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Physical rehabilitation for cancer survivors

Authors:

Jonas M Sokolof, DO

Maryam Rafael Aghalar, DO

Michael D Stubblefield, MD

Section Editors:

Patricia A Ganz, MD

Larissa Nekhlyudov, MD, MPH

Deputy Editor:

Sadhna R Vora, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Dec 2018. | This topic last updated: Aug 23, 2017.

INTRODUCTION — Cancer rehabilitation is a specialty of physical medicine and

rehabilitation that aims to meet these needs for cancer survivors. Rehabilitation focuses on
the evaluation and treatment of functional loss and pain disorders with the goal to restore
maximal function, which, depending on the patient’s specific needs, may involve a
multidisciplinary team, including a physiatrist (ie, physical medicine and rehabilitation
clinician), physical therapists, occupational therapists, speech and language therapists,
and a lymphedema therapist. The importance of cancer survivorship care inclusive of
attention to the medical, functional, and psychosocial consequences of cancer and its
treatment were cited as important areas to address in an Institute of Medicine (IOM)
consensus study report issued in 2006 [1]. It is important to identify and refer to those
healthcare professionals that are qualified and have the expertise in treating patients'
rehabilitation needs [2].

Cancer rehabilitation is typically a coordinated endeavor that requires an open channel of

communication to the primary oncology team (eg, medical oncologist, radiation
oncologist, and/orsurgical oncologist) and the primary care providers. In addition,
supportive services play a critical role in the rehabilitation of cancer survivors, including
those by nurses, recreational therapists, nutritionists, social workers, mental health
professionals, orthotic and prosthetic specialists, chaplains, vocational counselors, hospice
liaisons, home care agencies, support groups, and educational outreach programs [3].
MODELS OF REHABILITATION — The majority of rehabilitation programs address
specific physical impairments caused by the cancer and its treatments. It is important to
note that general physical exercise has been shown in many studies to have tremendous
benefits in cancer survivors, including improving fatigue, quality of life, mood, decreased
cancer recurrence, and improved survival [4]. This is beyond the scope of this chapter and
is discussed extensively elsewhere. (See "The roles of diet, physical activity, and body
weight in cancer survivors".)

Cancer rehabilitation plays a role throughout the continuum of cancer survivorship.

General cancer rehabilitation is often grouped into categories known as the Dietz
Classification [5]. These include:

●Preventative rehabilitation – The emphasis in preventative rehabilitation

(sometimes referred to as prehabilitation or prospective surveillance [6]) is on the use
of early intervention and exercise to prevent or delay complications related to cancer
or its therapies. It includes physical and psychological assessments done early in the
cancer continuum of care to identify physical impairments and to refer as deemed
necessary to qualified rehabilitation professionals. The rationale is that earlier
detection of impairments makes them easier to treat, which may reduce the
incidence and/or severity of future impairments [6].

●Restorative rehabilitation – For patients in whom a fully functional recovery is

expected, restorative rehabilitation envisions full reintegration of the patient back into
society, community, school, or work.

●Supportive rehabilitation – For patients in whom cancer treatment has resulted in

permanent deficits (including those in whom deficits are very unlikely to resolve), the
goal of supportive rehabilitation is to re-establish functional independence as much as
possible.

●Palliative rehabilitation – If intensive rehabilitation is not possible or deemed

clinically inappropriate, palliative rehabilitation may play a role in supporting the
patient, especially if he or she is facing a terminal diagnosis. The goals are to
maximize patient comfort and caregiver support.

These services are not necessarily delivered independently of each other. Instead, they
may be offered within a single program, allowing patients to transition to different services
as dictated by their needs. At our institution, this is done by utilizing both inpatient and
outpatient rehabilitation services:

●Preventative services are generally offered while patients are admitted for acute
care. When patients are referred, inpatient physical and occupational therapists
assess the patient’s current functional status in order to determine if and what types
of rehabilitation services might be necessary. This includes assessments of patient
safety, their independence in performing tasks (eg, bed mobility, transfers), and
ambulation.

