Chapter 59: Rehabilitation

Cancer and its treatments are a major cause for impairments and disability. Because cancer treatments have become increasingly successful and have improved survival, there has been an increasing focus on quality of life and, in particular, rehabilitation. Cancer rehabilitation is practiced in outpatient clinics, oncology wards, inpatient rehabilitation units, skilled nursing facilities, nursing homes, long-term acute care centers, palliative care units, and hospices. Common diagnoses addressed include asthenia, deconditioning, hemiplegia, spinal cord injury, peripheral neuropathy, somatic and neuropathic pain, steroid myopathy, lymphedema, bowel/bladder management, limb amputation, and limb dysfunction.

The major goal of cancer rehabilitation is to improve quality of life by minimizing the disability caused by cancer and its treatments and decreasing the “burden of care” needed by patients with cancer and their caregivers. The more patients can do for themselves, the more personal dignity they are able to maintain and the less help they require from those around them.

In 1978, Justus Lehmann, supported by the National Cancer Institute (NCI), screened 805 randomly selected patients with cancer, identifying multiple problems in the population of patients with cancer who are amenable to rehabilitation interventions along with barriers limiting the delivery of rehabilitation care. More than 30 years later, many of Lehmann’s remediable cancer rehabilitation problems and barriers to rehabilitation care remain the same (Table 59-1).

These problems are familiar to rehabilitation professionals because many are also found in traditional noncancer rehabilitation patients. Lehman also described major barriers to the delivery of cancer rehabilitation care, including the lack of identification of these problems by oncologists and the lack of referral to rehab professionals for a rehabilitation intervention. In addition, there are multiple patient-related factors that can affect the successful rehabilitation of the patient with cancer. Several reported by DeLisa include reduced life expectancy, extensive comorbidities, degree of pain, the dynamic nature of cancer lesions, the demands of anticancer therapies, and the desire to spend remaining time with loved ones (¹).

Phases of Cancer Rehabilitation

In 1980, Dietz categorized cancer rehabilitation into four stages: preventive, restorative, supportive, and palliative (²). Preventive rehabilitation occurs before or immediately after a treatment to prevent loss of function or disability. An example would include preamputation stump care teaching and ambulation with a walker in a patient with a lower extremity sarcoma. In 2001, Courneya described a concept called “buffering” whereby a patient with cancer undergoes exercises and therapies to increase the patient’s physical and functional reserves before cancer treatment (³).

Restorative rehabilitation occurs in patients who are believed to be disease free or will have an anticipated relatively stable disease course. Taking our previous example, a patient with lower extremity sarcoma with no known metastatic disease following amputation undergoes prosthetic rehabilitation. These first two stages are not significantly different from conventional nononcologic rehabilitation. Fortunately, as survivorship has increased, restorative rehabilitation has become more prominent in addressing issues in this population, including disability, return to work, and lymphedema management.

If patients are unable to achieve or maintain a state of remission, supportive rehabilitation is performed to sustain function and provide symptom management. Expanding on our example, a patient with metastatic sarcoma may be provided therapies and durable medical equipment (DME) to promote functional independence while receiving chemoradiation.

Unfortunately, patients may succumb to their malignancy, or its accompanying morbidities, and efforts to maximize function may require a transition to focusing on quality of life. Palliative rehabilitation is provided to reduce discomfort and improve independence in patients with advanced disease. Our example patient with sarcoma and advancing metastatic disease may have failed multiple treatment regimens and now requires rehabilitation to return home with some degree of assistance. The emphasis of palliative rehabilitation is typically to get the patient home safely as soon as possible. The patient likely has limited time to live and the costs of a lengthy inpatient rehabilitation stay must be taken into consideration. Goals once the the patient is home in a safe environment focus on family and transfer training. Higher-level goals should be addressed as an outpatient or through home health therapy.

The last two stages described by Dietz (¹) are relatively unique to cancer rehabilitation. The typical course for a patient in conventional rehabilitation (eg, after a stroke) is continued improvement after the inciting event. In the patient with cancer with persistent disease, however, the war continues with brief victories followed by declines as the disease progresses (³) (Fig. 59-1).

Multiple studies have established a need for rehabilitation in the population of patients with cancer (^4,5). Functional improvements of patients in cancer rehabilitation have been demonstrated in a number of settings, including inpatient (^6,7,8,9) and palliative care (^10,11), on a consultation basis (¹²), in a hospice setting (^13,14), and for outpatient settings (¹⁵). The maintenance of physical activity and exercise has been implicated in increasing survival, with the greatest quantity of evidence in patients with breast and colon cancer. Multiple mechanisms may exist, and some have proposed these findings to be related to levels of insulin/c-peptide, along with the positive effects of buffering on physiological reserves, potentially allowing for more treatment (^16,17). Cancer physiatrists must also address medical sequelae and complications that are unique to this patient population. With limited training in general medical and surgical fields, these comorbidities may serve as a significant challenge and require frequent communication between the primary oncology and rehabilitation teams. The transfer rate from inpatient rehabilitation to acute care teams is high compared to other rehabilitation diagnoses (¹⁸).

Rehabilitation goals are accomplished by the efforts of a comprehensive interdisciplinary team of health-care professionals, including the rehabilitation physician, rehabilitation nurse, physical therapist, occupational therapist, speech therapist, dietitian, pharmacist, chaplain, social worker, and case manager. Each member of the team has specific expertise in assisting the patient with a care plan of maximizing medical stability, function, financial resources, and caregiver involvement for a discharge that is as safe and meaningful as possible (Fig. 59-2).

Rehabilitation at MD Anderson

At the University of Texas MD Anderson Cancer Center (MDACC), our cancer rehabilitation practice includes seven physical medicine and rehabilitation physicians and a rehabilitation therapy staff of over 100 physical therapy and occupational therapy clinicians. Rehabilitation therapists see over 300 inpatients and 100 outpatients per day. Patients include those with most of the different tumor types seen in the institution, the most common being brain, spine, lung, breast, hematologic, genitourinary, gastrointestinal, and head and neck tumors. The most common inpatient rehabilitation diagnoses included asthenia, gait abnormality, dyspnea, hemiparesis, spinal cord injury, and neurogenic bowel and bladder. Common outpatient rehabilitation diagnoses include lymphedema, myofascial pain, rotator cuff dysfunction, peripheral neuropathy, and low back pain. Inpatient and outpatient electromyograms are performed for neuropathic and myopathic diagnoses and spasticity management.

Functional Metrics

When describing the functional status of a patient with cancer, the Karnofsky Performance Scale is often used. It is the most widely used scale both clinically and in research in oncology patients (¹⁹). It is an easy and quick generalized measurement of a patient’s function. Weaknesses of the scale include overgeneralization (unable to measure specific tasks) and poor correlation with cognition (²⁰).

In rehabilitation, the outcome scale most often used is the Functional Independence Measure (Fig. 59-3). This multidimensional scale addresses 18 items from a scale of 1 (total assistance) to 7 (complete independence). Items are subdivided into self-care, sphincter control, transfers, locomotion, communication, and social cognition. An aggregate score is also often useful out of a total of 126. Criticisms of the scale include that it is too general and omits items that are important for specific populations, such as those with spinal cord injuries (²¹).

