**Physical Therapy in Patients with Cancer**

Shinichiro Morishita and Atsuhiro Tsubaki

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67286

#### **Abstract**

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94 Clinical Physical Therapy

Physical therapists often treat cancer patients. Cancer treatment includes chemotherapy, radiotherapy, and surgery, which are being continuously developed and thus increase survival of patients with each cancer diagnosis. More specifically, 5-year survival rates increase with each cancer diagnosis. Cancer patients have many problems including muscle weakness, pulmonary dysfunction, fatigue, and pain. In the end, patients with cancer tend to have a decline in activities of daily living (ADL) and quality of life (QOL). Additionally, cancer patients often have progressive disease, depression, and anxiety. Physical therapy often helps patients regain strength and physical function and improve their QOL and independence of daily living that they may have lost due to cancer or its treatment. Physical therapy has an important role in increasing physical function of cancer patients, cancer survivors, and children with cancer. In the future, physical therapy may be progressively needed for management of cancer patients.

**Keywords:** physical therapy, cancer, cancer survivor, ADL, QOL

## **1. Introduction**

Cancer and its treatments are associated with a wide range of distressing physical and psychological symptoms that can affect patients for many years following treatment [1]. Many cancer patients also have physical dysfunction and experience deficits in muscle strength, flexibility, and endurance as a result of chemotherapy, radiation therapy, and surgery [2]. Physical therapy is a comprehensive, multidisciplinary approach to the evaluation and treatment of patients diagnosed with various forms of cancer. Physical therapy can improve functional problems such as weakness, soft tissue tightness, joint stiffness, fatigue, and swelling or edema [3, 4]. Physical therapy allows experts to find the best ways for cancer patients to stay active. Physical therapy-led exercise is clinically effective and can help cancer patients

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improve their quality of life (QOL) [5]. Physical therapy includes stretching, strengthening, and aerobic exercises for the inpatients, outpatients, and cancer survivors. It often helps patients regain strength, physical functioning, quality of life, and independence in activities of daily living (ADL) that they may have lost due to cancer or its treatment. Physical therapists are available in multiple treatment settings, including preoperative, postoperative, acute care, nursing home, and inpatient and outpatient rehabilitation. Physical therapists also work in conjunction with the rehabilitation team to design components of a survivorship care plan in order to optimize overall functional outcomes (**Figure 1**) [6]. Cancer has four stages, and cancer patients have differences in disease and disabilities during each stage (**Table 1**). Physical therapists often use four cancer rehabilitation stages and identify the stage before physical therapy for cancer patients (**Table 2**) [7]. There are different approaches for therapy of cancer patients during each stage.

**Figure 1.** Rehabilitation team for cancer patients.


**Table 1.** Cancer stage.

#### **Stage**

improve their quality of life (QOL) [5]. Physical therapy includes stretching, strengthening, and aerobic exercises for the inpatients, outpatients, and cancer survivors. It often helps patients regain strength, physical functioning, quality of life, and independence in activities of daily living (ADL) that they may have lost due to cancer or its treatment. Physical therapists are available in multiple treatment settings, including preoperative, postoperative, acute care, nursing home, and inpatient and outpatient rehabilitation. Physical therapists also work in conjunction with the rehabilitation team to design components of a survivorship care plan in order to optimize overall functional outcomes (**Figure 1**) [6]. Cancer has four stages, and cancer patients have differences in disease and disabilities during each stage (**Table 1**). Physical therapists often use four cancer rehabilitation stages and identify the stage before physical therapy for cancer patients (**Table 2**) [7]. There are different approaches for therapy

Stage 1 Cancer is relatively small and contained within the organ it originated from. This stage describes

cancer is often highly curable, usually by removing the entire tumor with surgery Stage 2 Cancer has not started to spread into surrounding tissue but the tumor is larger than in Stage 1.

Stage 3 Cancer is larger. It may have started to spread into surrounding tissues, and cancer cells may be present in the lymph nodes of the area. This stage indicates larger cancers or tumors Stage 4 Cancer has spread from where it started to another organs or parts of the body. This is also called a

secondary, advanced, or metastatic cancer

cancer in situ, which means "in place." Stage 1 cancers have not spread to nearby tissues. This stage of

Sometimes, Stage 2 means that cancer cells have spread into lymph nodes close to the tumor. At this stage, cancer or tumor is relatively small and has not grown deeply into the nearby tissues. It also has not spread to the lymph nodes or other parts of the body. It is often called an early-stage cancer

of cancer patients during each stage.

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**Figure 1.** Rehabilitation team for cancer patients.