●Physical medicine and rehabilitation clinicians provide early education regarding

potential impairments that can arise from cancer or its treatments. For example, for
patients admitted with newly diagnosed breast cancer, therapists are involved with
the early education about postoperative complications of breast surgery, including
shoulder range of motion limitation and lymphedema.
 ●At discharge, rehabilitation clinicians provide recommendations about safe
disposition of patients and when needed, assist in the transfer of appropriately
selected patients to an acute or sub-acute inpatient rehabilitation center or a skilled
nursing facility based on the individual’s needs and ability to participate in inpatient
rehabilitation. Alternatively, individuals who are functioning at a high level
independently may be discharged home with referral for outpatient rehabilitation to
work on specific functional skills. For other patients who are too sick or
immunocompromised to receive rehabilitation on an outpatient basis (but are not
candidates or otherwise refuse inpatient rehabilitation services), home therapy can be
coord

inated and implemented.

●Restorative services are provided on an outpatient basis. Patients are usually

referred from their primary care providers, oncologists, surgeons, and radiation
oncologists for a wide variety of symptoms and impairments. The work within our
program is performed in conjunction with the pain and palliative care service, the
anesthesia pain department, and integrative medicine.

Each patient is monitored closely amongst the clinicians and therapists, and any questions
regarding his or her safety or care are communicated with his or her respective
oncologists, surgeons, and primary care providers. Patients with diffuse metastases are
not excluded from rehabilitation, as rehabilitation can help achieve set functional goals.
Spinal precautions and weight bearing precautions are carefully executed to prevent injury
and harm. Once rehabilitation goals are met and patients have reached maximum benefit,
they are usually discharged with home exercises and reassessed by the physiatrists at a
later date to see if they would benefit from further rehabilitation.

Role of the physiatrist — The physiatrist is a clinician trained in physical medicine and
rehabilitation and typically leads an interdisciplinary team. The role of the physiatrist is to
conduct a full initial evaluation, including:

●A comprehensive functional assessment – Important aspects of the patient’s history

include their cancer history (initial diagnoses, prior and any ongoing treatments,
including surgery, radiation, and chemotherapy) and precautions that would be
important in the rehabilitation process, such as their weight bearing status and spinal
stability.

●Medication review – A thorough review of the patient’s medications is necessary to

evaluate for drug-related side effects that could be contributing to any presenting
impairment. Additionally, in the event that additional medications are indicated to treat
various pain conditions, it is important to identify any potential drug interactions.

●Specific testing as indicated, including imaging, nerve conduction studies (NCS),

electromyogram (EMG), or lab work.

Based on their rehabilitation needs, patients are then referred to specialized services (eg,
prosthetics, orthotics, physical therapy, occupational therapy, speech and swallow therapy,
or lymphedema therapy) with a detailed prescription outlining their rehabilitation course.
Interventions may be recommended depending on the precise functional deficits
encountered. Some examples include therapeutic exercise, manual therapy (eg,
myofascial massage, joint mobilization), electrical modalities (eg, transcutaneous electrical
nerve stimulation [TENS]), thermal modalities, lasers, and therapeutic taping.

SPECIFIC IMPAIRMENTS — Multiple clinical scenarios may be encountered after

treatment for cancer, which depend on the type of malignancy and the therapies
administered. The time course for both onset and exacerbation of symptoms is largely
dependent on whether or not there was a previous impairment that may have been mild
prior to the index diagnosis of cancer and its treatment, or had not yet manifested
clinically. For example, a patient with a prior history of mild or moderate joint arthritis may
be more symptomatic during or after cancer treatment due to a variety of factors, including
but not limited to overall deconditioning, weakness, or the adverse effects of anti-cancer
medications (eg, anastrozole-induced myalgia and arthralgia) and their potential impact on
overall tissue healing and homeostasis.

Common impairments are discussed below. Most of these are typically described following
treatment for breast cancer, reflecting both that patients treated for breast cancer are a
large proportion of cancer survivors [7] and that much of the literature on cancer
rehabilitation has been gained from studies involving these patients.

Upper extremity pain — Cancer survivors, in particular those treated for breast cancer,
face a myriad of upper extremity impairments resulting from their treatments, which include
surgery, radiation, chemotherapy, and hormonal therapies. Estimates are that between 10
and 64 percent of patients treated for breast cancer develop upper body symptoms
between 6 and 36 months after diagnosis [8]. Although the etiology is usually multifactorial,
it is important for the treating clinician to properly examine the patient to find the source
that can guide the course of rehabilitation and optimize his or her treatment strategy. Two
common conditions seen in our program include issues related to the shoulder and the
axillary web syndrome.

