Clinical and Health Affairs
Cancer Rehabilitation
By Nancy A. Hutchison, M.D.
Abstract
Cancer rehabilitation is a relatively new subspecialty. Its goal is to help patients who have been diagnosed with cancer minimize the physical effects of treatment and disease and regain control over many aspects of their life. This article introduces the concept of cancer rehabilitation and offers examples from a Minnesota clinic of how it can benefit patients at different stages of treatment.
I finished my chemo and radiation. ... I thought I would feel better by now, but I feel worse. ... My family and my employer don’t understand why I can’t do what I used to do. I did not understand how long it takes to recover from cancer treatment. ... I was not prepared for being disabled by cancer. ... I am having a hard time knowing what I should expect for my future.
The surprising reality for a large number of cancer survivors is that they feel and function worse after treatment than they did before. Cancer patients may experience lymphedema, fatigue, skin problems, pain, joint stiffness, weakness, paralysis, balance problems, and difficulty swallowing as a result of the disease itself or its treatment. A number of studies indicate that loss of function, fear of losing independence, and fear of becoming a burden is at the root of a great deal of depression and anxiety in cancer survivors.1-3
In the last 10 years, oncologists and other medical providers have become aware of the unique needs of cancer survivors. One field that has responded is physical medicine and rehabilitation.4-6 The subspecialty of cancer rehabilitation has emerged as studies have demonstrated the benefits of exercise and rehabilitation in improving function and quality of life for people with cancer, no matter what the stage or chance of cure.7,8 Some studies have even shown a survival benefit.9,10
Cancer rehabilitation is designed to help survivors regain control over many aspects of their lives and be as independent and productive as possible. It uses a variety of modalities including exercise, pain management, virtual reality therapies, advanced technologies such as tracheo-esophageal prostheses or computerized speech devices, and assistance with activities of daily living. This article introduces the concept of cancer rehabilitation and offers examples of how it can benefit patients at different stages of treatment.
A Team Approach
Physical medicine and rehabilitation physicians or physiatrists are best known for their work with patients living with conditions such as polio, spinal cord injury, stroke, and brain injury. The specialty has always focused on survivorship whether from an accident or an illness. Recently, some physicians have begun subspecializing in cancer rehabilitation in order to address the loss of functioning imposed by cancer and its treatments. Physiatrists who specialize in cancer rehabilitation are trained to address the physical and medical status of cancer patients and connect them with rehabilitation resources at critical points during their treatment and recovery. Currently, fewer than 50 physiatrists in the United States identify themselves as cancer rehabilitation subspecialists. However, many others treat the functional impairments caused by cancer.
The cancer rehabilitation physiatrist leads a team that might include a nurse practitioner who specializes in cancer care, physical therapists, occupational therapists, speech and language therapists, and others, and coordinates rehabilitation interventions for patients while communicating with their oncology providers and primary care physicians. Together, they design a program tailored to each patient’s needs that might include lymphedema management, physical therapy, occupational therapy, speech and language therapy, myofascial therapy, balance therapy, and special equipment or garments.
In our clinic, we recently worked with a 75-year-old man who was referred by his ENT surgeon after completing treatment for an aggressive tongue cancer. He had undergone removal of part of his tongue and reconstruction of his jaw and was weak from the chemotherapy and radiation therapy that followed. Consequently, he could not eat, communicate, walk significant distances, or care for himself. He received treatment from a team that included speech, physical, and occupational therapists. Through a comprehensive program of therapies over several months, he was able to regain his ability to eat a modified diet, speak so he could be understood, do light exercise, and live independently.
