Building a bridge between oncology and physical therapy

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The power of physical therapy to improve the health and well-being of patients
who have undergone treatment for cancer is practically undisputed. Cancer
treatments take a toll on a patient's body in addition to the disease itself, so
the eradication of cancer is not always the final step in a patient's recovery.
Laurie Sweet, a clinical resource analyst at The Johns Hopkins Cancer
Rehabilitation Program in East Baltimore, Maryland, describes physical therapy
as the Yin to cancer's Yang, and just as much a part of a cure for the disease as
chemotherapy, radiation, or surgery (Table 1).

Table 1. Common conditions treated with physical therapy

Conditions
Decline in balance
Difficulty with walking
Fatigue
Joint stiffness
Numbness in feet or hands
Pain
Poor endurance

Postural changes
Scar tissue restriction
Weakness
Source: Cancer rehabilitation. Johns Hopkins Medicine Web site.
http://www.hopkinsmedicine.org/physical_medicine_rehabilitation/services/outp
atient/cancer_rehabilitation.html. Accessed November 1, 2013.

Reducing pain and returning a patient, as closely as possible, to their original

physical baseline is what postcancer physical therapy is all about. It's part of
treatment, Sweet says.

Still, less-than-adequate communication between physical therapy

departments and oncology staff leave many patients without enough guidance
to properly continue their recovery after the treatment phase. A more formal
patient hand-off between oncology and physical therapy would improve and
quicken patient recovery and health-related quality of life, said Brandon
Wigglesworch, supervisor of the physical therapy department at the University
of California San Francisco.

Many cancer survivors come to us from out of the cold, with no doctor
referral, Wigglesworch told Oncology Nurse Advisor. They were never told by
their oncologist to expect [physical therapy]. But the truth is that every cancer
survivor requires some form of physical therapy. Regardless of whether the
patient underwent a biopsy or a mastectomy, lost movement must be
regained. If the condition was brain cancer, the concern focuses on motor skills.
The challenge may be to relearn how to move your fingers or touch your face.

DOCUMENTED NEED
In a study in which 202 people undergoing outpatient cancer treatment
responded to a 27-item questionnaire, 65.8% reported experiencing functional
problems and nearly a quarter (23.9%) reported having trouble walking.
However, only two of the 202 participants were given referrals to physical
therapy, and those were for pain and limb swelling. None of the patients'
functional problems were formerly addressed.1

A study on the prevalence and treatment patterns of physical impairments in

patients with metastatic breast cancer found that 92% of patients (150 of 163)
reported one or more physical impairments. Although 88% of the identified
impairments required physical therapy, only 21% of those requiring physical
therapy received treatment.2 The authors of these studies conclude that
functional problems are prevalent among outpatients with cancer and are
rarely documented by oncology clinicians.1,2

THE IMPACT ON PATIENTS

Teresa L. was never told by any of her oncologists to prepare for and commit to
physical therapy. Stage 3 Hodgkin lymphoma was diagnosed in the 59-year-old
New Yorker in 1995, and after undergoing standard MOPP chemotherapy and
radiation treatments, Teresa's lymphoma went into remission. In 2007, she
developed breast cancer. Her doctors believe the breast cancer was a side
effect of the lymphoma treatment. Following a bilateral mastectomy, she
experienced radiation fibrosis, which tightened her skin, and cardiovascular
issues. Severe neuropathy in her knees led to several broken bones in her feet.

There was never any doctor there saying to me you need to watch out for this
after treatment, you need to go to physical therapy,' recalls Teresa. It was
just goodbye' from the hospital staff and that was it. She sought treatment
from physical therapists unfamiliar with what she had endured as a cancer
patient. Still coping with the emotions of her cancer survival, Teresa
experienced guilt for complaining about pain after surviving cancer. I didn't
want to complain, she said. It would have been tremendously advantageous
to be told during my cancer treatment that I would require [physical therapy]
afterwards. I wouldn't have thought I was crazy or a malingerer.

Sweet told Oncology Nurse Advisor that everyone along the chain of care for
patients with cancer shares some part of the responsibility of ensuring that
proper physical therapy is a part of the patient's cancer treatment. It's sort of
all our responsibility to know what the patient's goals are and where physical
therapy comes in, said Sweet. There are so many people involvedthe
primary oncologist, the radiation oncologist, nurses, etc.and everyone needs
to watch for the red flags: Can a patient return to their precancer baseline? Is
surgical intervention being used to treat the cancer?
Building a bridge between oncology and physical therapy

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Even with a shared responsibility for communicating the need for physical
therapy to cancer survivors, only doctors can issue the referral necessary to
place a patient in a physical therapy regimen specifically aligned for cancer
survivorship. With the exception of the state of Maryland, where patients can
refer themselves into advanced physical therapy programs, private insurance
will not cover or reimburse physical therapy costs unless the patient has a
referral from the doctor, said Sweet.

The difference between physical therapy specifically designed for cancer

survivors and conventional physical therapy is as much about what to do right
as it is about what not to do wrong. For example, cancer survivors with
weakened immune systems or those who underwent bone marrow transplants
should avoid public gyms and pools until their white blood cell counts are
refortified. Patients exposed to radiation therapy should avoid chlorine. Patients
with severe neuropathy that effects balance should avoid treadmills, and so
on.3 Teaching cancer survivors to watch for any approaching threat to their
health is another dividend of cancer-specific physical therapy.

Becky O., a two-time breast cancer survivor from Portland, Oregon, developed
severe lymphedema in her right arm following her third breast cancer diagnosis
and a double mastectomy. I had a lot of pain from my arm, and it was swelling
to such a huge size, Becky recalls. But with the [physical therapy] I was
taught to watch for the beginning signs of a lymphedema attack, and was
given some great techniques to keep it at bay.

CONCLUSION
The science of physical therapy itself continues to advance beyond what used
to be its own boundaries. Techniques that were once avoided with cancer
patients are now being embraced, such as upper extremity resistance training
for survivors with upper extremity lymphedema. Once believed to be
dangerous, the practice has been found to be beneficial.3

Battling cancer at the patient level is so much about focusing on the now that
overlooking posttreatment issues is not difficult. Wigglesworch adds, It's like a
cancer patient asking if they are going to live. Oncology would rather
concentrate on the now.

But patients deserve to know enough to prepare for any future that arrives, and
they need to be assured that every aspect of their condition is documented so
any needed physical therapy is accurately targeted and covered by their
insurance. Nurses are in an ideal position to provide assistance here, said
Wigglesworch. Patients need to know physical therapy will be part of
recovery, he said. Patients should be observed with physical therapy in mind,
so insurance companies do not deny claims. Nurses foster this communication,
and that can save cancer survivors a lot of grief.

Dan Neel is a medical writer based in San Francisco, California.

REFERENCES

1. Cheville AL, Beck LA, Petersen TL, et al. The detection and treatment of
cancer-related functional problems in an outpatient setting. Support Care
Cancer. 2009;17(1):61-67.

2. Cheville AL, Troxel AB, Basford JR, Kornblith AB. Prevalence and treatment
patterns of physical impairments in patients with metastatic breast cancer. J
Clin Oncol. 2008;26(16):2621-2629.

3. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an

essential component of quality care and survivorship [published online ahead
of print July 15, 2013]. CA Cancer J Clin. 2013;63(5):295-317.
http://onlinelibrary.wiley.com/doi/10.3322/caac.21186/full. Assessed October
29, 2013.