Shoulder dysfunction — Surgery and radiation therapy (RT) that involves the upper
extremity (eg, indicated for breast cancer treatment) may induce painful scar tissue
formation and nerve damage. This in turn can lead to abnormal protective posturing by the
patient, which can result in the shortening of soft tissues in the anterior chest wall,
including the pectoralis major and minor muscles, causing a protracted or forward
depression of the shoulder girdle [9]. The misalignment can lead to subsequent
impingement of the rotator cuff leading to pain and immobility, which can eventually lead to
adhesive capsulitis. Shortening of the pectoral muscles can also lead to overuse and
strained scapular retractors, leading to subsequent myofascial dysfunction in the back and
neck muscles [10]. (See "Rotator cuff tendinopathy" and "Frozen shoulder (adhesive
capsulitis)".)

For patients experiencing shoulder symptoms, data are available to suggest there are
benefits to an exercise prescription [11-13]. As examples:

●In one randomized controlled trial involving 160 patients who underwent breast
cancer surgery, the patients were randomly assigned to either an eight-week exercise
program or to periodic assessments without an exercise prescription (controls) [11].
The exercise program consisted of weekly sessions and a home program of passive
stretching and progressive resistance training for shoulder muscles that started four
to six weeks postoperatively. Compared with controls, patients in the exercise group
gained slightly greater range of motion in both forward flexion and abduction and
 strength in abduction plane. Of note, resistance training in the postoperative period
was not associated with an increased risk of lymphedema.

●In another trial, 30 patients who had undergone breast cancer surgery and axillary
lymph node dissection were randomly assigned to receive standardized
physiotherapy treatment for the arm and shoulder (beginning two weeks post-surgery
and then for three months afterwards) or to a control group that received a leaflet
containing advice and exercise suggestions [12]. After three and six months, the
treatment group showed a significant improvement in shoulder mobility and had
significantly less pain than the control group. Quality of life improved significantly, and
arm volume did not change significantly.

Beyond exercise for shoulder symptoms, it is also important to evaluate patients for co-
existing edema involving the arm and/or chest wall, which are also etiologies of impaired
range of motion [10].

Exercise prescriptions must be accompanied by adequate pain control, which can be

achieved with anti-inflammatory agents (eg, non-steroidal anti-inflammatory drugs). At our
center, we will often offer subacromial and glenohumeral corticosteroid injections with
minimal complications. However, the role of corticosteroid injections for shoulder
dysfunction in this population needs to be further evaluated.

Axillary web syndrome — Axillary web syndrome or "cording" is characterized by

palpable cord-like subcutaneous tissue extending from the axilla into the medial arm and
sometimes to the palm, usually manifest when the shoulder is abducted. It may be due to
damage and sclerosis of the lymphatic and/or venous system [14], although the exact
etiology is not clear. Although not particularly painful, the cords can limit the range of
motion of the shoulder.

Therapy is usually directed at maintaining shoulder range of motion and reducing edema
through manual lymphatic drainage. Depending on the degree of range of motion deficit,
therapy can begin with gentle, gravity-assisted pendulum exercises (eg, Codman’s
technique) and can gradually progress to wall walking and active assisted range of motion.
Manual mobilization techniques can sometimes release or "break" the cords.

While treatment can be successful, patients may experience recurrence of axillary webs.
Further research is needed in the etiology and best management strategy for patients who
present with this syndrome.

Postmastectomy pain syndrome — Postmastectomy pain syndrome (PMPS) is

characterized as any pain persisting beyond the period of healing post-mastectomy,
although it is also seen post-lumpectomy. Among women with breast cancer treated with a
mastectomy, the risk factors for this syndrome include [15]:

●History of severe and acute pain postoperatively

●Younger age at diagnosis

●RT to the axilla

●Extensive axillary surgery

The pain is typically characterized as burning, stabbing, neuropathic (eg, numbness,
hyperesthesia, or paraesthesia), or as an "electric shock" at the operative site or ipsilateral
arm. It is thought to be caused by direct nerve injury during breast cancer operations or
from the development of a traumatic neuroma or scar tissue involving the neural tissue in
the axilla and/or chest wall (eg, brachial plexus, intercostobrachial, lateral cutaneous
branch of the second intercostal, long thoracic and medial and lateral pectoral nerves).

