Cancer Rehab with a Focus on Evidence-Based Outpatient Physical and OT Interventions

Authors: Julie K. Silver, MD Laura S. Gilchrist, PT, PhD

Affiliations: From the Harvard Medical School, Department of Physical Medicine and Rehabilitation, Boston, Massachusetts (JKS); and St Catherine University, Doctor of Physical Therapy Program, Minneapolis, Minnesota (LSG).

Correspondence: All correspondence and requests for reprints should be addressed to: Julie K. Silver, MD, Harvard Medical School, Department of Physical Medicine and Rehabilitation, Countway Library, 2nd Floor, 10 Shattuck Street, Boston, MA 02115.

INVITED REVIEW & ANALYSIS

Cancer Rehabilitation with a Focus on Evidence-Based Outpatient Physical and Occupational Therapy Interventions

Disclosures:

ABSTRACT

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Silver JK, Gilchrist LS: Cancer rehabilitation with a focus on evidence-based outpatient physical and occupational therapy interventions. Am J Phys Med Rehabil 2011;90(suppl):S5YS15.

0894-9115/11/9005(Suppl)-00S5/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2011 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0b013e31820be4ae

Cancer rehabilitation is an important part of survivorship as a distinct phase of treatment. Although cancer rehabilitation may involve many disciplines, this article specifically covers evidence-based treatment in physical and occupational therapy. Patients may need physical and occupational therapy services for a variety of cancer-related or cancer-treatment-related problems, including pain, fatigue, deconditioning, and difficulty with gait. They may also have problems resuming their previous level of function, which can impact on activities of daily living, instrumental activities of daily living, return to previous home and community activity levels, and return to work. This review discusses the role of physical and occupational therapy in helping cancer patients improve pain and musculoskeletal issues, deconditioning and endurance effects, fatigue, balance and falls, and lymphedema and psychosocial problems.

Key Words: Cancer, Oncology, Rehabilitation, Rehab, Physical Therapy, Occupational Therapy, Interdisciplinary, Survivorship

T

he Institute of Medicine1 report titled From Cancer Patient to Cancer Survivor: Lost in Transition documented the many unmet needs of those who finish acute oncology treatment and then are left to struggle with a host of issues including the toxic adverse effects of treatment that often leave survivors unnecessarily disabled or, at the very least, able to function but not at their previous level. Indeed, lingering pain, profound fatigue and deconditioning, loss of joint range of motion because of surgery and radiation treatments, and many other lingering adverse effects of treatment can all be mitigated with multidisciplinary rehabilitation services, although few survivors get such care.

There were ten key recommendations (Table 1) listed in the Institute of Medicine report, including creating cancer survivorship as a distinct phase of cancer care. One can assume that oncology rehabilitation would have a major role in this new phase of cancer care, although this was not explicitly stated in the report.

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Rehabilitation Therapy Interventions

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CURRENT STATE OF ONCOLOGY REHABILITATION IN SURVIVORSHIP CARE Perhaps, the Institute of Medicine report itself is a clue as to why the more than 11 million cancer survivors in the United States have not received oncology rehabilitation services. In this seminal report, rehabilitation medicine was largely downplayed, and the importance of oncology rehabilitation was generally ignored.

The Institute of Medicine report is not unusual in the omission of oncology rehabilitation as a major component of cancer care, especially survivorship care after acute interventions. There are many barriers to rehabilitation.2 Perhaps one of the most problematic barriers is simply a lack of training in the subcategory of oncology rehabilitation for providers of rehabilitation medicine.

Indeed, most physiatrists receive very little training in oncology rehabilitation. The same is true for

other rehabilitation professionals. Without specific training dedicated to learning the nuances of oncology rehabilitation, it can be challenging to become skilled and effective providers. This can be a daunting task for those already in practice who may feel overwhelmed by the knowledge they must accumulate to expertly treat cancer patients. In addition, there is a relative paucity of continuing education coursework and mentors to prepare existing clinicians for such practice.

Another barrier is the sometimes nonexistent or often weak interface between oncology and rehabilitation healthcare providers. These departments often exist separately in hospital systems and may not be near each other. Moreover, the oncology and rehabilitation professionals may not know each other well or have much interaction. This can be challenging as providers in both medical specialties need to be able to identify patients with rehabilitation needs and then to refer them for

TABLE 1 Ten key recommendations for cancer survivorship from the Institute of Medicine (adapted from Hewitt and Ganz1) Recommendation 1: Establish cancer survivorship as a distinct phase of cancer care.

This should include raising the awareness of the need for oncology rehabilitation and a concerted effort to ensure the delivery of appropriate rehabilitation interventions to survivors.

Recommendation 2: Provide a comprehensive care summary and follow-up plan (survivorship care plan) to survivors.

The survivorship care plan should have recommendations regarding rehabilitation assessments and interventions.

Recommendation 3: Use evidence-based clinical practice guidelines, assessment tools, and screening instruments to identify and manage late effects of cancer and its treatment.

These measures should include those that identify and help guide the rehabilitation treatment of cancer survivors.

Recommendation 4: Develop quality-of-care measures that pertain specifically to cancer survivors and implement quality assurance programs to monitor/improve the care that all survivors receive.

The quality-of-care measures that are developed and implemented should include oncology rehabilitation.

Recommendation 5: Test models of interdisciplinary survivorship care in diverse patient populations and across systems of care.