The case of a 70-year-old man who was diagnosed with a brain tumor that was found to be from a previously unknown lung cancer also illustrates the importance of the team approach. The patient received radiation therapy to the brain followed by chemotherapy for the lung cancer. He had a reaction to the chemotherapy that caused him to become extremely weak. The man developed severe back pain and could not sit up for more than 15 minutes without discomfort, had difficulty walking, and was short of breath with even minimal exercise. He also had memory and concentration problems that were made worse by his fatigue and pain. In addition, he had difficulty with language and reading. In this patient’s case, an occupational therapist led him through a memory-training program. A speech therapist addressed his issues with language. A physical therapist used myofascial techniques to reduce muscle spasm and pain, and a neurologic physical therapist taught him to walk without a walker and helped increase his endurance for other activities. The cancer rehabilitation physician coordinated the timing of these therapies according to the patient’s tolerance of oncology treatment in order to optimize recovery.
The Timing of Rehabilitation
Cancer rehabilitation can be prescribed before, during, and after treatment. Rehabilitation prescribed before treatment can help patients build strength and endurance and minimize the physical impact of treatments such as radiation. Patients with breast cancer and head and neck cancers benefit most from “pre-hab” because of the effects of the disease and treatment on the chest, shoulder, and neck muscles.
If cancer treatment might affect a structure critical to a person’s job, hobby, or ability to eat, balance, or use his or her hands a consultation with a cancer rehabilitation physician before treatment is recommended. Professional musicians, athletes, or others who work in physically demanding jobs are obvious examples of people who can benefit from a pretreatment consultation. For example, a 55-year-old professional violinist was referred to our center by her surgeon after being diagnosed with cancer in the right breast. She was scheduled to undergo a mastectomy and axillary lymph node dissection, placing her at high risk for nerve pain and lymphedema in her bowing arm. She wanted to have implant reconstruction but needed information on how that might affect her career. We discussed the physical impact of each surgery and its follow-up treatment, then referred her to a certified lymphedema therapist who had expertise working with performing artists. The patient was given specific exercises and extensive education on the methods to protect against lymphedema. Along the way, she was given instructions on how to schedule practice sessions in order to avoid overuse. The woman successfully returned to playing the violin after treatment.
Another patient we worked with was a 40-year-old yoga instructor who had been diagnosed with breast cancer. She was referred to our clinic by her plastic surgeon for assistance in deciding the type of reconstruction to undergo after mastectomy. Some of the reconstruction procedures involved muscle transfers. We performed a complete review of her job tasks specific to yoga and other fitness routines. She decided to undergo latissimus muscle flap reconstruction.
After cancer treatment, rehabilitation can provide interventions for weakness, neuropathy, swelling, muscle pain, difficulty swallowing, and memory problems—potential side effects of various cancer treatments. The yoga instructor experienced some mild restriction of movement of the shoulder blade after sugery. The asymmetry made it difficult for her to balance her torso and caused pain after a day at work. She returned to our clinic and was referred to a physical therapist who specializes in chest wall, arm, and rib cage problems that can occur after breast reconstruction surgery. She was successfully treated and has resumed work without any difficulties or pain. In another case, a 45-year-old man diagnosed with gallbladder cancer was seen at our clinic after undergoing extensive abdominal surgery for removal of the tumor and lymph nodes. He had postoperative infection, and his wounds were slow to heal. He then underwent chemotherapy. Although he had a good response to cancer treatment, he had constant pain and weakness in the abdominal wall. This limited his ability to lift his children, walk up steps, and play golf. Examination of the trunk and legs revealed specific areas of weakness. He was prescribed an exercise program that primarily focused on core muscle strength, and he eventually resumed all activities. Yet another patient, a 60-year-old man diagnosed with tonsil cancer, was referred to us after tonsillectomy and neck lymph node resection. He developed severe nausea and weight loss during treatment that necessitated the insertion of a feeding tube. He received physical and speech therapy. Several months later, he was able to have the feeding tube removed, was swallowing normally, and had only mild restriction of movement in his arm and neck.