Although there are no prospective data on the impact of rehabilitation services on PMPS,
physical therapy (PT) is often prescribed to help relieve the symptoms of PMPS. This
includes modalities such as desensitization techniques, transcutaneous electrical nerve
stimulation (TENS), and the application of cold packs topically. The approach also includes
pain management, including neural stabilizers (pregabalin or gabapentin), serotonin-
norepinephrine reuptake inhibitors ([SNRIs]; eg, duloxetine), or topical agents
(eg, lidocaine or non-steroidal anti-inflammatory drugs).

Interventional techniques such as intercostal or paravertebral nerve blocks and/or ablation

can be used in the usual manner to treat regional pain syndromes.

Botulinum neurotoxin type A (BoNTA) injections into hyperirritable muscles such as the
pectoralis major and serratus have been safely used in our practice with good efficacy to
treat refractory PMPS. Its use is extrapolated from other data showing that BoNTA may
prevent postoperative pain after mastectomy and subsequent breast reconstruction [16].
However, no clinical trials exist on its use in PMPS.

Aromatase inhibitor-associated musculoskeletal syndrome — Aromatase inhibitors

(AIs) are important agents utilized in the treatment of hormone receptor-positive breast
cancer in the adjuvant and metastatic disease settings. However, the AIs can cause
arthralgia, joint stiffness, and bone pain, which can be severe in up to 30 percent of
patients, sometimes referred to as the Aromatase Inhibitor-associated Musculo-Skeletal
Syndrome (AIMSS). The pain and stiffness typically involves the hands, arms, knees, feet,
pelvic and hip bones, or back. It is usually symmetrical and may be associated with mild
soft-tissue thickening [17]. Trigger finger and carpal tunnel syndrome are often the most
frequently reported signs [18].

There are no large randomized controlled trials to inform the optimal management of these
patients. In addition to patient education, medications such as anti-inflammatories, opioids,
antidepressants such as duloxetine, Vitamin D supplementation, and over the counter
supplements such as glucosamine with chondroitin have been evaluated [19,20]. One
approach to the patient experiencing symptoms is discussed separately, but includes
options such as conversion to a different medication (for those unwilling to stay on the
specific AI causing symptoms) or a limited course of duloxetine (for those willing to stay on
their prescribed AI).

Beyond medical therapy, complementary modalities such as acupuncture may be helpful

[21]. If carpal tunnel syndrome or trigger finger is present, an injection with
corticosteroids and/or splinting may relieve symptoms. In our experience, injections to
alleviate the symptoms associated with carpal tunnel syndrome did not worsen
lymphedema in patients with mild to moderate lymphedema; therefore, the presence of
lymphedema should not be taken as an absolute contraindication to this therapy. Of note,
isolated knee pain can also be treated with intraarticular corticosteroid injections.
At least one trial demonstrated that patients with AIMSS derive benefit from exercise. In
the Hormones and Physical Exercise (HOPE) study that included over 120 women,
exercise resulted in a greater reduction in pain scores compared with usual care, and it
was associated with greater weight loss and improved exercise capacity [22].

At our center, we have approached these patients in a similar way to those who present
with signs and symptoms of fibromyalgia. Physical and occupational therapy is aimed at
increasing range of motion, while strengthening exercises aim to increase flexibility and
relieve tension. Any exercise prescription should also include weight-bearing exercises to
prevent osteoporosis.

Lymphedema — Lymphedema is the collection of protein-rich fluid into the interstitial

spaces due to disruption of lymphatic flow. Cancer and/or its treatment are the most
common causes of lymphedema in the developed world and can be a significant cause of
both physical and functional distress. The most common cancer associated with
lymphedema is breast cancer, although it is not uncommon among patients treated for
other cancers, including soft-tissue sarcoma, lower extremity melanoma, gynecologic or
genitourinary cancers, and cancers of the head and neck.