This testing should include oncology rehabilitation.

Recommendation 6: Develop comprehensive cancer control plans that include survivorship care and promote the implementation, evaluation, and refinement of existing state cancer control plans.

These comprehensive cancer control plans should also include oncology rehabilitation.

Recommendation 7: Expand and coordinate efforts to educate healthcare providers so that they may be equipped to address the healthcare and quality-of-life issues facing cancer survivors.

Rehabilitation healthcare professionals should receive ongoing education in oncology rehabilitation for them to optimally treat cancer survivors. Oncology healthcare professionals should be educated about the benefits of rehabilitation medicine and the best ways to interface with rehabilitation professionals.

Recommendation 8: Act to eliminate discrimination and minimize adverse effects of cancer on employment while supporting cancer survivors with short-term and long-term disabilities that affect work.

Rehabilitation may enable more survivors to return to work and to function at the highest level possible.

Recommendation 9: Act to ensure that all cancer survivors have access to adequate and affordable health insurance with help from insurers and healthcare payors.

Rehabilitation interventions are part of conventional medicine and thus generally covered by health insurance and health care payors.

Recommendation 10: Increase funding support of survivorship research in order to better guide effective survivorship care.

Oncology rehabilitation research should be emphasized in both oncology and rehabilitation medicine.

Italicized sentences are the authors’ comments and recommendations about oncology rehabilitation as they pertain to the Institute of Medicine report.1

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appropriate services. Of course, these services need to be developed in many hospitals, cancer centers, and outpatient facilities.

There are increasing awareness and determination from healthcare providers to address the immense rehabilitation needs of cancer survivors.

Editorials by rehabilitation professionals are shedding light on this issue.3,4 There is a new textbook titled Cancer Rehabilitation that addresses the specific area of oncology rehabilitation.5 There is increasing research focusing on rehabilitation outcomes in oncology.

The need for rehabilitation in cardiology and orthopedics and many other specialties is well established. However, the need for rehabilitation in oncology is not. This supplement (and the articles contained within it) is an example of how oncology rehabilitation is starting to be viewed as an essential component of both rehabilitation medicine and oncology care. However, there is still much to do in terms of educating both oncology and rehabilitation healthcare providers in the importance and the execution of oncology rehabilitation care.

NEED FOR ONCOLOGY REHABILITATION INTERVENTIONS There is no question that many cancer survivors live with considerable disability and lasting effects of treatment.6,7 For example, in a populationbased cohort study of 975 Australian working adults with colorectal cancer, 33% of men and 40% of women were not able to return to work 12 mos after their diagnosis.8 Another example is a study conducted by Yuen et al.9 that surveyed 83 head and neck cancer patients during and after treatment. In this study, 67.5% of respondents reported driving less or discontinuing driving altogether during treatment. After therapy, 26.5% continued to drive less or not drive at all.

Consider the following typical patients who enter the medical system with the diagnosis of cancer: & A 13-yr-old girl who plays elite soccer in her hometown notices bruising and is diagnosed with leukemia. & A 35-yr-old mother of two young children finds a lump on her breast and is diagnosed with breast cancer. & A 50-yr-old officer in the United States Army has an increased prostate specific antigen level on his annual military physical examination and is diagnosed with prostate cancer. & A 60-yr-old business executive has a routine colonoscopy and is diagnosed with colon cancer. www.ajpmr.com

In all of these scenarios, the patient is high functioning and, at the time of the cancer diagnosis, is not feeling any ill effects from the disease. Obviously, if the cancer progresses, then there will be significant morbidity and eventual mortality.

However, the experience of entering the medical system for many cancer patients is that they feel very good at the beginning, and then the treatments make them profoundly ill and often disabled. When they are sicker and more debilitated than they have ever been, they are discharged to follow-up care, which may include such things as routine screening for cancer recurrence, managing ongoing medications, and others, but this does not generally include a multidisciplinary (or interdisciplinary) rehabilitation intervention. In effect, the medical system creates a situation where high-functioning individuals are given life-prolonging treatments and then left to struggle with how to recover from the toxic adverse effects of these therapies (Table 2).

Of course, there are many other examples of people diagnosed with cancer who span the spectrum of cancer stage and physical function. Even in cancer’s later stages or palliative care, rehabilitation is an important component.10,11 Wherever individuals are on the spectrum of health and ability to function, cancer treatments typically are so toxic that patients end up with a significantly lower level of health and function, at least for a period of time that can last from weeks to indefinitely.

Intuitively, this does not seem reasonable when state-of-the-art medical care for individuals who have been injured in motor vehicle accidents, stroke and head injury survivors, and those who have undergone major surgeries such as coronary artery bypass grafts or anterior cruciate ligament repairs almost universally include some type of rehabilitation intervention. These are not patients who are left to figure out how they can best rehabilitate themselves. Instead, they receive expert advice from rehabilitation professionals, and subsequent treatment generally includes, but is not limited to, the focus of this article: physical therapy and, in some cases, occupational therapy. Many other rehabilitation interventions exist but are not the topic of this article.

Evidence-based medicine drives conventional medical treatment, and in all the examples provided (e.g., stroke and cardiac surgery), there are many studies supporting rehabilitation interventions.