Physiatry is a holistic specialty that accounts for medical needs while focusing on a patient’s functional issues. Safety is a primary concern of rehabilitation health-care professionals. The first question a physiatrist often asks is, What is the minimum level of safe function for this patient to be discharged? That “safe” functional level goal depends on the patient’s current functional level, strength, cognition, amount of supervision or assistance available on discharge, accessibility of home conditions, and financial resources. Physiatrists must ask patients and their caregivers detailed social questions.

Common obstacles confronted are a lack of assistance or supervision at home. This often is due to the patient’s significant other being required to work during the day, the significant other’s inability either physically or mentally (eg, dementia) to care for the patient, or having no one available to care for them.

One of the most practical and simple rehabilitation techniques that an inpatient must learn is to transfer. A transfer is a change in station or position from sitting in bed to standing or from sitting in bed to sitting in a chair. A person must transfer to get into a wheelchair or into a car seat. Patients cannot effectively mobilize until this is accomplished. Depending on the patient’s level of disability, a transfer may be performed to sit to stand, to stand and pivot, with a sliding board, or with a lift requiring total assistance. After basic transfers are mastered, ambulation may be the next goal to increase mobility. Weakness from paresis, deconditioning, neuropathy, or brain injury can also make self-care difficult. Practical skills such as feeding, grooming, bathing, and dressing are taught or relearned to improve independence.

Rehabilitation begins when a patient is admitted into the hospital. Impairments are identified, and based on the practical considerations mentioned previously, realistic and suitable rehabilitation goals are set. If a patient is medically stable with unmet functional and safety goals, the patient’s activity tolerance and performance trajectory are used to guide determination of the appropriate intensity and location for additional rehabilitation.

Primary brain tumors are less than 2% of all malignancies but are the second leading cause of death from neurologic disorders after stroke (²²). One-half to two-thirds of intracranial tumors have been reported to be primary tumors (²³). Primary brain tumors are classified by cell of origin; the primary system of classification is that of the World Health Organization (WHO), which divides tumors into nine categories. The most common categories include tumors that displace brain parenchyma of the intracranial supratentorial compartment. Of these tumors, the most common in adults are the astrocytomas, in particular grade IV astrocytoma, otherwise known as glioblastoma multiforme (GBM) (²⁴). The median survival for a patient with GBM has been reported between 7 and 17 months (²⁵).

In addition to primary brain tumors, brain metastases are estimated to occur in 20% to 40% of patients with cancer. The most common mechanism of metastasis to the brain is through hematogenous spread. Most of the metastases are located in the cerebral hemispheres, followed by the cerebellum and then the brainstem. The incidence of brain tumor metastases is rising, possibly due to the increasing length of survival of a patient with cancer (²⁶), increasing ability to diagnose a tumor with improved radiographic imaging (²⁷), and possibly recent chemotherapy agents, which may weaken the blood-brain barrier (²⁸).

Normal brain parenchyma can be destroyed or compressed by the tumor, and the location of the tumor determines the resultant neurologic deficit. Surgical resection may exacerbate these deficits by creating inflammation or peritumoral infarct (²⁹). Radiation treatment has long been an integral part of brain tumor treatments and often results in collateral damage. Early acute radiation leukoencephalopathy is likely due to increased cerebral edema. Late delayed radiation reactions include focal cerebral radiation necrosis, diffuse cerebral radiation injury (DCRI), and combined-therapy diffuse white matter injury/leukoencephalopathy. Clinical DCRI has been reported in 2% to 5% of patients with metastases and 19% of 1-year survivors after whole-brain radiation (^30,31).

The most common neurologic deficits include impaired cognition (80%), weakness (78%), visual-perceptual deficits (53%), sensory loss (38%), and bowel/bladder dysfunction (37%). Other deficits include cranial nerve palsy, dysarthria, dysphagia, aphasia, ataxia, and diplopia, which are less common. Approximately 75% of patients with a brain tumor have three or more neurologic deficits concurrently, and 39% have five or more deficits (³²). Because of the diverse nature of these neurologic deficits, comprehensive multidisciplinary inpatient rehabilitation is often necessary for these patients. In rehabilitation medicine, the physical impairments that could result in functional deficits are primarily addressed.

Patients who have impairments resulting in functional decline that could affect bed mobility, ambulation, transferring from sitting or lying to a standing position, or activities of daily living (ADLs) (eg, eating, grooming, dressing, bathing, and toileting) can benefit from comprehensive inpatient rehabilitation. Comprehensive cancer rehabilitation services are not widely available for these patients (³³). Because of this, many patients with a brain tumor receive their rehabilitation at general rehabilitation facilities alongside patients with stroke and traumatic brain injury. Patients with a brain tumor have similar efficiencies of improvement when compared to traumatic brain injury, stroke, and between brain tumor types. Lengths of stay tend to be shorter among patients with a brain tumor, possibly secondary to a need to return the patients home sooner given their shorter life expectancies (^{34,35,36,37,38}). However, some notable differences between these populations should be noted (eg, physiatrists may need to be cognizant of the continued decline of patients with progressive tumors).

Neurologic Motor Impairment

Motor impairment can be due to hemiparesis, ataxia, and apraxia. Motor impairment may lead to an unsafe gait pattern creating a higher risk for falls and a need for inpatient rehabilitation transfer. In inpatient rehabilitation, the patient will be seen by physical and occupational therapists. Physical therapy would focus on gait and transfers. To address transfers, efforts could be focused on sliding board transfer or stand pivot transfers. With respect to mobility, physical therapists focus on wheelchair mobility and gait with or without an assistive device (eg, a single-point cane, quad cane, rolling walker, hemiwalker). Occupational therapy would focus on problems with ADLs. Commonly addressed basic ADLs include dressing, bathing, toileting, grooming, eating, and the like. The occupational therapist and physical therapist are also aware of the cognitive component necessary for mobility and ADLs. Once a patient is functionally safe using an assistive device such as a rolling walker, he or she can be discharged home. Then, the patient can continue with outpatient rehabilitation, gradually improving his or her ambulation with an assistive device and further strengthening weakened muscles by way of a progressive resistance exercise program.

The pattern of recovery of muscle strength and function does not always follow the pattern of recovery observed in patients with stroke. However, the stroke recovery pattern is often used as a guideline for patients with brain tumors. The recovery of strength occurs in a proximal-to-distal direction, with flaccidity and decreased muscle tone progressing to spasticity and increased muscle tone. The spasticity in the affected limbs can evolve into flexor or extensor synergy patterns. Recovery of muscle movement may plateau at any stage or may progress to isolated coordinated volitional motor movement (^39,40).

Several techniques and exercises are used for neuromuscular facilitation in patients with stroke. Often, a combination of procedures and techniques from the various programs are used in patients with cancer with neuromuscular weakness. Proprioceptive neuromuscular facilitation developed by Kabat, Knott, and Voss relies on several mechanisms, such as spiral diagonal movement patterns of the extremities and quick stretch. Brunnstrom movement therapy facilitates the use of the synergy patterns mentioned as a means of developing voluntary control. Rood proposed that cutaneous sensory stimulation in the form of superficial stroking, tapping, brushing, vibrating, or icing provides facilitatory or inhibitory inputs (⁴¹).

