Prehabilitation to Improve Positioning Reproducibility in Patients Undergoing Pelvic Radiation Therapy

Prehabilitation to improve patient positioning: pelvic exercises assist in reducing sacral slope variability during radiation therapy Purpose/Objective(s): Reproducible patient positioning is essential for precision in radiation therapy (RT) delivery. However, a retrospective review of pre-treatment imaging demonstrated variability in daily patient set-up. We tested the hypothesis that a structured daily pre-treatment stretching regimen is both feasible and effective for minimizing variability in positioning, as measured by sacral slope angles (SSA). Materials/Methods: After obtaining IRB approval, we had 8 female patients undergoing pelvic radiotherapy perform a structured daily hip exercise regimen (extension and external rotation) immediately prior to both simulation and daily treatment, throughout the RT course. The control group of 20 patients (17 female and 3 male) had usual care. SSA measurements on daily pre-treatment imaging were compared to SSA measurements from the simulation CT for 5 weeks. The extent of SSA variability between two groups and over time was analyzed using a linear mixed model. The same two readers independently measured SSA of all subjects, comparing SSA on the day of simulation to SSA measured on each day of RT. Results: The average variation in SSA among the intervention subjects was 0.913° (±0.582°), with a range among subjects of 0.57°-1.3°. The average variation for the control subjects was 2.27° (±1.43°), with range among subjects of 1.22° - 5.09°. The difference between the two groups was statistically significant (p=0.002). There was a statistically significant SSA variation between groups at each week of treatment (Week (wk) 1: p = 0.007, wk 2: p = 0.008, wk 3: p = 0.01, wk 4: p = 0.005, wk 5: p = 0.008). There was no significant variation among the intervention subjects between week 1 and later weeks (wk 2: p = 0.88, wk 3: p = 0.74, wk 4: p = 0.97, wk 5: p = 0.40), whereas subjects in the control group demonstrated significant SSA variation between week 1 and the fourth week of therapy (wk 2: p = 0.87, wk 3: p = 0.92, wk 4: p = 0.02, wk 5: p = 0.22). There were no reported adverse effects of the stretching regimen. Conclusion: We demonstrated a significant decrease in the variability of SSA by implementing a simple pre-treatment stretching program, whereas control subjects exhibited an increasing variability of SSA over the course of treatment. We conclude that there is a potential benefit for prehabilitation during pelvic RT. A larger clinical trial is required to determine whether a pre-treatment stretching program would result in clinical benefit.https://escholarship.umassmed.edu/capstones/1006/thumbnail.jp

Pelvic prehabilitation: pelvic exercises assist in minimizing inter-fraction sacral slope variability during radiation therapy

Introduction: Prehabilitation for radiation therapy is not well studied. Retrospective data shows variability in set-up positioning of patients during daily pelvic RT. We hypothesize that a brief structured daily exercise regimen is feasible for subjects to perform before RT and may minimize variability in positioning as measured by sacral slope angles (SSA) on lateral views. Determining feasibility and effectiveness of these exercises in decreasing set-up variability has clinical implications, both for targeting treatment sites and preventing adverse effects. Methods: Subjects in the exercise intervention condition (n=8, 8 F) performed a structured daily hip exercise regimen throughout the duration of RT, and subjects in the historical control condition (n=20, 17 F, 3 M) had usual care. For each patient, SSA measurements were compared to SSA measurements from the simulation CT for 5 weeks during RT. The extent of variability of measurements between two conditions was studied using a linear mixed model. For all patients in both conditions, the same two readers independently measured SSA to compare angles on day of simulation against the angles measured from each day of RT. Results: The average variation in SSA for intervention condition was 0.913° (±0.582°), with range among patients 0.57°-1.3°. The average variation for control condition was 2.27° (±1.43°), with range among patients 1.22° - 5.09°. The difference between two conditions was statistically significant (p=0.0019). Comparison of SSA variation between conditions demonstrated a statistically significant difference at each week (wk 1: p = 0.0071, wk 2: p = 0.0077, wk 3: p = 0.011, wk 4: p = 0.005, wk 5: p = 0.0079). The exercise intervention condition had no significant variation between week 1 and later weeks (wk 2: p = 0.876, wk 3: p = 0.741, wk 4: p = 0.971, wk 5: p = 0.397). The control condition showed greater SSA variation between week 1 and later weeks (wk 2: p = 0.868, wk 3: p = 0.915, wk 4: p = 0.015, wk 5: p = 0.224), with significant variation between weeks 1 and 4. No subject reported any adverse effects. Conclusion: We observed a significant decrease in sacral slope variability in our exercise cohort as compared to historical controls. SSA variation for control condition increased over the course of treatment with significant difference noted between week 1 and 4. A larger clinical trial is required to evaluate the potential clinical benefits of a structured daily exercise regimen during pelvic RT. References: Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. American journal of physical medicine & rehabilitation. 2013 Aug 1;92(8):715-27. Lukez A, O’Loughlin L, Bodla M, Baima J, Moni J. Positioning of port films for radiation: variability is present. Medical Oncology. 2018 May 1;35(5):77. Kwon JW, Huh SJ, Yoon YC, Choi SH, Jung JY, Oh D, Choe BK. Pelvic bone complications after radiation therapy of uterine cervical cancer: evaluation with MRI. American Journal of Roentgenology. 2008 Oct;191(4):987-94. Stubblefield MD. Radiation fibrosis syndrome: neuromuscular and musculoskeletal complications in cancer survivors. PM&R. 2011 Nov 1;3(11):1041-54