Evidence-based studies supporting oncology rehabilitation are emerging, but there are clearly many gaps. For example, one area where more research is needed is showing that oncology rehabilitation Rehabilitation Therapy Interventions

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TABLE 2 Adverse effects of cancer treatment that may be reduced with rehabilitation intervention Pain Fatigue Deconditioning Reduced physical strength Reduced range of motion of joints Decreased cardiovascular capacity Lymphedema Mood disorders including depression and anxiety Bone loss Heart disease (future) Diabetes (future) Second malignanciesa Recurrence of primary malignancya a Positive effect on reducing primary and/or secondary malignancies.

saves enormous sums of money in unnecessary work-ups for cancer recurrence. Here is our hypothesis: cancer survivors who are treated for treatment-related musculoskeletal pain will require fewer work-ups for cancer recurrence. When cancer survivors have pain, they worry about cancer recurrence. Even if it is treatable musculoskeletal pain, they may have extensive work-ups for cancer recurrence. Unfortunately, this hypothesis is not yet supported by evidence-based clinical studies.

There are many other gaps and much research to be done in establishing oncology rehabilitation as an effective part of cancer survivorship. However, there is some convincing evidence that oncology rehabilitation is effective, and we will describe some of them here. It is important to note that there are many other therapeutic interventions in rehabilitation medicine that may significantly improve cancer survivors’ quality-of-life and ability to function that we are not covering in this review.

OUTPATIENT PHYSICAL AND OCCUPATIONAL THERAPY IN ONCOLOGY REHABILITATION The Role of Exercise in Cancer Prevention Perhaps the most studied area of oncology rehabilitation is exercise. The role of exercise in primary cancer prevention has been extensively studied in some cancers. For example, there are more than 60 cohort and case-controlled studies that have examined the role of physical activity in breast cancer.12 Although the findings are not entirely consistent, there does seem to be a 20%Y30% risk reduction for active women compared with sedentary women.13,14

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Certainly, there is evidence that exercise can help prevent many primary cancers, and perhaps, some of the same influences that exercise has on the body that make one less susceptible to getting cancer in the first place might be the reason that cancer recurrence (secondary prevention) is less likely. Whether exercise may play a protective role in preventing cancer recurrence is not clear. Some studies suggest that it might.15Y18 Others have not found exercise to be protective.12

SPECIFIC DEFICITS AMENABLE TO REHABILITATION IN CANCER SURVIVORS Patients with a diagnosis of cancer are at risk of becoming survivors with lasting impairments across multiple body systems that could be addressed by rehabilitation professionals if these are appropriately identified. In this section, we will review a few of the most frequent impairments and limitations found in cancer survivors. These potential changes in body structure and function can unfortunately lead to a progressive loss of physical function if not addressed.

Pain and Musculoskeletal Issues Unfortunately, many cancer survivors experience pain. One large study of symptom burden in a broad range of cancer survivors indicated that 34% of adult survivors have recurrent pain as compared with 17% of the control group.19 Cancerrelated pain may arise from residual tissue damage from the cancer and/or its treatment. The origin of a cancer survivor’s pain needs to be closely assessed, as this pain may arise from muscular complications such as contracture formation, skeletal morbidity such as compression fractures or osteonecrosis, or neuropathic pain as a result of nerve compression or chemotherapy-induced peripheral neuropathy. Each of these types of pain will need to be managed differently, and thus, the assessment process is especially important for the best clinical management.

Other musculoskeletal issues exist in many cancer survivors that may be amenable to physical or occupational therapy treatments. One area of focused study is the arm disability found in many breast cancer survivors. In one study of arm morbidity, 6Y12 mos after breast cancer surgery, 50% of women were found to have range-of-motion deficits on the surgical side, although few discussed this issue with healthcare professionals.20 Other studies have also demonstrated decreased strength

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in shoulder musculature of breast cancer survivors21 that could be a result of surgery22,23 or pharmacologic treatments.24 Both strength and rangeof-motion deficits can lead to altered movement patterns, and indeed, breast cancer survivors have been found to have altered scapulothoracic kinematics that correlate with pain and functional disability.25 Less work has been completed in other types of cancers, but survivors of head and neck cancers,26 as well as childhood cancer survivors,27 have also been shown to have both range-of-motion restrictions and strength deficits, making it likely that these issues are broadly shared among many cancer types.

Deconditioning and Endurance Deficits Decreased exercise tolerance and reduced cardiorespiratory fitness have been well documented for both cancers that directly impact the cardiopulmonary systems (e.g., primary or metastatic lung cancers)28 and cancers that do not directly impact the cardiopulmonary systems.29 Multiple mechanisms are potentially responsible for this decline in exercise capacity. Surgery involving removal of lung tissue directly impacts exercise tolerance by limiting oxygen diffusing capacity, but other types of surgery may also acutely impact cardiovascular fitness because of bed rest and deconditioning. Both radiation therapy involving the chest wall and pharmacologic management of cancers can impact the exercise tolerance of cancer survivors. One lasting adverse effect of ionizing radiation is excessive fibrosis, and if the chest wall and heart are incidentally exposed during treatment (such as in cancer of the left breast), myocardial perfusion can be decreased.30 Many different pharmacologic agents have demonstrated acute impact on the cardiopulmonary systems, but one agent, anthracycline, can induce permanent cardiac toxicity.31 On a positive note, exercise training has been shown to improve exercise capacity in cancer survivors without serious adverse events.29 Indeed, exercise training not only improves cardiopulmonary measures but also reduces fatigue and improves physical function and quality-of-life.