In addition to the traditional range-of-motion and strengthening exercises as well as neuromuscular facilitation techniques, functional electrical stimulation can also be incorporated into the rehabilitation program for neuromuscular weakness. It uses a low-level electrical current that stimulates motor nerves or reflex sensory nerves to produce muscle contraction. The goal of functional electric stimulation is to produce purposeful, functional movements in paretic or paralytic muscles (⁴²).

Sometimes, owing to weakness of the ankle dorsiflexors, it is necessary to use an ankle-foot orthosis (AFO) to improve hemiparetic gait. There are two major types of AFOs: the double metal upright AFO attached to an orthopedic shoe and the molded plastic AFO, which is more commonly used. With the plastic AFO, the footplate sits within the shoe and extends upward behind the calf. The advantages of a plastic AFO over a double metal upright AFO include better cosmesis, lighter weight, and the freedom to wear different shoes.

Shoulder subluxation, predominantly inferior, which is caused by the loss of normal motor control of the shoulder stabilizers, including the deltoid and supraspinatus muscle, is often seen in the hemiparetic patient (⁴³). It can often be the cause of shoulder pain in hemiplegic patients (^44,45). Other possible causes of shoulder pain in this patient population include complex regional pain syndrome, traction injury of the brachial plexus, rotator cuff tendinitis or tear, subacromial or subdeltoid bursitis, adhesive capsulitis, or heterotopic ossification. Diagnosis of glenohumeral subluxation is made through physical examination and radiographic evaluation. The acromiohumeral interval is compared on each side with the arms in an unsupported position during physical examination, and radiographic evaluation is used to quantify the amount of subluxation. Radiographic studies can provide an early evaluation for subluxation with slight gapping of the superior aspect of the glenohumeral joint (⁴⁶).

Treatment of hemiparetic shoulder subluxation involves proper positioning of the arm, physical modalities, and exercise. The use of an arm sling can help maintain proper positioning and posture during ambulation. However, this is discouraged when the patient is seated, and its overuse may contribute to compromise of superficial blood flow as well as to joint contracture. Arm troughs and lapboards are used while patients are seated (⁴⁷). Other interventions include biofeedback and functional electrical stimulation.

Hemisensory deficit and homonymous hemianopsia may be seen with hemiparesis. Visual or somatic hemineglect is more frequently seen when the nondominant cerebral hemisphere is affected. Hemispatial neglect has a negative effect on sitting balance, visual perception, wheelchair mobility safety awareness, and risk of falling (⁴²). Patients with neglect have difficulty with hygiene and self-care activities on the affected side. Rehabilitation programs must address the issue of hemispatial neglect through focused measures led by speech therapists, occupational therapists, and physical therapists. Family training and education are important in this setting as well.

Ataxia

Cerebellar ataxia may be seen with mass effect within the posterior fossa. Of note, cerebellar ataxia can also be seen in paraneoplastic cerebellar degeneration and with high-dose administration of cytarabine (ara-C) or 5-fluorouracil (5-FU) (^48,49). Involvement of the cerebellum can produce intention tremors, dysmetria, and dysdiadochokinesis as patients lose the ability to coordinate the agonist and antagonist muscle groups (⁵⁰). The response to pharmaceutical management has been poor; consequently, physical and occupational therapy has been the mainstay of treatment for ataxia. This includes the teaching of compensatory techniques for performing basic self-care and occupational activities and the possible use of weighted bracelets or similar devices to help decrease the oscillations. Physical therapy directed at gait training with the use of assistive devices can help improve mobility in ataxic individuals (⁵¹).

Aphasia

Depending on its location, a tumor may be associated with deficits in speech, which can vary in severity and type. Often, one can diagnose the type of aphasia from a comprehensive neurologic examination, including speech comprehension, fluency, and repetition. These include Broca’s aphasia, Wernicke’s aphasia, anomic aphasia, global aphasia, conduction aphasia, and the transcortical motor and sensory aphasias.

A speech pathologist will implement treatment approaches, including melodic intonation therapy, Amer-Ind Code treatment, functional communication treatment, stimulation approach, and Promoting Aphasics’ Communication Effectiveness (PACE) therapy (⁵²).

Cognitive Deficits

Cognitive deficits often are more problematic than motor deficits. They can arise from direct injury to the brain tissue due to the tumor itself, from surgical resection, radiation, chemotherapy, depression/anxiety, as well as medications, particularly steroids and anticonvulsants (²⁸). Impairments most commonly seen involve limited memory and attention, decreased initiation, and psychomotor retardation (⁵³).

The rehabilitation physician will assess the patient’s cognitive status as part of the physical examination. This assessment is needed to formulate a rehabilitation program involving speech pathologists. Specific deficits in language and cognition can further be delineated through specific testing performed by a speech pathologist. However, it is sometimes necessary to have formal neuropsychological testing done, especially if the patient wishes to return to work.

Dysphagia

A disruption in the swallowing process can also occur in patients with brain tumors or following craniotomies. It is important to determine, through clinical assessment, whether dysphagia is present because there is the potential for serious complications, such as malnutrition and aspiration pneumonia, if dysphagia remains undetected. Often, its presence can be established from a history and neurologic examination. If dysphagia is suspected, a speech pathologist is consulted; then, daily swallowing therapy and exercises are incorporated into the therapeutic milieu.

Treatments include dietary modifications and dysphagia exercise and facilitation techniques (⁵⁴). Depending on the results from a clinical swallowing evaluation or videofluoroscopic evaluation, food can be modified to different consistencies, including puree, semisolid, or solid. Liquids may also have to be thickened using various thickening (⁵⁵).

Exercises and facilitation techniques are employed to aid and strengthen various components of the swallowing process. These include exercises employed for treatment for the lips to facilitate the ability to prevent food or liquid from leaking out of the oral cavity. There are exercises to assist the pharyngeal swallow by improving tongue base retraction. Vocal cord adduction exercises are instituted to strengthen weak cords to prevent aspiration.

Compensatory strategies include proper head and trunk positioning, which for most patients is to be seated upright with head midline, trunk erect, and the neck slightly flexed forward. Other techniques include the chin-tuck method and head turning and tilting during swallowing.

After dysphagia has been identified and measures are implemented for its treatment, regular follow-up to assess for improvement is required. This again can be done through clinical examination or radiographically. If improvement is noted, the diet may be advanced appropriately.

Spasticity

Spasticity is defined as velocity-dependent resistance to passive movement across a joint. It is an abnormality involving increased muscle tone and is one of the positive findings of the upper motor neuron syndrome. Spasticity must be distinguished from soft tissue contractures. Soft tissue contractures result from scar tissue formation and may be the result of a number of causes, including uncontrolled spasticity.

Often, brain tumors can cause muscle spasticity. This can affect the gait pattern or ADLs and, in severe cases, can cause pain and joint contractures as well as being a detriment to hygiene of the involved areas. Sometimes, spasticity may be beneficial, as when a patient may use knee extensor spasticity to assist in transferring from a sitting to a standing position. Indications for the treatment of spasticity include the need to decrease pain, improve hygiene, improve gait and transfers, minimize contractures, and improve self-care.