Positioning of Patients for Pelvic Radiation: Variability Across Treatment

Objectives: We aimed to determine the variability in position of the pelvis for patients while receiving daily radiation treatments for pelvic malignancies. Design: Therapeutic radiation targets lymph nodes that lie along the curvature of the sacrum. Any change in pelvic tilt could inadvertently move these targets in or out of the radiation field. This variability has clinical significance both to target cancerous lymph nodes and avoid healthy sacrum. To better understand this variability, we observed trends in the change in the sacral slope. This measurement was chosen because it is an objective radiographic finding, there is no significant difference between men and women, and joint replacement does not appear to change this measurement. Twenty subjects were identified from patients receiving whole pelvis radiation for at least four weeks. CT simulator images and lateral radiographs obtained as part of standard radiation care were reviewed. We manually calculated this measurement with sloping lines drawn with computer graphics on the same single lateral view daily for the course of radiation per subject. Results: Compared to the initial imaging, the average sacral slope variation across all 20 subjects was 2.27 degrees, with a standard deviation of 1.43, and average variation among patients ranged from 1.22-5.09 degrees. Variation in sacral slope across all 20 subjects from one treatment day to the next was 2.05 degrees, with a standard deviation of 1.47, and ranged from 0.97-3.21 degrees. Conclusions: Despite the best efforts of the provider, there may be some variability in the daily pelvic position of the patient between fractions. This is clinically important because presacral lymph nodes are part of the radiation target volume and sacral fractures are a potential adverse effect of radiation treatment. Exercises for pelvic relaxation could be explored to potentially reduce this variability

Treatment Toxicity: Radiation

Radiation exposures, both intentional and unintentional, have influence on normal tissue function. Short-term and long-term injuries can occur to all cell systems of both limited and rapid self-renewal potential. Radiation effects can last a lifetime for a patient and can produce complications for all organs and systems. Often invisible at the time of exposure, the fingerprints for cell damage can appear at any timepoint after. Health-care providers will need comprehensive knowledge and understanding of the acute and late effects of radiation exposure and how these interrelate with immediate and long-term care

The Role and Scope of Prehabilitation in Cancer Care

OBJECTIVES: To recognize cancer prehabilitation as a pretreatment regimen to increase functional status for patients requiring cancer treatment. This article presents current evidence addressing the efficacy and benefits of prehabilitation regimens in different cancer survivor populations. DATA SOURCES: Studies and case reports in the PubMed database. CONCLUSION: Cancer prehabilitation may improve outcomes. Prehabilitation may include targeted or whole-body exercise, nutrition, education, psychologic counseling, and smoking cessation. Opportunities exist to further improve access to and delivery of multimodal prehabilitation, and nurses play a critical role in connecting patients to these services. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses who are knowledgeable of cancer treatment-related effects are poised to assess survivors for existing impairments, advocate for prehabilitation for existing and potential morbidities, and monitor functional status over time. As patient educators, they are key to informing cancer survivors about the role of prehabilitation