Exercise has been studied most extensively in the female breast cancer population.32 As previously noted, there has been great interest in studying the effects of exercise in women with breast cancer.

Both aerobic conditioning and strength training have been found to be beneficial in breast cancer survivors.33Y36 The concern that strength training might promote the development of lymphedema or worsen existing symptoms in breast cancer www.ajpmr.com

survivors has been mitigated by two important developments that have paved the way for a more encouraging attitude toward this component of exercise. First, the trend in developed countries has been to use sentinel lymph node biopsy rather than axillary lymph node dissection in many women with early-stage breast cancer. Sentinel lymph node biopsy is a less invasive procedure that generally results in reduced morbidity.37,38 Second, there is increasing evidence that strength training does not promote the onset or progression of lymphedema.34,39 Strength training is an important component of both bone and muscle health, and the deleterious adverse effects of cancer treatments to these tissues can be significant, resulting in muscular weakness and osteoporosis.

Although exercise both during and after breast cancer treatment is advisable for most women, there may be circumstances when exercise is not appropriate. For example, women who develop cardiac complications from chemotherapy (e.g., doxorubicin [Adriamycin]) might not be able to exercise or might need to have specific monitoring, restrictions, or parameters (e.g., keep heart rate lower than a certain level). Also, overly rigorous exercise in someone who is significantly deconditioned and recently had a mastectomy is not recommended. On the other hand, if reconditioning is done gradually in a stepwise manner with appropriate levels of intensity, time, and resistance (for strength training), then it is often safe and effective to aim for a vigorous aerobic exercise program.40 In a review of 65 exercise studies that evaluated whether exercise was an acceptable and practical therapy for cancer survivors, the authors found that approximately two of three cancer survivors are interested in participating in a formal exercise program.32 In this same review, there were no specific characteristics that influenced the proportion of patients who started and completed an exercise program. However, the main reason for refusing to start an exercise program was disinterest or the impracticality of undertaking the program.

The main reasons for starting a program and then withdrawing from it included medical complications or health deterioration. In the studies reviewed, greater proportions of cancer survivors agreed to participate if walking was the main exercise, if there were shorter bouts of low-intensity exercise, and if the program was of shorter overall duration.

Despite the profound benefits of physical activity, most people do not adhere to recommended levels of exercise. Among cancer survivors, Rehabilitation Therapy Interventions

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the rate of adherence is typically lower than in the general population despite the known benefits of exercise in this population.41 There are significant proven benefits of exercise in cancer survivors, including better overall health (including the prevention of common diagnoses such as heart disease and diabetes), strength, endurance, psychologic benefits, and quality-of-life.42Y49

is category 1 based on the number of studies conducted, good quality of the designs, large effect size of exercise on cancer-related fatigue, and consistent outcomes across studies.52

Fatigue Fatigue occurs in most patients who receive treatment for cancer,50 and in many, this fatigue does not resolve upon the completion of cancer treatment.51 There are excellent clinical guidelines for cancer-related fatigue (CRF) that have been developed by the National Comprehensive Cancer Network.52 The National Comprehensive Cancer Network generally defines CRF as a ‘‘distressing persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.’’ This sense of tiredness is usually not relieved with rest and is not related to an excessive amount of activity.

Recent efforts have been made to increase practitioner awareness of this pervasive disorder, and a number of measurement tools are available to document the severity and impact of this symptom.

Because fatigue can have many different components, a multidimensional measure, such as the Functional Assessment of Chronic Illness TherapyY Fatigue subscale,53 should be used to capture the physical, emotional, and mental aspects of fatigue.

Rehabilitation professionals may play an important role in the management of CRF. Multiple treatment regimes have been shown to reduce fatigue in the oncology population, including exercise, pharmacologic management, and psychologic support. Among these, physical activity is the most extensively studied treatment and has consistently demonstrated good results in cancer survivors.

According to the National Comprehensive Cancer Network Clinical Practice Guidelines on CRF:

Exercise has a powerful effect on cancer-related fatigue, and fatigue levels were 40% to 50% lower in exercising participants, even in studies with small sample sizes. The evidence supporting exercise as an intervention for fatigue

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The other treatment category with promising research that supports its use in treating CRF includes psychosocial interventions.52,54,55 It is likely that a multifaceted approach may be best, and rehabilitation professionals are well suited to develop such an approach.10

Balance and Falls There is clear evidence that cancer survivors are at an increased risk of functional decline, but little attention has been placed on the increased risk of falls and fractures in the cancer survivor population. Cancer survivors often have multiple risk factors for falls, including decreased lower limb strength,56 decreased sensation and reflexes because of chemotherapy-induced peripheral neuropathy,57,58 and decreased static and dynamic balance control.57 When paired with decreased bone mineral density found in many cancer survivors, this leads to an increased risk of fall-related fractures.

Impairments in balance control in cancer survivors have not been frequently studied, but recent work in breast cancer57 and leukemia59 survivors indicate that subtle yet important changes in balance control exist after completion of cancer treatment. Indeed, a study on men with prostate cancer on androgen deprivation therapy found that these men had increased functional and physical impairment and were at greater risk for falls than were similar-aged peers.60 Because the changes in balance may be subtle, it is important to measure postural control in a variety of challenging positions to detect deficits.4 Rehabilitation professionals need to be able to recognize the wide variety of patients who may present with postural instability and problems with balance.