Lymphedema
Lymphedema is a common problem among people who’ve been diagnosed with and treated for cancer. Lymphatic swelling is caused by a build-up of fluid in the soft tissue. It frequently affects an arm or leg as well as other parts of the body. Breast cancer, melanoma, head and neck cancers, and gynecologic cancers are associated with a higher risk of lymphedema because of the location of the lymph nodes that may have to be removed. Lymphedema has been studied mostly in breast cancer patients, as up to 50% of breast cancer survivors who have axillary lymph nodes removed will experience arm lymphedema. In addition, breast lymphedema can occur after lumpectomy and radiation therapy. Being obese or having a wound infection are other risk factors for developing the condition.
The risk of developing lymphedema can be reduced by protecting the remaining lymphatic tissue. Avoiding trauma and infection to the affected areas are the main recommendations for prevention. Additional instructions for reducing the risk of lymphedema are available from the National Lymphedema Network (www.lymphnet.org). Tai chi and some types of yoga, along with circuit-type exercise programs, are good forms of exercise for those at risk for lymphedema. Judicious weight lifting can be tolerated, but patients should seek professional guidance from a cancer rehabilitation physician or certified lymphedema therapist before starting a weight-lifting program. Early education and appropriate exercises can minimize the impact of cancer-related edema and weakness. Recently, a 50-year-old man who was diagnosed with melanoma of the leg had lymph nodes removed from the groin, which placed him at risk for lymphedema. He had a history of varicose veins and vein stripping, increasing his risk of swelling. His surgeon referred him to our clinic, where he was taught to protect against lymphedema using guidelines tailored to his health history and about the early signs of lymphedema. He also was prescribed a medical support stocking.
A 63-year-old man with advanced pancreatic cancer came to our clinic after developing such severe swelling and weakness of his legs during chemotherapy that he could not wear shoes or walk without help. He wanted to be able to walk his daughter down the aisle for her wedding in two months. In his case, he received lymphedema therapy along with a strengthening and endurance program. His treatments consisted of lymphatic massage (known as manual lymphatic drainage), compression wraps on the edematous area, and light stretching exercises to move lymph. Because of the severity of his weakness, the initial exercises were done with the assistance of a physical therapist. As he gained strength, he was able to do more arm and leg exercises using machines under the supervision of the therapist. Eventually, he was able to do light weight lifting and walk on his own while wearing support stockings. After several weeks of therapy, he was able to walk his daughter down the aisle and even danced at her wedding.
New information on lymphedema, risk reduction, and new treatments is emerging. In the past 10 years, exercise regimens have been developed that allow patients to exercise in ways that will protect against worsening lymphedema. In 2009, a group of U.S. researchers delineated a safe weight lifting program for breast cancer survivors with lymphedema.11,12 Studies are also showing that breast cancer patients who have had sentinel lymph node biopsy, rather than full lymph node dissection, have a reduced risk of arm lymphedema of about 6%.13,14
Awareness Needed
Some medical providers are not yet aware that rehabilitation is beneficial before, during, and after cancer treatment, and many people who have been diagnosed and treated for cancer have never heard of cancer rehabilitation. In addition, there is still a misconception that cancer patients are too overwhelmed to access or will not benefit from rehabilitation services. The reality is that even patients in the late stages of cancer can improve their physical functioning and, thus, their quality of life. For that reason, it is important that primary care physicians and oncologists become familiar with cancer rehabilitation and inform patients that services exist to help them cope with some of the side effects of cancer and its treatment.
A consultation with a cancer rehabilitation specialist is helpful for those individuals who find they are having difficulty with activities of daily living, returning to work, keeping up with responsibilities at home, and engaging in their avocations. A cancer rehabilitation physician can help survivors set realistic expectations about what is reversible, explain the treatment options that are available, and talk about the time it takes to make progress. Restoring the patient to the highest function and maximizing independence is the goal of cancer rehabilitation and the key to helping patients achieve physical and psychological wellness. Thus, cancer rehabilitation is a key component in the comprehensive care of cancer survivors. MM
Nancy Hutchison is medical director for cancer rehabilitation and lymphedema at the Virginia Piper Cancer Institute and Sister Kenny Rehabilitation Institute.
References
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