The hallmark of treatment for lymphedema is complete decongestive therapy, which is

discussed separately. In addition, for patients referred to rehabilitation, the application of
Kinesio tape may be an additional modality for treatment [23,24]. Kinesio taping is a
specific type of modality that involves the use of an elastic adhesive tape applied to a
patient’s skin to facilitate proper fascial plane alignment. It is theorized that re-aligning
such fascial planes will enhance tissue healing and serve to alleviate pain. Kinesio taping
has rapidly become popular in the fields of sports medicine and rehabilitation, but clinical
trials demonstrating its efficacy are currently lacking.

Neuropathy — Chemotherapy-induced neuropathy (CINP) may result from direct toxic

effects on the nervous system or indirectly from drug-induced metabolic derangements or
cerebrovascular disorders. The platinum compounds (cisplatin, oxaliplatin), taxanes
(paclitaxel), and microtubule binding agents (vincristine, ixabepilone) are among the more
common agents implicated [25]. Clinically, patients experience burning paresthesias, pain,
sensory ataxia, and sometimes loss of motor function.

It is important to rule out other causes of neuropathy, and the following important
conditions should be excluded when a patient presents with neuropathic complaints:

●Diabetes mellitus

●Vitamin B12 deficiency

●Alcoholism

●Lyme disease

●Immune-mediated neuropathies

●Charcot-Marie-Tooth disease

Others on the differential should include primary CNS lesions (eg, epidural tumor,
leptomeningeal metastases, and intramedullary metastasis), other etiologies causing
peripheral nervous system dysfunction (eg, carpal tunnel syndrome and ulnar nerve
neuropathy), and degenerative disorders (herniated disks and spinal stenosis).

Successful treatment is based on accurate diagnosis, which can guide the proper care and
treatment. In addition, rehabilitation, which includes physical and/or occupational therapy,
may be useful to work on deficits such as decreased balance, gait abnormalities, muscle
weakness, and difficulties with performing activities of daily living. Pain or discomfort
should be properly managed for full participation in therapy.

Nerve conduction studies (NCS) and needle electromyography (EMG) studies are often
used to characterize the location and severity of nerve damage and help to rule out other
causes of neuropathy, including carpal tunnel syndrome or radiculopathy. They may
strengthen the working diagnosis based on the history and physical exam. NCS/EMG may
be useful for deciphering the location of a nerve lesion such as root, plexus, or peripheral
nerve itself. This, in turn, may prompt additional work-up, including blood work, as in the
case of peripheral neuropathy, to determine potential reversible causes.

Spinal accessory nerve palsy — For patients with tumors involving the head, neck, or
spine, the spinal accessory nerve can be damaged directly or indirectly from
surgery and/or radiation and can result in pain and decreased muscle function [26]. For
patients treated for head and neck cancer, symptoms typically consist of trapezius atrophy,
shoulder girdle depression, limited active shoulder abduction to less than 90 degrees,
shoulder pain, and shoulder weakness. Radiation and surgery can also lead to
hyperirritable muscles and nerves, resulting in spasm, pain, and muscle tightness.

Rehabilitation includes preserving range of motion of the shoulder, strengthening of

alternate scapular elevators and retractors, neuromuscular retraining of shoulder girdle
muscles, postural modification, and using electrical stimulation [27]. Patients with complete
spinal accessory nerve palsy can be fitted with an orthosis to reduce pain [28]. For patients
experiencing spasm or tightness of a specific muscle group, we have found a combination
of PT as well as botulinum toxin injections into the sternocleidomastoid muscle to
decrease painful spasms [29,30]. Integrative techniques, such as acupuncture, may also
be helpful [31].

Dropped head syndrome — Patients with history of radiation to head and neck can
develop neck extensor weakness secondary to myopathy and atrophy leading to dropped
head syndrome, or inability to keep the head up for a prolonged period of time. We see
this mostly with survivors from Hodgkin lymphoma who have received mantle field
radiation. Radiation leads to progressive fibrosis of the anterior and lateral cervical soft
tissue, reducing range of motion, which results in difficulty keeping the head upright.

PT can improve patients' quality of life by improving core muscles as well as neck strength,
posture, body mechanics, proprioception, and endurance with emphasis on a lifelong
home exercise program, as over time patients can develop neck flexor contractures [3].
Manual myofascial release techniques are beneficial over fibrotic tissue. A cervical collar
such as the Headmaster or a similar device can be used for functional assistance in
elevating the neck, energy conservation, and improving quality of life.