Another issue in the detection of balancerelated deficits has been the underappreciation of chemotherapy-induced peripheral neuropathy by healthcare professionals.58 Currently, there is no standard evaluation for chemotherapy-induced peripheral neuropathy, although a number of clinical and patient-reported measures have been developed. Rehabilitation professionals, specifically

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physical therapists and physiatrists, are well educated to evaluate and treat balance-related disorders. By focusing on decreasing the impact of balance disorders and increasing bone mineral density through exercise, rehabilitation professionals could make an important contribution to improving the overall health and well-being of cancer survivors.

Lymphedema Physical and occupational therapists should be specifically trained and certified in lymphedema treatment. However, even skilled clinicians may misdiagnose lymphedema owing to the fact that it is a clinical diagnosis with variation in how the diagnosis can be achieved. In our experience, most clinicians use girth measurements. A 2-cm girth measurement difference between limbs is generally used as the diagnostic criteria for lymphedema.61 Volume measurements can also be done, and a 200-ml limb volume difference is significant. Some clinicians use a 10%Y20% limb volume change as it takes into account the body habitus of the patient.62 Diagnosing lymphedema after cancer treatment can be difficult. A reasonable clinical pathway can include evaluating the patient preoperatively and 3 mos postoperatively.63 Limb girth changes before the 3-mo postoperative mark may be caused by postoperative swelling. If there is a greater than 3% change on the affected side from preoperative measurements, then a 4-wk trial with a sleeve or gauntlet is recommended. If the swelling improves, then surveillance is recommended in 3-mo intervals. If the swelling does not improve, then decongestive therapy is initiated. This means that decongestive therapy is not typically initiated in patients until at least the 4-mo postoperative mark.

There may be circumstances that dictate intervention more quickly, but this is a reasonable timeframe for most oncology patients.

Lymphedema is not a curable condition.

Treatment for lymphedema relies on the fact that patients who have swelling with pitting edema (and thus, little or absent fibrosis) respond to compression, making earlier stages of lymphedema more amenable to treatment. Lymphedema, regardless of etiology, develops in stages, from mild to severe, and there are various methods of staging/grading.

Two of the most commonly used methods for lymphedema staging and grading include the Fifth World Health Organization Expert Committee on Filariasis64 and the Consensus Document of the International Society of Lymphology,65 respecwww.ajpmr.com

tively. Each stage/grade is grossly equivalent in comparing these two methods: Stage/Grade 0 (latent or subclinical): edema is not evident despite impaired lymph transport caused by some damage to lymph vessels.

Transport capacity is still sufficient for the amount of lymph being removed. It may exist months or years before overt edema occurs.

Stage/Grade 1 (spontaneously reversible): edema pits in response to pressure by fingertips, is reduced significantly by elevation, with normal or near-normal size upon waking in the morning, and no clinical evidence of fibrosis.

Stage/Grade 2 (spontaneously irreversible): tissue has ‘‘spongy’’ consistency and is considered ‘‘nonpitting’’ when pressed by the fingertips; moderate to severe fibrosis is found, with hardening and increased size of limb.

Stage/Grade 3 (lymphostatic elephantiasis): lymphedema irreversible, limb usually very large and hardened with unresponsive tissue, a result of repeated inflammatory insults and subsequent fibrosis and sclerosis of skin and subcutaneous tissues.

This means that the ideal patients to treat are stage 1 patients. Patients at stage 0 can be given compression garments and education but usually do not undergo more extensive treatment.

Patients at stage 2 may respond to treatment and should be given a trial. Patients at stage 3 can be exceedingly difficult to treat and may need support and information on how to live with stage 3 lymphedema as a chronic disease.

The evidence-based treatment for lymphedema is variably called decongestive lymphatic therapy, complex decongestive physiotherapy, and complete decongestive therapy. Despite various names, these treatment strategies consist of an empiric system of therapy, which includes the following: & manual lymph drainage (i.e., lymphatic massage) & short-stretch compression bandaging & therapeutic limb exercises & skin care Typically, this treatment is initially done daily (Monday through Friday) for a period of a few weeks, depending on how quickly the patient’s swelling is resolved or improved. In a clinical setting, there are often scheduling issues that make it difficult to treat a patient 5 days a week for several weeks. Home care involves compression wraps or stockings to discourage regression.

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In some cases, surgery may be considered if a patient is not responding to treatment.66 Available studies investigating the effectiveness of pneumatic compression pump therapy, although having some study weaknesses, do suggest that pneumatic pump therapy may be most effective when done in combination with other treatments (i.e., manual lymph drainage, compression garments, and self-massage) and, with continued pump usage, may be effective in maintaining initial volume reductions. There are a handful of studies that have investigated concentrated or scanning laser therapy, with benefits including improved subjective symptoms and quality-of-life. These studies on pneumatic pump and laser therapies, as well as studies on other common conservative therapies, are outlined in a systematic review by Moseley et al.67

Psychosocial A cancer diagnosis can be emotionally and physically devastating. Recently, the issue of posttraumatic stress disorder has been raised in the survivor population.68 The treatment itself may cause emotional problems with hormonal fluctuations or even delayed emotional recovery because of taxane-based chemotherapy regiments.69 Reducing distress has been shown to lower levels of symptoms and achieve higher levels of functioning.70 A systematic review of exercise studies done in women with metastatic breast cancer concluded that ‘‘there is strong evidence that exercise positively influences QOL (quality of life) in women living with breast cancer.’’71 Whether addressing psychosocial function will improve survival is not clear but is being studied.72

CONCLUSION It is clear that rehabilitation services are needed but not usually received by cancer survivors. To address this population’s need, a number of different issues should be addressed.