**Stage Characteristics**

**Table 1.** Cancer stage.

#### (1) Preventive

Intervention focused on improving the patient's level of function prior to the onset of the effects of the cancer and its treatment, patient education, and psychological support

#### (2) Restorative rehabilitation

Intervention focused on returning the patient to a previous level of function and addressing impairments from cancer and its treatment

#### (3) Supportive rehabilitation

Intervention is meant to assist the cancer patient to function at the highest level within the context of his or her impairments, activity limitations, and participation restrictions

#### (4) Palliative rehabilitation

Intervention focused on minimizing complications such as pressure ulcers, contractures, and muscle deconditioning ensuring adequate pain control and emotional support for the family

**Table 2.** Four cancer rehabilitation stages.

This chapter introduces overview, treatment, common dysfunctions, physical therapy assessment, physical therapy, key points in diagnosis, and palliative care of following cancer types: breast cancer, gynecologic cancers, brain tumor, head and neck cancer, lung cancer, esophagus cancer, bone cancer, and blood cancer. This chapter also shows the important role of physical therapy in cancer patients.

### **2. General concept of physical therapy**

Physical therapists must undergo assessment based on the International Classification of Functioning, Disability and Health (ICF) model before, during, and after physical therapy for each cancer patient (**Figure 2**). ICF enables physical therapist to provide cancer patients with therapy. Cancer patients have many problems caused by cancer treatment or cancer itself. Physical therapy assessment should include manual muscle testing (MMT), range of motion (ROM), balance test, endurance test, and ADL test. Performance status (PS; **Table 3**) [8], Palliative Performance Scale (PPS; **Table 4**) [9], Barthel index (BI) [10], functional independence measure (FIM) [11, 12], and QOL are also used as assessment tools for cancer patients. Physical therapists should be aware that cancer patients are exposed to various risks such as infectious diseases due to immunosuppressive effects of the treatment. Thus, physical therapists must manage risks that are related to cancer and its treatment (**Table 5**) [13]. Additionally, physical therapists must recognize that cancer is a progressive disease. In general, cancer patients have a gradual decline in their physical function. Once a goal is set, physical therapists must be aware of cancer progression and patients' prognosis [14]. Physical therapists also must know a variety of other problems that occur in cancer patients. Cancer patients might not only have physical function problems but may also develop depression and anxiety in the future [15]. Cancer patients might feel the fear of cancer recurrence or death. Physical therapy may be effective in reducing fatigue, increasing muscle strength and exercise capacity, and improving QOL in various cancer patients.

**Figure 2.** International Classification of Functioning, Disability, and Health.


#### **Table 3.** Performance status (PS).



1 PPS scores are determined by reading horizontally at each level to find a "best fit" for the patient who is then assigned as the PPS% score.

2 Begin at the left column, read downward until the appropriate ambulation level is reached, and then read across to the next column and downward again until the activity/evidence of disease is located. These steps are repeated until all five columns are covered before assigning the actual PPS for that patient. In this way, "leftward" columns (columns to the left of any specific column) are "stronger" determinants and generally take precedence over others.

3 PPS scores are in 10% increments only. Sometimes, there are several columns easily placed at one level but one or two which seem better at a higher or lower level. One then needs to make a "best fit" decision. Choosing a "halfwit" value of PPS 45%, for example, is not correct. The combination of clinical judgment and "leftward precedence" is used to determine whether 40% or 50% is the more accurate score for that patient.

**Table 4.** Palliative Performance Scale (PPSv2).

1. Hematologic profile: hemoglobin <7.5 g, platelets <20,000, white blood cell count <3000

2. Metastatic bone disease

**Figure 2.** International Classification of Functioning, Disability, and Health.

sedentary nature, e.g., light house work, office work

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or

3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more

**Self-care Intake Conscious level**

Full Normal Full

Full Normal Full

Full Normal or reduced Full

Full Normal or reduced Full

Normal or reduced Full or confusion

Occasional assistance necessary

**Grade ECOG performance status**

5 Dead

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**Table 3.** Performance status (PS).

than 50% of waking hours

**PPS level Ambulation Activity and evidence** 

100 Full Normal activity and

90 Full Normal activity and

80 Full Normal activity with

70 Reduced Unable normal job/

60 Reduced Unable hobby/house

**of disease**

disease

work

disease

of disease

work no evidence of

Some evidence of

effort Some evidence

work Significant disease

work Significant disease

3. Compression of a hollow viscous (bowel, bladder, or ureter) vessel or spinal cord

4. Fluid accumulation in the pleura, pericardium, abdomen, or retroperitoneum associated with persistent pain, dyspnea, or problems with mobility

5. CNS depression or coma or increased intracranial pressure

6. Hypokalemia/hyperkalemia, hyponatremia, or hypocalcemia/hypercalcemia

7. Orthostatic hypotension

8. Heart rate in excess 110 beat/min or ventricular arrhythmia

9. Fever greater than 101°F

**Table 5.** Precaution rehabilitation for cancer patients.