Trismus — Trismus is a common complication of head and neck cancer and is usually
due to a combination of factors, including direct tumor invasion, surgery, and/or radiation.
Treatment should be aggressive and started early, as mature scar tissue becomes more
resistant to exercise therapy [32]. Multiple modalities have been implemented and can be
used alone or in combination. Aside from an evaluation from a speech and swallow
specialist, dentist, and nutritionist, PT should be initiated for myofascial release techniques
as well as initiation of oromotor tongue and jaw exercises to preserve range of motion
[33,34]. The most commonly prescribed devices used to treat trismus in this population are
the TheraBite System [35] and The Dynasplint Trismus System [36,37]. In the past,
stacked tongue depressors and/or corkscrew-like devices were used but have now fallen
out of favor due to the oral and dental trauma associated with their use. Botulinum toxin
injections to the masseter or pterygoid by themselves do not improve mouth opening, but
they can help with muscle pain and decrease dynamic muscle spasm [38]. Pain
medications, including muscle relaxants, analgesics, and nerve stabilizers can be used to
diminish the pain and spasm, which can make jaw opening devices and therapy more
effective.

Speech and swallowing dysfunction — This should be evaluated in every head and
neck cancer patient and should be treated appropriately.

Cognitive dysfunction — Cognitive dysfunction is associated not only with intracerebral

malignancies, but is also secondary to cancer treatments such as chemotherapy,
radiation, corticosteroids, and immunotherapy, as well as other medications such as
antiepileptics, opioids, and antiemetics. Although "chemo brain" is commonly used,
cognitive dysfunction is usually multifactorial in nature, and the treating clinician should
rule out other concomitant factors such as anxiety, depression, fatigue, and sleep
disturbances. Cognitive dysfunction can include memory impairment, mental fogginess,
difficulty concentrating, slower processing speed, and difficulty with executive functioning.
These symptoms can persist even after treatment cessation. Neuropsychological
evaluation and testing are important to determine the nature and extent of the patient’s
impairment, which then would guide appropriate treatment interventions.

Cognitive rehabilitation for cancer patients is not yet based on solid evidence-based
research and oftentimes uses the guidelines approached for traumatic brain injury and
stroke patients [39]. Goals usually involve maximizing functioning, coping, and quality of
life through the use of compensatory strategies and reliance on residual abilities [40].
Compensatory strategies include making changes in the patient’s home or hospital
environment to increase structure, decrease demands for planning and decision making,
and enhance orientation. External memory aides such as checklists, planners or memory
books, wall calendars, and alarms can be used. It is important to treat other etiologies
such as fatigue, sleep disturbances, stress, and depression as well.

Pharmacological interventions (eg, cytokine antagonists, anti-inflammatory agents,

stimulants, and anticholinergics) have also been used in conjunction with formal
rehabilitation. Exercise has not yet been studied for cognitive dysfunction in cancer
patients, but it has shown improvement in cognitive recovery among patients with acquired
brain injury [41]. Exercise is generally advocated for its overall benefits, including
decreasing fatigue, depression, anxiety, improving quality of life, and decreasing bone loss
and fracture.

SUMMARY AND RECOMMENDATIONS

●Cancer rehabilitation is a specialty of physical medicine and rehabilitation that aims

to meet these needs for cancer survivors.
 ●Cancer rehabilitation plays a role throughout the continuum of cancer survivorship.
General cancer rehabilitation is often categorized as: preventative, restorative,
supportive, and palliative. However, these services do not necessarily occur
independent of each other. Instead, they may be offered within a single program,
allowing patients to transition to different services as dictated by their needs.

●Once a diagnosis of cancer has been established, patients should be evaluated for
potential physical impairments that may be exacerbated during the treatment phase.

•If such impairments are identified, enrollment in a formal rehabilitation program

may help to prevent greater functional deficits in the future.

•If no impairments exist, then a short course of supervised therapeutic exercise

in the form of physical therapy (PT) or occupational therapy, or speech therapy,
may be helpful in developing a strengthening program and guiding the patient on
safety awareness in anticipation of potential functional deficits arising directly
from cancer treatment.

●For individuals who have completed treatment, careful monitoring should take place
in order to identify various impairments as early as possible.

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