Treatment measures for spasticity include physical and medical interventions. Proper positioning, passive range-of-motion exercises, serial casting, splints, and braces are some of the physical interventions used in treating spasticity. Oral medications may also be used, including tizanidine, dantrolene sodium, and baclofen. Because these medications work systemically, the most common limiting side effects are excessive drowsiness and cognitive changes. Tizanidine or dantrolene is recommended by most clinicians for treating spasticity stemming from primary brain pathology (⁵⁵). Often, because of the cognitive side effects of these oral medications, botulinum toxin injections, phenol injections, or intrathecal baclofen pumps may be useful. These medications act locally but are harder to administer and more invasive.

Bladder Dysfunction

As in patients with stroke, bladder incontinence may be present in patients with brain tumors. The causes of bladder incontinence can be multifactorial and include an untreated urinary tract infection, inability to ambulate to the bathroom, and altered cognitive status. If the pontine micturition center is preserved, patients with brain tumors can have upper motor neuron bladder dysfunction, which is characterized by bladder hyperreflexia with reflex or urge incontinence and complete emptying (⁵⁶). Postvoid residual volumes are generally low in the absence of bladder outlet obstruction. Persistent areflexia and retention may occur with bilateral lesions (⁵⁷).

Treatment first involves identifying the cause of the bladder dysfunction. Obtaining a urinalysis with cultures and sensitivities and then starting appropriate antibiotics is the treatment for urinary tract infections. Using a bedside commode or a urinal is of benefit for patients who have weakness or inability to safely ambulate to the bathroom. A timed voiding program that has the patient urinate at set times throughout the day, before the bladder can contract, can be of help for patients with hyperreflexic urgency. Anticholinergic medications such as oxybutynin (Ditropan) or tolterodine tartrate (Detrol) can be used for persistent incontinence in this setting of a hyperreflexic detrusor (⁵⁷). If the patient’s blood pressure can tolerate it, a trial of an alpha-adrenergic agent (eg, tamsulosin, terazosin) may be useful in reducing urinary resistance in older male patients who are experiencing symptoms of urinary retention.

Physiatrists are often asked to assist with the care of patients with lymphedema. Malignancy (including breast, melanoma, gynecologic, lymphoma, and urologic cancers) is the number one cause of secondary lymphedema in the United States. The lymphedema can be caused by a combination of the cancer, surgical treatments, and radiation treatments. Breast cancer is the leading cause of upper extremity lymphedema in the United States and develops in 2% to 40% of patients after surgery, radiation, or both (^58,59).

The majority of lymphedema cases are diagnosed clinically. The differential diagnosis would include deep venous thrombosis (DVT), venous insufficiency, myxedema, lipedema, heart failure, kidney failure, and hypoproteinemia. In difficult-to-diagnose cases, lymphoscintigraphy is the gold standard.

The treatment of lymphedema typically starts with conservative treatments consisting of manual lymph drainage, compression sleeves, and sometimes pneumatic compression sleeves. Over one or two sessions by lymphedema-trained physical therapists, patients are taught a lymphedema regimen to do at home. Measurements are often taken, and the patients are followed up periodically to ensure that they are completing the regimen as prescribed and to measure changes in their lymphedema. Progression of lymphedema can be measured using a number of techniques, including volumetric/circumferential measurements, bioelectric impedance, tonometry, and perometry. In patients with severe or difficult-to-treat lymphedema, a number of surgical options are available, including microsurgery, liposuction, and debulking procedures.

Spinal cord injury in the patient with cancer has several etiologies. These involve primary spinal cord tumor or metastatic lesions. Primary tumors such as meningiomas, neurofibromas, and gliomas are relatively rare, and the majority of tumors involving the spinal cord are metastatic. The metastatic lesions that cause nerve root or spinal cord compression can be paravertebral, extradural, intradural, or intramedullary; however, 95% of metastatic lesions are extradural. These lesions most often originate from primary tumors of the breast, lung, and prostate. Other tumors that metastasize to the spine include renal, melanoma, myeloma, and thyroid. Most extradural metastases arise from the vertebral body and result in compression of the anterior spinal cord. Approximately 70% of spinal metastases occur in the thoracic spine, which has a smaller ratio of canal-to-cord diameter than the other two spinal segments (⁶⁰).

Pain worse at night and in the supine position is a common clinical presentation. Weakness and sensory loss, along with the development of bowel or bladder incontinence, may indicate spinal cord compromise. Rapid progression of paraparesis over only a few hours indicates arterial compromise by tumor invasion or pressure; slowly evolving symptoms suggest gradual cord impingement and may respond to steroids and radiotherapy (⁶¹).

Corticosteroids can alleviate pain and improve neurologic function, and radiation therapy is the treatment of choice with most cases of cord compression. If the tumor involves two or three columns of the spine, spinal stability is of concern; consequently, treatment is aimed toward stabilization of the spinal column. This can be done with cervical orthoses. Sternal occipital mandibular immobilization is well tolerated and provides adequate flexion and extension as well as stability to the lower cervical segments. Philadelphia collars provide stability in flexion and extension for higher levels but do not restrict rotation and lateral bending in the lower cervical segments. The “clamshell” thoracic lumbar-spinal orthosis is used to provide thoracic and lumbar support but may not be an option in patients with friable or intolerant skin following chemotherapy or steroid use. Therefore, the Taylor-Knight brace, which limits spinal extension, and the Jewitt brace, which limits spinal flexion, can be used to provide thoracic and lumbar support (⁶²).

Surgery is also indicated sometimes with instability and neurologic compromise; indications include pathologic fracture and dislocation, failure of radiation therapy, and rapidly progressing myelopathic signs and symptoms. Surgical stabilization can frequently alleviate the need for external bracing, which is an added benefit.

Once spinal stabilization is achieved, comprehensive inpatient rehabilitation can address the impairments, functional limitations, and disabilities associated with spinal cord compression and injury due to cancer. Individuals with nontraumatic spinal cord injuries can achieve significant gains in functional independence measurements during inpatient rehabilitation (¹⁰). It has also been suggested that due to the limited prognosis of patients with cancer with spinal cord compression, an expedited inpatient rehabilitation stay with the focus on family training and home safety should be emphasized.

Bladder Management

For all patients with cancer with neurologic involvement and those with profound deconditioning, it is prudent to check postvoid residuals for signs of bladder dysfunction. This can be performed noninvasively by an ultrasound-mediated bladder scanner or, more accurately, by straight catheterization and measurement postvoid. If the postvoid volumes are 100 to 150 mL or greater, an intermittent catheterization program is initiated.

Tumors involving the spinal cord cause suprasacral neurogenic bladder problems, which typically result in a hyperreflexic detrusor; this is characterized by low urinary volumes, high bladder pressures, and diminished bladder compliance. Incomplete lesions may produce the supraspinal pattern, with urgency and adequate emptying, while patients with complete lesions have reflex incontinence and incomplete voiding due to detrusor-sphincter dyssynergia (⁵⁷). Some patients have hypocontractile or areflexic bladders, with urinary retention and associated overflow incontinence if the lesion involves the sacral micturition center. Sometimes, there is a mixed picture of upper motor neuron dysfunction, hyperreflexic bladder and lower motor neuron dysfunction, and areflexic bladder.

Management of lower motor neuron bladder dysfunction involves the use of a condom catheter for men or an indwelling catheter for women if sphincter tone is diminished with normal or compromised detrusor tone. When the sphincter tone is competent but the bladder tone diminished, an intermittent catheterization program is instituted. This can frequently be seen in patients with sacral tumors such as chordomas and chondromas. The management of upper motor neuron bladder dysfunction involves the use of an anticholinergic medication such as oxybutynin to decrease detrusor tone and allow for greater capacity; then, an intermittent catheterization program can be instituted.