Nonoperative Approach to Treatment of a Gluteus Medius Tear

Case Diagnosis: We present two cases of atraumatic gluteus medius tear. Case Description: Patient 1 is a 58-year-old female with right gluteal and hip pain. On physical exam, there was focal tenderness in the right gluteal area with pain on external rotation of the right hip and an antalgic gait. Patient 2 is an 82-year-old male status-post left gluteus medius repair with subsequent revision. Since the surgery, the patient continued to have episodic left hip pain and suffered multiple falls. Physical exam demonstrated limited left hip abduction and tenderness of the iliopsoas muscle. Both patients exhibited a sedentary lifestyle and neither had fluoroquinolone or steroid exposure near the time of tear. Differential diagnoses included avascular necrosis of the femoral head, greater trochanteric bursitis, gluteal nerve injury, iliotibial band syndrome, paralabral cyst, and gluteus medius tear. For each patient, an MRI confirmed the diagnosis of gluteus medius tendon tear. Both were referred to physical therapy. Patient 1 experienced decreased pain and Patient 2 experienced decreased pain, increased strength and range of motion, and increased ambulation. Discussions: Chronic gluteus medius tears may be seen more frequently in those with decreased flexibility or strength. Neither patient had medication risk factors for muscle tear, but both endorsed a sedentary lifestyle. These tears can be treated successfully nonoperatively or with surgery. Nonoperative management includes pain control and physical therapy to target the hip rotators. Conservative treatment may provide up to 90% of patients with pain relief. However, few studies have evaluated the best exercises for the management of gluteus medius tears. Exercise can improve patient function without the risks associated with surgery. Conclusions: This case series suggests that atraumatic gluteus medius tendon tears may be effectively treated nonoperatively, especially for patients with a sedentary lifestyle. Further studies should be conducted to evaluate the role of nonoperative treatment

Positioning of port films for radiation: variability is present

PURPOSE: Pelvic radiation treatment demands precision and consistency in patient setup for efficacy of therapy and to limit radiation dosage to normal tissue. Despite the use of immobilization devices and positioning techniques, there is still concern for variation in daily setup. The purpose of this retrospective study was to determine the presence and degree of variation in sacral slope in 20 subjects receiving radiation therapy for pelvic malignancies. METHODS: Each of the 20 subjects received between 20 and 25 fractions of external beam radiation treatment to the pelvis. The sacral slope was measured on each of the daily port films taken prior to treatment and compared to the sacral slope angle measured on the initial treatment planning simulation digitally reconstructed radiographic imaging. RESULTS: Compared to this initial imaging, the average sacral slope variation across all 20 subjects was 2.27 degrees (+/- 1.43 degrees ), and the average variation among patients ranged from 1.22 degrees to 5.09 degrees . Variation in sacral slope across all 20 subjects from one treatment day to the next was 2.05 degrees (+/- 1.47 degrees ), and ranged from 0.97 degrees to 3.21 degrees . CONCLUSIONS: This study demonstrates that despite the rigorous use of immobilization devices, there still exists day-to-day variation in sacral slope angle between treatment days and compared to initial baseline imaging off which the treatment plan is developed. There is an on-going study at our institution with an attempt to reduce this variation by offering exercises prior to radiation

Prehabilitation for patient positioning: pelvic exercises assist in minimizing inter-fraction sacral slope variability during radiation therapy

Reproducible patient positioning is essential for precision in radiation therapy (RT) delivery. We tested the hypothesis that a structured daily pre-treatment stretching regimen is both feasible and effective for minimizing variability in positioning, as measured by sacral slope angles (SSA). Eight female subjects undergoing pelvic radiotherapy performed a structured daily hip exercise regimen (extension and external rotation) immediately prior to both simulation imaging and daily treatment, throughout their RT course. This exercising cohort was compared to a retrospective review of 20 subjects (17 women and 3 men) undergoing RT, who had usual care. SSA measurements from daily pre-treatment imaging were compared to SSA measurements from the simulation CT. The average variation in SSA among the intervention subjects was 0.91 degrees (+/- 0.58 degrees ), with a range among subjects of 0.57 degrees -1.27 degrees . The average variation for the control subjects was 2.27 degrees (+/- 1.43 degrees ), ranging 1.22 degrees -5.09 degrees . The difference between the two groups was statistically significant (p = 0.0001). There was a statistically significant SSA variation between groups at each week of treatment. There was no significant variation among the intervention subjects between week 1 and later weeks, whereas subjects in the control group demonstrated significant SSA variation between week 1 and later weeks. We demonstrated a significant decrease in the variability of SSA by implementing a simple pre-treatment exercise program, while control subjects exhibited increasing variation in SSA over the course of treatment. We conclude that there is a potential benefit of prehabilitation during pelvic RT; however, a larger randomized control trial is required to confirm the findings.Clinical Trial: This research project was approved by the University of Massachusetts Medical School IRB (IRB ID H00012353) on January 21, 2017. The study is listed on ClinicalTrials.gov, provided by the U.S. National Library of Medicine, found with identifier NCT03242538

Treatment Toxicity: Radiation

Intentional and unintentional radiation exposures have a powerful impact on normal tissue function and can induce short-term and long-term injury to all cell systems. Radiation effects can lead to lifetime-defining health issues for a patient and can produce complications to all organ systems. Providers need to understand acute and late effects of radiation treatment and how the fingerprints of therapy can have an impact on health care in later life. This article reviews current knowledge concerning normal tissue tolerance with therapy