1. More rehabilitation professionals (including, but not limited to, physiatrists, physical therapists, occupational therapists, and speech and language pathologists) need to have specific training in the field of oncology rehabilitation.

The American Academy of Physical Medicine and Rehabilitation has developed a Medical Rehabilitation Council that specifically contains a Cancer Rehabilitation Medical Subspecialty Group Listserv to help physiatrists share information, network, and foster the development of oncology rehabilitation. Currently, the American Physical Therapy Association has a

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section on oncology rehabilitation that produces a journal and continuing education programming, and work is underway on developing a clinical specialist examination for this practice area. Although this group is still small within the physical therapy profession, it is growing both in number and evidence base.

Occupational therapists are becoming more involved in oncology rehabilitation and are creating mechanisms for increased professional development in this area through the American Occupational Therapy Association.73 2. Oncologists and other physicians need education on appropriate screening for and referral to rehabilitation for cancer survivors. Rehabilitation professionals need to present at oncology and family medicine conferences to educate others about the need for oncology rehabilitation to be included as a key part of survivorship as a distinct phase of cancer care. At the same time, rehabilitation professionals can learn from their oncology and family medicine counterparts and be educated themselves. This cross-disciplinary interaction is an important part of developing and fostering oncology rehabilitation services.

3. Interdisciplinary care for oncology patients and cancer survivors needs to become part of the standard of treatment. In the best case scenario, rehabilitation professionals would be working with patients at risk for developing deficits both before and during cancer treatment, such as breast cancer patients before mastectomy and childhood leukemia patients as they begin their 2- to 3-yr cancer treatment plan. In a few medical centers, this has become the standard of care. For example, at Children’s Hospitals and Clinics of Minnesota, the Stoplight program for children with acute lymphoblastic leukemia was established to identify children with physical deficits caused by cancer therapies during therapy, address these deficits with physical therapy, and keep them as active as possible during their 2- to 3-yr treatment. This oncology practice has gone as far as to have a physical therapist work within their outpatient clinic as a rehabilitation case manager to oversee their population’s rehabilitation needs.

4. Oncology rehabilitation research needs to be a priority to document the best ways to treat this population. Evidence-based care is the cornerstone of optimal treatment, and with oncology rehabilitation still in its infancy, there is much work to be done.

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5. Rehabilitation and oncology professionals need to find ways to work together to provide optimal cancer rehabilitation services to the many patients who need them. There is clearly a significant deficit in cancer care when rehabilitation is not offered to those who will likely benefit from it. Bridging the gap between these two disciplines can be challenging but is an important goal to provide the best possible care for cancer survivors.

REFERENCES 1. Hewitt M, Ganz PA, (eds): From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006 2. Silver JK, Mayer RS: Barriers to pain management in the rehabilitation of the surgical oncology patient.

J Surg Oncol 2007;95:427Y35 3. Vargo MM: The oncology-rehabilitation interface: better systems needed. J Clin Oncol 2008;26:2610Y1 4. Gilchrist LS, Galantino ML, Wampler M, Marchese VG, Morris GS, Ness KK: A framework for assessment in oncology rehabilitation. Phys Ther 2009;89: 286Y306 5. Stubblefield MD, O’Dell MW, (eds): Cancer Rehabilitation: Principles and Practice. New York, NY: Demos Medical; 2009 6. Hewitt M, Rowland JH, Yancik R: Cancer survivors in the United States: age, health and disability.

J Gerontol A Biol Sci Med Sci 2003;58:82Y91 7. Hudson MM, Mertens AC, Yasui Y, et al: Health status of adult long-term survivors of childhood cancer: a report from the childhood cancer survivor study.

JAMA 2003;290:1583Y92 8. Gordon L, Lynch BM, Newman B: Transitions in work participation after a diagnosis of colorectal cancer. Aust N Z J Public Health 2008;32:569Y74 9. Yuen HK, Gillespie MB, Day TA, Morgan L, Burik JK: Driving behaviors in patients with head and neck cancer during and after cancer treatment: a preliminary report. Head Neck 2007;7:675Y81 10. Cheville AL, Beck LA, Petersen TL, Marks RS, Gamble GL: The detection and treatment of cancer-problems in an outpatient setting. Support Care Cancer 2009;17:61Y7 11. Cheville AL: Cancer rehabilitation. Semin Oncol 2005;32:219Y24 12. Sternfeld B, Weltzien E, Quesenberry CP Jr, et al: Physical activity and risk of recurrence and mortality in breast cancer survivors: findings from the LACE study. Cancer Epidemiol Biomarkers Prev 2009;18:87Y95 13. Physical activity. In: Lee IM, Oguma Y, Schottenfeld D, Fraumeni JF Jr (eds). Cancer Epidemiology and Prevention. ed 3. New York, NY: Oxford University Press; 2006:449Y67 14. Lee IM: Physical activity and cancer preventionVdata www.ajpmr.com

