@xxxxxxxxxxxxx<mailto:APTAOncology@xxxxxxxxxxxxx>
Subject: [aptaoncology] Radiation and STM

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I received a call from a physiatrist yesterday who specializes in onc rehab and
he advised me that I should be doing more aggressive STM in a patient’s axilla
where he is currently receiving radiation. I typically go hands off when skin
starts to get pink, sooner if there are other factors that concern me.
What is the current best practice for STM in the radiated field?

Thank you!
Claudia Wiser

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--
Deb Doherty, PT, PhD
she/her/hers
Associate Professor
Chair of Human Movement Science Department
Chair Interprofessional Education Task Force
Coordinator of the Graduate Certificate in Oncology Rehabilitation
Oakland University
Physical Therapy Program
3176 Human Health Building Room
433 Meadowbrook Road
Rochester, Michigan 48309
Phone: (248) 364-8683; FAX: (248) 364-8660
E-mail:  doherty@xxxxxxxxxxx<mailto:doherty@xxxxxxxxxxx>

Oakland University sits on traditional and ancestral lands and waters of the
Anishinaabe people, also known as the Three Fires Confederacy comprised of the
Ojibwe, the Odawa, and the Potawatomi. I recognize that my privilege of
learning and teaching in this space is a result of the forcible removal of
these Native and Indigenous peoples, and commit to aligning my work with acts,
words, and deeds that illustrate my solidarity with and acknowledgment of the
sovereignty of these displaced tribes.

References:
- [aptaoncology] Re: [EXTERNAL] Re: Radiation and STM
  - From: Kristin Carroll
- [aptaoncology] Re: [EXTERNAL] Re: Radiation and STM
  - From: Paula Stout
- [aptaoncology] Re: [EXTERNAL] Re: Radiation and STM
  - From: Baker Jennifer

[aptaoncology] Re: [EXTERNAL] Re: Radiation and STM

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