An intermittent catheterization program first involves daily measurements of postvoid residuals or the volume of urine left in the bladder after a void. If the postvoid volumes are 100 to 150 mL or greater, the patient is catheterized initially every 4 hours. The goal is to have the catheterized volumes not exceed 400 to 500 mL. If the volumes remain consistently below those numbers, the frequency of catheterization can be decreased to every 6 hours.

In addition, management of bladder dysfunction in this population involves assessing for urinary tract infections, which can be common. Appropriate antibiotics should be started based on urinalysis, cultures, and sensitivities.

It is important to note that, in the cancer population, life expectancy often plays a part in rehabilitation management. Intermittent catheterization is the preferred method of management for the scenarios mentioned; however, a Foley catheter is sometimes used instead for ease and comfort in those patients with limited prognosis.

Bowel Management

Typically, with lesions above the conus medullaris, an upper motor neuron bowel dysfunction is present, with the muscles of the external anal sphincter and pelvic floor becoming spastic. The connection between the spinal cord and the colon remain intact and bowel and stool can be propelled by reflex activity. With lesions below the conus medullaris, an areflexic lower motor neuron bowel dysfunction is present, with the myenteric plexus intrinsically moving stool slowly (⁶²).

A complicating matter with patients with cancer is opioid-induced constipation. This and other premorbid factors and current bowel function must be ascertained before instituting a bowel program. Often, a plain x-ray of the abdomen is obtained to assess for obstipation before beginning a bowel program. If obstipation is present, suppositories or enemas can be given to clean out the bowels and especially to evacuate the rectal vault.

The goals of a bowel management program are to prevent fecal impaction and to facilitate bowel evacuation on a routine schedule compatible with one’s daily activities. This is a logical, structured program based initially on evaluation of the current bowel pattern. A bowel management program begins with a proper diet, which should contain adequate amounts of fluid and fiber to create soft bulky stools, which can decrease bowel transit time. Fatty foods can increase transit time. Medication management involves the introduction of a stimulant such as senna. A bisacodyl suppository can be used as an adjunct.

In stepwise fashion, a bowel program begins with an x-ray to determine whether evacuation by enemas is necessary; then, an appropriate diet is begun, along with stool softeners or stimulants. To take advantage of the gastrocolic reflex, the patient is placed on the commode approximately 30 minutes after a meal, preceded by a bisacodyl suppository 10 minutes before the patient is placed on the commode. In addition, manual digital stimulation 20 minutes after suppository insertion can induce the rectocolic reflex (⁵⁷).

Spasticity

Similar to brain injury, many patients with spinal cord injury suffer from spasticity, which is an abnormality of muscle tone and is velocity-dependent resistance to passive movement across a joint. In addition, they experience muscle flexor spasms, which also respond to the same treatment strategies as those used for spasticity.

Treatment begins with proper positioning and can also involve splinting, casting, stretching, range-of-motion exercises, and the use of medications. In contrast to spasticity originating from brain pathology, spasticity associated with spinal cord injury is treated medically, primarily with baclofen. Tizanidine is also an appropriate choice. In addition, chemical neurolysis, botulinum toxin, and—for severe cases—an intrathecal baclofen pump may be used.

Generalized weakness and deconditioning are common problems in patients with cancer, and they simply imply a loss of their prior state of conditioning. Asthenia is also a common diagnosis in patients engaging in inpatient cancer rehabilitation. It implies a combination of weakness and decreased exercise tolerance arising from a number of factors, including muscle wasting, disuse atrophy, malnutrition, anemia, and cardiac or pulmonary comorbidities. Functional impact from asthenia can include difficulty with transfers and ambulation, difficulty with ADLs, and decreased balance with risk for falls.

Rehabilitation treatment can begin with increased sitting time and gentle range-of-motion exercises. This is followed by a progressive increase in exercise dose, duration, and intensity, along with instruction in fatigue management and balance training. It is also important to address other medical conditions, such as anemia, malnutrition, sleep, pain, and mood disorders. Short-term inpatient rehabilitation can be effective in improving functional status after an acute decline, and outpatient therapy can help in maintaining or more slowly improving functional performance. However, if the primary malignancy progresses, functional performance will likely deteriorate.

To better grasp these concepts, an understanding of basic muscle physiology is important. There are three types of muscle fibers. Type I muscle fibers are the slow-twitch oxidative metabolism fibers, which have slow fatigability and are used for prolonged activity. Type IIB fibers are the fast-twitch fibers, which use glycolytic anaerobic metabolism and have rapid fatigability. Type IIA is an intermediate fiber.

Prolonged bed rest can result in muscle weakness. In a classic study by Mueller, the muscles of a person on strict bed rest can decrease approximately 1.0% to 1.5% of their initial strength per day, corresponding to approximately a 10% to 20% loss of strength per week (⁶³). Antigravity muscles like the gastrocnemius and back extensor muscles tend to lose strength disproportionately, with larger muscles losing strength more quickly than smaller muscles; handgrip strength is unaffected (^64,65). Type I fibers are more affected than type II fibers (⁶⁶).

These effects on muscles can be counteracted by a daily stretching program, which delays muscle atrophy (⁶⁷). In addition, daily isometric muscle contractions of 10% to 20% of maximal tension for 10 seconds can help maintain muscle strength (⁶⁴). Electrical stimulation of muscles can also be used. In general, it may take two or more times as long as the period of immobilization to recover muscle strength (⁶⁸).

Joint contracture is an abnormal limitation of passive joint range of motion and can be caused by prolonged immobilization. Typical contractures from immobilization include hip flexion, knee flexion, elbow flexion, and internally rotated shoulder contractures as well as ankle plantar flexion contractures. Once they have developed, contractures are treated with range-of-motion exercises. For more severe cases, deep heating followed by range-of-motion exercises and serial casting may be necessary. One goal of nursing and inpatient therapy should be to prevent joint contractures before they occur. Hip flexion contractures can be prevented with the avoidance of an overly soft mattress and lying occasionally in a prone position. Dorsiflexion exercises and footboards can help prevent ankle plantar flexion contractures.

Immobilization can also affect the bones. Wolff’s law states that the ratio of formation to resorption is influenced by the stresses to which bones are subjected. The primary stress on most bones is weight bearing, which causes a buildup of bone; a lack of stress on bones leads to a predominance of bone resorption. Weight bearing is eliminated when lying in bed in a supine position and can lead to disuse osteoporosis. This is best treated with preventive measures such as active muscle contraction and active weight-bearing exercises. Exercises conducted in bed are not particularly effective (⁶⁹). Activities involving getting out of bed to a chair are encouraged as soon as possible.

There are cardiovascular effects from prolonged bed rest. The first such form of cardiac deconditioning is resting tachycardia. After a period of bed rest, the heart rate can increase by about one-half beat per minute each day for the first 3 to 4 weeks of immobilization (⁷⁰). In addition, there are decreased diastolic filling times, with resultant decreased myocardial perfusion, decreased stroke volume with submaximal and maximal exercises, decline in cardiac output at submaximal exercise, and deleterious hemodynamic and orthostatic changes.