from epidemiologic studies. Med Sci Sports Exerc 2003;35:1823Y7 15. Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA: Physical activity and survival after breast cancer diagnosis. JAMA 2005;293:2479Y86 16. Holick CN, Newcomb PA, Trentham-Dietz A, et al: Physical activity and survival after diagnosis of invasive breast cancer. Cancer Epidemiol Biomarkers Prev 2008;17:379Y86 17. Irwin ML, Smith AW, McTiernan A, et al: Influence of pre- and postdiagnosis physical activity on mortality in breast cancer survivors: the Health, Eating, Activity, and Lifestyle study. J Clin Oncol 2008;26: 3958Y64 18. Pierce JP, Stefanick ML, Flatt SW, et al: Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. J Clin Oncol 2007;25:2345Y51 19. Mao JJ, Armstrong K, Bowman MA, Xie SX, Kadakia R, Farrar JT: Symptom burden among cancer survivors: impact of age and comorbidity. J Am Board Fam Med 2007;20:434Y43 20. Thomas-Maclean RL, Hack T, Kwan W, Towers A, Miedema B, Tilley A: Arm morbidity and disability after breast cancer: new directions for care. Oncol Nurs Forum 2008;35:65Y71 21. Merchant CR, Chapman T, Kilbreath SL, Refshauge KM, Krupa K: Decreased muscle strength following management of breast cancer. Disabil Rehabil 2008;30:1098Y105 22. Helms G, Ku¨hn T, Remmel E, Kreienberg R: Shoulder-arm morbidity in patients with sentinel node biopsy and complete axillary dissectionVdata from a prospective randomized trial. Eur J Surg Oncol 2009;35:696Y701 23. Nesvold IL, Dahl AA, LLkkevik E, Marit Mengshoel A, Fossa˚ SD: Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol 2008;47:835Y42 24. Henry NL, Giles JT, Ang D, et al: Prospective characterization of musculoskeletal symptoms in early stage breast cancer patients treated with aromatase inhibitors. Breast Cancer Res Treat 2008;111:365Y72 25. Shamley D, Srinaganathan R, Oskrochi R, LascurainAguirreben˜a I, Sugden E: Three-dimensional scapulothoracic motion following treatment for breast cancer [published online ahead of print 2008]. Breast Cancer Res Treat 2009;118:315Y22 26. Gu¨ldiken Y, Orhan KS, Demirel T, Ural HI, Yu¨cel EA, De?er K: Assessment of shoulder impairments after functional neck dissection: long term results. Auris Nasus Larynx 2005;32:387Y91 27. Hartman A, van den Bos C, Stijnen T, Pieters R: Decrease in peripheral muscle strength and ankle dorsiflexion as long-term side effects of treatment for childhood cancer. Pediatr Blood Cancer 2008; 50:833Y7 28. Travers J, Dudgeon DJ, Amjadi K, et al: Mechanisms of exertional dyspnea in patients with cancer. J Appl Physiol 2008;104:57Y66

Rehabilitation Therapy Interventions

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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29. Jones LW, Eves ND, Haykowsky M, Freedland SJ, Mackey JR: Exercise intolerance in cancer and the role of exercise therapy to reverse dysfunction.

Lancet Oncol 2009;10:598Y605 30. Marks LB, Yu X, Prosnitz RG, et al: The incidence and functional consequences of RT-associated cardiac perfusion defects. Int J Radiat Oncol Biol Phys 2005;63:214Y23 31. Ewer MS, Lippman SM: Type II chemotherapyrelated cardiac dysfunction: time to recognize a new entity. J Clin Oncol 2005;23:2900Y2 32. Silver JK: Rehabilitation in women with breast cancer. Phys Med Rehabil Clin N Am 2007;18:521Y37 33. Courneya KS, McKenzie DC, Mackey JR, et al: Moderators of the effects of exercise training in breast cancer patients receiving chemotherapy: a randomized controlled trial. Cancer 2008;112:1845Y53 34. Kilbreath SL, Refshauge KM, Beith JM, Ward LC, Simpson JM, Hansen RD: Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial. BMC Cancer 2006;6:273Y7

45. Schwartz AL, Mori M, Gao R, Nail LM, King ME: Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy. Med Sci Sports Exerc 2001;33:718Y23 46. Segal R, Evans W, Johnson D, et al: Structured exercise improves physical functioning in women with stage I and II breast cancer: results of a randomized controlled trial. J Clin Oncol 2001;19:657Y65 47. Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS: Randomized controlled trial of exercise in postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes. J Clin Oncol 2003;21:1660Y8 48. Pinto BM, Trunzo JJ: Body esteem and mood among sedentary and active breast cancer survivors. Mayo Clin Proc 2004;79:181Y6 49. Nikander R, Sieva¨nen H, Ojala K, Oivanen T, Kellokumpu-Lehtinen PL, Saarto T: Effect of a vigorous aerobic regimen on physical performance in breast cancer patients - a randomized controlled pilot trial. Acta Oncol 2007;46:181Y6

35. Hewitt J, Mokbel K, van Someren K, Jewell A, Garrod R: Exercise for breast cancer survival: the effect on cancer risk and cancer-related fatigue (CRF). Int J Fertil Womens Med 2005;50(5 pt 1):231Y9

50. Ahlberg K, Ekman T, Gaston-Johansson F, Mock V: Assessment and management of cancer-related fatigue in adults. Lancet 2003;362:640Y50

36. Valenti M, Porzio G, Aielli F, et al: Physical exercise and quality of life in breast cancer survivors. Int J Med Sci 2008;5:24Y8

