1. Cancer Rehabilitation
Mrinal Joshi
Director, Rehabilitation Research Center
Senior Professor & Unit Head, Department of Physical Medicine & Rehabilitation

2. Rhinoceros Syndrome

7. Cancer Rehabilitation
A concept that is defined by the patient and involves helping a
person with cancer to obtain maximum physical, social,
psychological, and vocational functioning within the limits
imposed by the disease and its treatment.

8. 52% had psychological problems, 35% had generalised weakness, 30% had
ADL problems, 25% had difficulties with ambulation, 7% had deficits in transfer
& 7% had deficits in communication

9. Dr J Herbert Dietz stated in 1974 “This trend towards increased and improved life
expectancy is having an important impact on concepts of caring of the cancer patients;
how best we can help these patients readapt to society?”
A history of cancer rehabilitation. DeLisa J A. Cancer Vol 92, Issue S4, 15th Aug 2001, 970-974

10. Cancer Rehabilitation Approaches
• Preventive, when the disease can be predicted and
appropriate prior training can reduce the severity of its effect
• Restorative, when the disability can be expected to result in
only minimal or residual handicap
• Supportive, when the disability must be tolerated and
appropriate gains made toward control of problems and
improvement in performance
• Palliative, when there is advanced disease and the basic
disability cannot be corrected, but training can aid
performance
A history of cancer rehabilitation. DeLisa J A. Cancer Vol 92, Issue S4, 15th Aug 2001, 970-974

11. Impairments associated with
surgery & chemotherapy
• Impaired postoperative healing
• Neurologic deficits
• Musculoskeletal disorders due to maladaptive movement
• Peripheral neuropathy
• Cognitive dysfunction
• Cardiomyopathy
• Pulmonary fibrosis

12. Impairments associated
with radiation therapy
• Desquamation of dermis
• Muscle hypertonicity
• Tissue necrosis & fibrosis
• Delayed radiation myelopathy
• Delayed brachial & lumbar plexopathy
• Delayed encephalopathy
• Cerebral atrophy

13. • Constitutional symptoms
• Fatigue & pain
• Functional decline
• Impairments caused by tumour effects
• Bone metastases
• Brain Tumours: primary & metastases
• Epidural spinal cord compression
• Brachial & lumbar plexopathy
• Paraneoplastic syndromes
• Cadiopulmonary metastases
BUT THIS 70s momentum failed to
progress due to lack of education,
prioritise or PMR’s bias towards other
field

14. Much of the disability associated with advanced cancer can be addressed.
One of the central question of this review was “why does functional loss in patients
with cancer fail to trigger rehabilitation referrals”?

15. Willingness to refer/accept a patient with advanced cancer regardless of estimated
prognosis, only 8.4% of oncologists were willing in contrast to 15.1% physiatrists
reported as 35% willing to accept the referrals.

19. Survivorship & Rehab
• Attention focuses on special needs of disease free cancer
survivors
• Model of care to maximise health and well being of survivors
• Effective symptom management, prevention of late effects and
health promotion
• Shift from hospital based to physician based
• Poor integration in current tertiary program
• Poor trainee exposure
• Comprehensive model instead of fragmented model of care

20. Survivorship & Rehab
• HRQOL is much worse in cancer survivors
• Leading cause is physical disability
• Rehab potential screening
• GOAL setting
• SMART goals
• Identification of appropriate health professionals

22. Oncology-Rehabilitation Interface

23. O’Toole DM, Golden AM: Evaluating cancer patients for rehabilitation potential. West J Med 1991 Oct; 155:384-387

25. Cancer Rehab & Palliative Care
• Subspecialties are similar in many respect
• Managing cancer related or treatment related symptoms
• Improving HRQOL
• Lessening care giver burden
• Valuing patient centred care
• Shared decision making
• Goals are often aligned but different specialised skills & approaches
• Rehab physicians tend to focus more on functions

26. • A medical intervention can be considered futile if it has little or no chance of
achieving the intended outcome.
• It is not uncommon for the rehabilitation team to feel that the patient and/or the
patient's family has “unrealistic” or unachievable goals. In those cases, we try to
help them reshape and reframe goals to match what we know about patients'
impairments and prognosis for recovery. If that is not possible, where does it leave
us?

27. DRS Admission
n Mr X referred from RAH
n Following functional decline medical condition

28. Presenting Complaint
n Difficulty in swallowing
n Difficulty in speech
n Falls
n Excessive salivation

29. HPC
n History of recurrent 4th ventricle
subependymoma
n Recurrent aspiration
n 7th, 9th,10th &12th palsy
n Dysphagia
n Tracheostomy

30. Medical Problem List
n Drooling
n Orthostatic Hypotension
n Dysphagia
n Dysarthria
n Dysphonia
n Cough after swallow
n Abnormal Gag Reflex
n 9th , 10th & 12th Palsy

31. Spasticity Clinic Evaluation @ RGH
n 13/5/08: using 10 boxes of tissue/week,
distressed with drooling
n 21/5/08: B/L parotid & submandibular
salivary glands injected with 40 Units of
botulinum toxin A under ultrasound
guidance

32. Oncology Rehab
• DG
• Grey zone lymphoma
• Treated by MGH Oncology team
• 3 CHOP + Prednisolone

33. Problem List
• Feels better after chemotherapy
• Disabling neuropathic pain both lower limbs
• Distal sensory loss both lower limbs
• Distal motor weakness - unsteady slapping gait
• Unsteady gait
• Confined to bed
• Not able to attend job responsibilities
• Financial distress

34. Interventions
• TCAs & Anti-convulsants
• Silicon gel socks and inserts
• Ankle Foot Orthosis
• Physical therapy for motor weakness & gait training
• Gait aid - walking stick
• Able to walk with minimal discomfort
• Plans return to work , part time
• Feels better and confident
• Family is happy with the outcome