The treatment of the cardiovascular effects is mainly aimed at prevention. Sitting in a chair prevents deterioration of (maximum oxygen consumption) and orthostatic intolerance. Isometric exercise minimizes decreases in (⁷¹). Cardiovascular deconditioning can be reversed by a progressive increase in activity and regaining an upright posture. Orthostatic intolerance can be helped by range-of-motion exercises, progressive ambulation, abdominal strengthening, and leg exercises to reverse venous stasis. In addition, supportive treatments for orthostatic intolerance include the use of a tilt table, supportive garments, leg stockings, abdominal binders, and medications such as ephedrine, midodrine, and fludrocortisone acetate (Florinef Acetate).

Thrombotic complications, such as the development of a DVT or a pulmonary embolism (PE), are a risk of immobility. Virchow’s triad states that hypercoagulability, endothelial injury, and stasis of blood flow are factors that can contribute to clot formation. Rehabilitation often begins after a prolonged state of immobility, and it is imperative we take measures to prevent DVT or PE development. Patients should be mobilized, encouraged to ambulate, provided with external intermittent leg compression devices, and administered low-dose anticoagulation when contraindications are not present (⁷⁰).

Patients with cancer may have a number of rehabilitation-related DME needs, both as inpatients and outpatients. Many are covered by Medicare and third-party payers when patients demonstrate appropriate need. These can include, but are not limited to, artificial limbs; braces (arm, leg, back, and neck); canes; commode chairs; continuous passive motion machines; crutches; orthotics; patient lifts; prosthetic devices; reachers; tub benches; walkers; wheelchairs; and other power mobility devices. Table 59-2 lists several commonly prescribed pieces of equipment with a few of their most common indications. Many variations exist within the categories of orthotics and DME mentioned. Thus, consultation between a trained a physiatrist, therapist, and orthotist may be required to ensure adequate performance, safe mobility, and optimization of self-care.

According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer is an area of unrelieved pressure over a defined area, usually over a bony prominence, resulting in ischemia, cell death, and tissue necrosis. Incidence of pressure ulcers in the acute care setting is 7% to 9%; long-term care incidence is estimated to be between 3% and 31%; estimates for home care incidence are 0% to 17%. Patients with cancer have a number of risk factors that can place them at risk of developing pressure ulcers (Table 59-3).

The NPUAP staging system for pressure ulcers includes the following:

• Stage I: intact skin with nonblanchable redness of a localized area, usually over a bony prominence.

• Stage II: partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

• Stage III: full-thickness tissue loss; subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.

• Stage IV: full-thickness tissue loss with exposed bone, tendon, or muscle.

In suspected deep-tissue injury, there is localized discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. An ulcer that cannot be staged is described as full-thickness tissue loss with slough or eschar covering the wound bed. The mainstay of pressure ulcer treatment is the off-loading of pressure. This is frequently accomplished by a turning schedule if the patient cannot get out of bed. If the patient is a wheelchair user, frequent position changes (up to every 20 minutes) are recommended.

Other interventions include the use of appropriate support surfaces for the bed and wheelchair, nutritional consultation, physical and occupational therapy consultation for mobility issues, and addressing incontinence. Topical dressings may be used based on wound characteristics (Table 59-4). Surgical treatment can include sharp debridement of devitalized tissue if the patient’s immune status allows, and plastic surgery may be able to assist with flap coverage. If available, wound care nursing specialists can also assess the wound and help guide treatment recommendations.

Pressure ulcer healing will also depend on improvement in the patient’s overall health and medical condition. Healed ulcers can have decreased tissue tolerance and are at risk for reinjury without ongoing prevention measures. Patients should be monitored throughout cancer treatment for signs of skin compromise or wound degradation.

Thrombocytopenia, along with the suppression of other cell lines, is commonly seen in patients with cancer. These findings are especially frequent in patients receiving chemotherapy or extensive irradiation, with resulting myelosuppression, bone marrow infiltration, and splenomegaly. Hematologic malignancies introduce a variety of associated complications, which previously limited implementation of intensive rehabilitation programs with patients at greatest risk. A rehabilitation program or exercise in a severely thrombocytopenic patient remains somewhat controversial. The major concern in this situation is the development of a spontaneous intracranial hemorrhage.

Dimeo et al monitored patients during a 6-week intensive aerobic exercise program after high-dose chemotherapy and autologous stem cell transplantation. The investigators did not exclude for neutropenia, anemia, or thrombocytopenia, but in the end, they observed no adverse effects. Based on this initial study, the authors proposed utilizing lower-limit thresholds of 20,000/μL for platelet counts and 1,500/μL for leukocyte counts prior to safely engaging in a rehabilitation program (⁷²). With platelet counts over 5,000/mm³, another study found fatal intracranial hemorrhage in only 1 of 92 patients receiving chemotherapy (⁷³).

No clear guidelines exist, but one recommendation is to allow nonresistive activities at platelet counts between 5,000 and 10,000/mm³ and light resistive exercises with counts above 10,000/mm³, with ambulation allowed with counts above 5,000/mm³ (⁷⁴). Clinicians must use their own judgment with individual patients. In addition, platelet transfusions with counts below 10,000 should be performed in patients undergoing comprehensive rehabilitation.

Long considered a time to decrease physiologic burden, treatment algorithms for many patients with cancer often neglected to incorporate physical exercise as a primary component of care. More recently, however, many studies have emerged not only quelling the idea of exercise causing significant undue harm but also substantiating the short- and long-term benefits of a well-constructed exercise program. Along the time spectrum of cancer prevention, treatment, and survivorship, patients may benefit from an individualized exercise regimen at each stage.

As the prevalence of cancer continues to climb, researchers have developed an increased interest in prevention strategies. According to the International Agency for Research on Cancer, obesity and a sedentary lifestyle may contribute to a quarter of new cancer cases. Women are at greatest risk, with nearly three times the rate of overweight- and obesity-related cancer (⁷⁵).

In addition to reducing the burden of primary risk factors, physical activity may serve as a cancer prevention strategy by directly improving musculoskeletal strength, endurance, balance, and flexibility, while indirectly enhancing the performance of the body’s cardiovascular, pulmonary, neurologic, and immune systems. A systematic review performed by Rajarajeswaran (⁷⁶) found convincing evidence for average risk reduction in colon (40%-50%) and breast (30%-40%) cancers. Additional evidence suggesting reduced risk for the development of prostate, endometrial, lung, and many other cancers has also been identified, but the relatively sparse quantity of evidence available for review continues to limit the strength of our recommendations.

In addition to the more obvious direct effects, there is an increasing body of research demonstrating improved cancer- and treatment-related symptoms with moderate increases in activity (⁷⁷). Rehabilitation regimens including a combination of aerobic and resistance training have demonstrated improvements in body weight, body composition, flexibility, strength, fatigue, depression, anxiety, rigor, anger, mood, self-esteem, perception of well-being, pain, nausea, diarrhea, functional capacity, and life satisfaction (⁷⁸). Many patients with cancer experience significant amounts of weight loss, particularly involving lean tissues. This problem may be exacerbated by hormone or chemotherapy treatments used to combat their primary malignancy and may contribute to generalized weakness and fatigue. Cornie et al (⁷⁹) evaluated the potential to reduce factors leading to treatment-related deconditioning while promoting those that would maintain or improve fitness. In a randomized controlled trial among 63 men with prostate cancer receiving androgen-deprivation therapy, participants performed at least weekly 150 minutes of moderate-intensity training during a 3-month period. Compared to the control group, the exercise group demonstrated preserved appendicular lean mass and prevented gains in whole-body fat and trunk fat mass. Between-group analyses also demonstrated significant improvements in peak oxygen consumption, muscle strength, cholesterol levels, sexual function, and fatigue.