51. Bower J, Ganz P, Desmond K: Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol 2000;18:743Y53

37. Courneya KS, Segal RJ, Mackey JR, et al: Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 2007;25:4396Y404 38. Haid A, Ko¨berle-Wu¨hrer R, Knauer M, et al: Morbidity of breast cancer patients following complete axillary dissection or sentinel node biopsy only: a comparative evaluation. Breast Cancer Res Treat 2002;73:31Y6

52. Mock V, Atkinson A, Barsevick AM, et al: Cancerrelated fatigue. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2007;5:1054Y78

39. Milne HM, Wallman KE, Gordon S, Courneya KS: Impact of a combined resistance and aerobic exercise program on motivational variables in breast cancer survivors: a randomized controlled trial. Ann Behav Med 2008;36:158Y66 40. Daley AJ, Crank H, Mutrie N, Saxton JM, Coleman R: Patient recruitment into a randomised controlled trial of supervised exercise therapy in sedentary women treated for breast cancer. Contemp Clin Trials 2007;28:603Y13 41. MacVicar MG, Winningham ML, Nickel JL: Effects of aerobic interval training on cancer patients’ functional capacity. Nurs Res 1989;38:348Y51 42. MacVicar MG, Winningham ML: Promoting functional capacity of cancer patients. Cancer Bull 1986;38:235Y9 43. Mock V, Dow KH, Meares CJ, et al: Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer.

Oncol Nurs Forum 1997;24:991Y1000 44. Mock V, Pickett M, Ropka ME, et al: Fatigue and

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quality of life outcomes of exercise during cancer treatment. Cancer Pract 2001;9:119Y27

Silver and Gilchrist

53. Yellen SB, Cella DF, Webster K, Blendowski C, Kaplan E: Measuring fatigue and other anemiarelated symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manage 1997;13:63Y74 54. Goedendorp MM, Gielissen MF, Verhagen CA, Bleijenberg G: Psychosocial interventions for reducing fatigue during cancer treatment in adults.

Cochrane Database Syst Rev 2009;1:CD006953 55. Kangas M, Bovbjerg DH, Montgomery GH: Cancerrelated fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients.

Psychol Bull 2008;134:700Y41 56. Simmonds MJ: Physical function in patients with cancer: psychometric characteristics and clinical usefulness of a physical performance battery. J Pain Symptom Manage 2002;24:404Y14 57. Wampler MA, Topp KS, Miaskowski C, Byl NN, Rugo HS, Hamel K: Quantitative and clinical description of postural instability in women with breast cancer treated with taxane chemotherapy. Arch Phys Med Rehabil 2007;88:1002Y8 58. Markman M: Chemotherapy-induced peripheral neuropathy: underreported and underappreciated.

Curr Pain Headache Rep 2006;10:275Y8 59. Wright MJ, Galea V, Barr RD: Proficiency of balance in children and youth who have had acute lymphoblastic leukemia. Phys Ther 2005;85:782Y90

Am. J. Phys. Med. Rehabil. & Vol. 90, No. 5 (Suppl), May 2011

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

60. Bylow K, Dale W, Mustian K, et al: Falls and physical performance deficits in older patients with prostate cancer undergoing androgen deprivation therapy.

Urology 2008;72:422Y7 61. Harris SR, Hugi MR, Olivotto IA, Levine M: Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer: Clinical Practice Guidelines for the Care and Treatment of Breast Cancer: 11. Lymphedema. CMAJ 2001;164:191Y9 62. Spillane AJ, Saw RP, Tucker M, Byth K, Thompson JF: Defining lower limb lymphedema after inguinal or ilio-inguinal dissection in patients with melanoma using classification and regression tree analysis.

Ann Surg 2008;248:286Y93 63. Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P: Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer 2008;112:2809Y19 64. Lymphatic filariasis: the disease and its control. Fifth report of the WHO Expert Committee on Filariasis.

World Health Organization Technical Report Series 1992;821:1Y71 65. Consensus document of the International Society of Lymphology. In: the diagnosis and treatment of peripheral lymphedema. Lymphology 2003;36: 84Y91 66. Warren AG, Brorson H, Borud LJ, Slavin SA:

www.ajpmr.com

Lymphedema: a comprehensive review. Ann Plast Surg 2007;59:464Y72 67. Moseley AL, Carati CJ, Piller NB: A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. Ann Oncol 2007;18:639Y46 68. Bush NJ: Post-traumatic stress disorder related to the cancer experience. Oncol Nurs Forum 2009;36: 395Y400 69. Thornton LM, Carson WE III, Shapiro CL, Farrar WB, Andersen BL: Delayed emotional recovery after taxane-based chemotherapy. Cancer 2008;113: 638Y47 70. Andersen BL, Farrar WB, Golden-Kreutz D, et al: Distress reduction from a psychological intervention contributes to improved health for cancer patients.

Brain Behav Immun 2007;21:953Y61 71. Bicego D, Brown K, Ruddick M, Storey D, Wong C, Harris SR: Effects of exercise on quality of life in women living with breast cancer: a systematic review. Breast J 2009;15:45Y51 72. Andersen BL, Yang HC, Farrar WB, et al: Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial. Cancer 2008; 113:3450Y8 73. AOTA Website. Available at: www.aota.org. Accessed September 30, 2009

Rehabilitation Therapy Interventions

Copyright Š 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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