Speck et al (⁸⁰) performed a comprehensive meta-analysis of 82 studies involving 6,838 cancer survivors and assessing 60 different outcome measures. Of the studies reviewed with high internal validity, nearly all demonstrated positive effects of exercise on their respective primary outcome measures (Table 59-5). Additional studies also demonstrated positive effects on lean body mass, lower body flexibility, vigor/vitality, IFG-BP-III levels, pain, breast cancer subscale, and immune parameters such as neutrophil count, natural killer cell activity, C-reactive protein, and cytokines.

Significantly improved weighted mean effect sizes of outcomes were stratified by timing of rehabilitation administration (⁷⁹).

Safety of Exercise in Cancer

The reason for the limited numbers of intensive exercise regimens for patients with cancer is likely multifactorial but may often emanate from patient and provider fears. Cheville (⁸¹) interviewed a group of patients with late-stage non–small cell lung cancer and identified potential exercise barriers that included fear of harm and a lack of direction from their physician. Patients were found to be less receptive to guidance from ancillary health professionals, but early expert consultation with a physiatrist may prove helpful in formulating an individualized rehabilitation program with medical monitoring as it may alleviate some potential barriers.

Reported adverse events following a structured rehabilitation program are primarily limited to musculoskeletal injuries. Patients with breast cancer and survivors are among the most commonly studied, and population-specific concern exists for exacerbation of lymphedema (⁸²). However, evidence suggests breast cancer survivors undergoing a strength training protocol demonstrate a reduced risk of lymphedema exacerbations, while improving strength and bone mineral density (^83,84).

Hayes et al (⁸⁵) allocated patients following stem cell transplantation to a control group receiving a stretching program and an intervention group receiving an aerobic and resistance program performed three times a week over 3 months. Similar to findings of studies in solid tumor populations, results demonstrated increased recovery of fat-free mass and no significant body weight differences at the conclusion of the intervention period.

Prescribing Exercise in Cancer

With growing amounts of data supporting the benefits of exercise along the cancer diagnosis and treatment continuum, there has grown an emerging need for expert clinical exercise guidelines. The 2008 US Department of Health and Human Services (US DHHS) report of physical activity guidelines for Americans provides a generic foundation for patients with cancer to follow. The report recommends patient participation in physical activities as their abilities and conditions permit, with a goal weekly duration of 150 minutes of moderate intensity or 75 minutes of vigorous intensity (Fig. 59-4) (⁸⁶).

In 2009, the American College of Sports Medicine (ACSM) assembled an expert panel of 13 researchers and clinicians to evaluate the available evidence of safety and benefits of exercise in cancer. In the ACSM report, studies were stratified by cancer type, and the strength of evidence was assessed on the basis of several outcome measures. Many risks specific to particular cancer types have been outlined, but the experts concluded that exercise testing and prescriptions are safe and efficacious for patients with cancer. The authors recommended utilization of 2008 US DHHS guidelines for aerobic training and supported the addition of resistance training exercises for a comprehensive rehabilitation program (⁸⁸).

Current research is demonstrating improved mortality in patients with cancer participating in an exercise program. However, due to the observational nature of many of these studies, significant variability exists in the prescribed intensity, frequency, duration, and combination of exercises. A clear dose response has yet to be established, and future research may require a more detailed evaluation of tumor marker expression and a patient’s immunologic, hormonal, and metabolic factors, much in the same way targeted medical therapies are based on host factors (^89,90).

In the face of chronic disease or acute illness, the goal of rehabilitation is to restore a meaningful transition back to one’s previous state of health and level of functional performance. The absence of function invokes the term disability. The WHO defines disability as “a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives.” To better elucidate such problems, health-care providers must first seek to identify a problem within a particular body structure or system, defined as the “impairment.” Some impairments may directly or indirectly result in difficulty performing a specific task or action, coined an “activity limitation” or alternatively, a “disability.” If an individual is unable to perform a specific activity in his or her normal environment or community, the individual is described as having a “participation restriction” (⁹¹).

Identifying each patient’s unique set of impairments, activity limitations, and participation restrictions is an initial step in defining functional concerns. Unfortunately, such concerns are often missed by many primary and consulting providers. On reviewing 6 months of previous electronic medical record notes, Cheville et al found oncology patient-reported symptoms to be fairly well documented in the medical record, while activity limitations were very unlikely to be noted. Referrals for such problems were yet rarer, leaving a significant gap in functional problems requiring further assessment and those that were addressed (⁹²).

Physiatrists are optimally trained to help facilitate a patient’s transition from illness, and its associated medical care, to home with functional restoration. With the appropriate tools and resources, we can modify, support, or remove impairments to focus on strengths and abilities. In general, musculoskeletal injuries are among the most common causes of debility and contribute to a great deal of functional impairment. In a population of patients with cancer, these injuries may be overlooked due to more serious illnesses, but a well-trained physiatrist is well equipped to detect, diagnose, and treat them. If resolution of an impairment is feasible and presents relatively low risk, treatment should be pursued to alleviate activity limitations (Table 59-6). If treatment is inappropriate or not feasible, a physiatrist may employ alternative strategies, such as orthotics or DME, to reduce the burden of activity limitations and participation restrictions.

Employment-Related Disability Management

Impairment and disability evaluations are complicated by the fact that there are considerable variations between objectively measured impairments and subjectively reported disability. Psychological, social, and behavioral factors must be recognized as significant contributors to the relationship between impairment and disability.

Increasing survivorship among patients with cancer has led to an increased focus on disability. Many cancer survivors are unable to work secondary to the effects of chemotherapy, operations, the tumor itself, and symptoms associated with the tumor, including chronic pain and fatigue. The patient may have been cured of the cancer, but the patient must live with the sequelae of those treatments. It has been reported that 38% of cancer survivors are working age (⁹³). Survivors frequently wish to return to work for continued insurance benefits, income, and self-esteem. Quality-of-life assessments show that employed cancer survivors have a higher quality of life. It provides a sense of normalcy and control when cancer takes control away from other aspects of their lives (⁹⁴). Survivors may report an inability to work for a variety of reasons, including fatigue, physical limitations, emotional problems, changing personal priorities, cognitive deficits, awkward interaction with coworkers, and unsympathetic employers (⁹⁵).

Yankelovich surveyed 200 supervisors of cancer survivors in two studies. Of the supervisors, 66% were concerned about the cancer survivor’s ability to work. Prior to the survivor returning to work after cancer treatment, 33% believed the survivor would not be able to handle the job, and 31% believed the survivor needed to be replaced. After the survivor returned to work, 34% of supervisors and 43% of coworkers were less concerned regarding the survivor’s ability to work. About 50% of supervisors admitted that a cancer diagnosis would affect their decision to hire (⁹⁶). Ferrell surveyed 662 fellow employees of cancer survivors. Of these fellow employees, 14% felt that cancer survivors probably would not be able to do their job, and 27% of workers felt that they would have to pick up the slack of their cancer survivor colleague (⁹⁷).

Of patients with cancer, 20% report some cancer-related disability. However, most working patients with cancer do return to work after treatment. At 1 year, 73% are employed, and 84% are at 4 years. Patients with central nervous system, head and neck, and stage IV hematologic cancer had the highest risk of disability. Also, patients who were involved in more physically demanding work, were less educated, were women, and were of older age were less likely to return to work after treatment. Also, 87% reported that their employer was accommodating (⁹⁸). Of employed cancer survivors, 54% reported having to adjust their work schedule during their cancer treatment (⁹⁹). The Americans With Disabilities Act of 1990 brought legislative protection to cancer survivors with disabilities. It requires employers to make “reasonable accommodation” for employees with disabilities and prevents discrimination in pay, hiring, firing, fringe benefits, and working conditions. It also requires employers to make accommodations for family members that are not an “undue hardship.” Accommodations can include extended leave, flexible work schedules, permitting working from home, changing work environment, and allowing rest periods.

If there is uncertainty regarding whether a cancer survivor can return to work, several options are available. If the primary concern is energy and endurance, the cancer survivor’s hours are gradually increased each week, with the patient reporting any difficulties to the physician. When issues of coordination, strength, or endurance are uncertain, a functional capacity evaluation can be performed by a physical or occupational therapist. The evaluation can be useful for determining tolerance for lifting, bending, squatting, and the like. Often, the therapist is able to replicate the duties of the patient and recommend ergonomic or environmental modifications if necessary.

Without proper physiatric training and experience, a variety of impairments may serve as barriers to initiating or maintaining exercise programs for patients with cancer. There is no doubt that social, economic, and psychological factors often also present significant problems for the successful implementation of a rehabilitation program. The involvement of a multidisciplinary team is essential to adequately address such problems. The assistance of a social worker, case manager, chaplain, registered dietician, registered nurse, and the appropriate therapists working with a physiatrist as an experienced team can be a great asset for a patient or family with multidisciplinary needs.

Mackey described caregiver concerns, which can include fear of hurting the patient physically by moving the patient, fear of hurting themselves when moving or transferring the patient, and a lack of clarity regarding how hard to push the patient. Family education in transfer training and positioning can decrease caregiver stress of providing care and also the patient’s concern about being a burden.

The practices of cancer rehabilitation and palliative care share several similarities. Both support qualify of life and relieving discomfort. The framework for intervention can be similar with a multidisciplinary team to adequately assess and treat the patient. Both have an emphasis not only on the disease process but also on physical symptoms, limitations of the patient, and how to improve or relieve them. Both emphasize the family in patient care and education. Rehabilitation interventions at the end of life can include mobility and ADL training, positioning and pressure relief techniques, chest physiotherapy, swallow therapy, edema management, and physical modalities to treat pain and bracing and splinting to relieve pain and assist with mobility.

Survivorship

There are 13.7 million Americans who are cancer survivors. That number is expected to increase to 18 million by 2022 (¹⁰⁰). According to the National Coalition for Cancer Survivorship, a cancer survivor is any person diagnosed with cancer from the time of initial diagnosis until his or her death (¹⁰¹). This definition includes patients receiving active treatment for malignant disease. The numbers of long-term cancer survivors without evidence of disease is also growing. These growing numbers of long-term cancer survivors suffer from a multitude of disabilities that were acquired during cancer treatment. Rehabilitation can help patients with hemiparesis (¹⁰²), neuropathy/plexopathy (¹⁰³), myopathy (¹⁰⁴), chronic fatigue (¹⁰⁵), radiation fibrosis syndrome (¹⁰⁶), postmastectomy pain syndrome, cognitive deficits (¹⁰⁷), lymphedema (¹⁰⁸), spasticity (¹⁰⁹), cervical dystonia (¹¹⁰), trismus (¹¹¹), and chronic musculoskeletal pain (¹¹²). Once the focus has been changed from surviving the cancer to quality of life, rehabilitation often plays an integral role. The bulk of the growth in the field of cancer rehabilitation over the past two decades has been surrounding the growth in the numbers of long-term cancer survivors. This rehabilitation is predominantly provided in outpatient clinics.

Increasing Recognition

Cancer rehabilitation has suffered from underreferrals by oncologists and lack of availability at many cancer centers (¹¹³). Cancer rehabilitation education is still lacking in PM&R departments (¹¹⁴). However, the field has experienced tremendous growth and increasing acceptance over the past 5 to 10 years. Cancer rehabilitation has become increasingly viewed as important by physiatry academic departments across the United States (¹¹⁴). Furthermore, cancer rehabilitation research publications have grown at a significantly faster rate than the whole field of rehabilitation (¹¹⁵).

Exercise and Cancer Survival

Most of the prior research in the field of cancer rehabilitation has shown improvements in quality of life, function, symptoms, and cardiopulmonary and muscular strength benefits. It has been noted that patients with a lower functional status have a higher risk of graft-versus-host disease and reduced survival (^{116,117,118,119,120}). Some studies have shown possible beneficial effects of exercise programs on medical outcomes of patients with cancer, including survival (¹²¹). The mechanisms for improved survival could be because performance status does have an impact on treatment decisions, treatment completion rates, treatment response, disease progression, and death from other causes (¹²²). This has led some to call exercise a cancer “medicine” that should be discussed with all oncology patients.

In 1980, Dietz described four types of cancer rehabilitation. The first was called preventive rehabilitation (¹²³). This concept has been more recently coined as “prehabilitation.” While the concept of prehabilitation is not unique to cancer, it has become of great interest to cancer researchers. Several studies have been published in the recent past, mostly regarding patients receiving oncologic surgery. The results suggest better medical and surgical outcomes with prehabilitation programs (^{124,125,126,127,128}). However, further study is needed.

The Anti-Inflammatory Effects of Exercise

The anti-inflammatory effects of physical activity may also contribute to improved survival. The role of inflammation in cancer symptoms has been well established in multiple studies. Exercise has been shown to reduce cancer symptoms, including fatigue, appetite, and cognitive dysfunction, presumably through an anti-inflammatory mechanism. A hyperinflammatory state has been shown to be involved in the development of several maladies, including cardiovascular disease, Alzheimer’s dementia, and cancer. Inflammation also plays a role in tumor progression and proliferation (^129,130). This has resulted in an increased interest in anti-inflammatory treatments. Research has identified the anti-inflammatory effects of exercise in different patient populations, including those with cancer (^131,132).

Return to the Primary Acute Care Service

It has been shown that cancer rehabilitation inpatients are transferred back to the primary acute care service more frequently than patients without cancer (¹³³). The medical fragility of these patients has led to interest in identifying predictors of medical complications while on inpatient rehabilitation. Published research has identified a number of factors in general oncology patients (^134,135) and more specific groups, including those with lymphoma (¹³⁶), leukemia (¹³⁷), or hematopoietic stem cell transplantation (¹³⁸). The presence of antimicrobial agents, elevated creatinine, and thrombocytopenia at the time of inpatient rehabilitation transfer have been identified as possible predictors of transfer back to the primary acute care service.