This document discusses conservative management of cancer patients through rehabilitation. It describes how cancer rehabilitation aims to help patients achieve maximum physical, social, psychological and vocational functioning given disease limitations. It outlines common rehabilitation problems in cancer patients such as side effects from chemotherapy and radiation, fatigue, myopathies, neuropathies, pain, edema, immobility and depression. It also discusses rehabilitation approaches for issues like lymphedema, bone destruction, and system-specific cancers. Exercise is presented as a key part of managing many side effects and improving patient quality of life.

1. CONSERVATIVE MANAGEMENT
OF CANCER PATIENTS
Dr. Vinod K Ravaliya, MPT
Assistant Professor, KMPIP
Karamsad
Saturday 10th November 2012

2. Why needed?
 Cancer survival rates
>50%.
 Willingness to discuss
cancer and the needs of
the patient.
 Thrust in cancer care is
not simply on survival, but
on QoL of survivors.

3. Cancer Rehabilitation: Definition
Cancer Rehabilitation defined as helping a person
with cancer to help himself or herself to obtain maximum
physical, social, psychological, and vocational
functioning within the limits imposed by disease and its
treatment.
Cromes GF Jr. Implementation of interdisciplinary cancer rehabi- litation.
Rehabil Counseling Bull 1978; 21: 230–237.

4. Quality of life (QOL)
Quality of life (QOL) is defined as an individual’s perceptions of
his position in life, in the context of the culture and value systems
in which he lives and in relation to his goals, expectations,
standards and concerns

5. Owing to the potentially progressive
nature of cancer
successful outcomes depend upon
timely recognition of functional problems
and prompt referral for rehabilitation

6. Rehabilitation Aims:
 Restorative care aims to return the individual to
premorbid function with a minimum of functional
impairment.
 Supportive care aims to reduce functional difficulties and
compensate for permanent deficits
 Palliative treatment, usually of the terminal patient,
works to eliminate or reduce complications, especially
pain
 Preventive rehabilitation would include for example,
preoperative education regarding maintenance of
strength and range of motion in the upper extremity
following breast surgery

7. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Fatigue
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

8. Chemotherapy- Side Effects
 Nausea and Vomiting
 Fatigue
 Hair loss
 Susceptibility to infections
 Decrease in Blood Cell Counts
 Mouth sores and ulcers

9. Decrease in Blood Cell Counts
 Exercise training :
 Increase total Hb and red cell mass, which enhances oxygen-
carrying capacity.
 Possible mechanisms:
 Stimulated erythropoiesis with hyperplasia of the hematopoietic
bone marrow
 Improvement of the hematopoietic microenvironment induced by
exercise training, and hormone- and cytokine-accelerated
erythropoiesis.
 Need for further investigation- chemotherapy/Radiation
therapy
Acta Haematol. 2012;127(3):156-64. Epub 2012 Jan 31.
Effects of exercise training on red blood cell production: implications for anemia.
Hu M, Lin W.

10. Decrease in Blood Cell Counts
Duration of neutropenia and thrombopenia
after adjuvant chemotherapy are significantly
shorter in the Aerobic Exercise training group
than in controls

11. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

12. Rehabilitation- Radiation therapy
 Skin & Soft Tissue Fibrosis
 Effects of Radiation
 Loss of Elasticity, Vascularity & Moisture
 Tissue Thickening & Edema • Contracture
 Management
 Moisturizing Creams
 Splinting & Orthotics
 Stretching Exercises

13. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

14. Rehabilitation- Fatigue
 Defined as the feeling of
extraordinary exhaustion
associated with a high level of
distress, disproportionate to
the patients' activity, and is not
relieved by sleep or rest.
 Up to 70% of cancer patients
during chemo and radiotherapy
 Inactivity
 Muscle catabolism
 Perpetuate Fatigue
 Self care and social activities
 QoL

15. Fatigue Burden….
Oncologist. 2007;12 Suppl 1:4-10.
Cancer-related fatigue: the scale of the problem.
Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P, Morrow GR.

16. Management of Fatigue:
 Bed rest or Aerobic Exercise
 Energy Conservation
Techniques
 Activity/Exercise Program
 Diversional Activities
 Rest/Sleep Patterns
 Stress Management
 Nutritional management

17. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathy
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

18. Rehabilitation- Myopathy
 Tumor Infiltration
 Paraneoplastic
 Carcinomatous Myopathy & Neuromyopathy
 Radiation
 Steroids & Other Chemotherapy
 The Role of Exercise
 Adaptive Equipment etc.

19. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

20. Rehabilitation- Neuropathy & Plexitis
 Causes
 Neurotoxic Chemotherapy
 Direct Invasion – Radiation
 Compression – Paraneoplastic
 Management
 Pain Control – Bracing
 Adaptive Devices – Other

21. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

22. Rehabilitation-Pain
 Physical Modalities
– Electrical Stimulation
 Heat Modalities
 Relative Contraindication to Therapeutic Heat

23. W Evidence Says- Does TENS relieves
hat
Cancer Pain ?
J Pain Symptom Manage. 2009 Apr;37(4):746-53. Epub 2008 Sep 14.
A cochrane systematic review of transcutaneous electrical nerve
stimulation for cancer pain.
Robb K, Oxberry SG, Bennett MI, Johnson MI, Simpson KH, Searle RD
.
There is insufficient available evidence to determine the
effectiveness of TENS in treating cancer-related pain. Further
research is needed to help guide clinical practice, and large multi-
center RCTs are required to assess the value of TENS in the
management of cancer-related pain in adults.

24. W Evidence Says- Does TENS relieves
hat
Cancer Pain ?
Cochrane Database Syst Rev. 2012 Mar 14;3:CD006276.
Transcutaneous electric nerve stimulation (TENS) for cancer pain in
adults.
Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG
.
Despite the one additional RCT, the results of this updated
systematic review remain inconclusive due to a lack of suitable
RCTs. Large multi-centre RCTs are required to assess the value of
TENS in the management of cancer-related pain in adults.

25. W Evidence Says- Does Acupuncture relieves
hat
Cancer Pain ?
 Acupuncture as an effective
analgesic adjunctive method
for cancer patients is not
supported by the data
currently available from the
majority of rigorous clinical
trials.
 W idespread acceptance,
appropriately powered RCTs
needed.
Eur J Pain. 2005 Aug;9(4):437-44. Epub 2004 Nov 11.
Acupuncture for the relief of cancer-related pain--a systematic review.
Lee H, Schmidt K, Ernst E.

26. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

27. Rehabilitation- Lymphedema
 Management
 Elevation
 Active Exercises
 Compressive Garments & Pumps
 Manual Lymph Drainage,
Massage and Other Treatments
Caution: Risk of Mobilizing Tumor Cells

28. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

29. Rehabilitation- Immobility
 Effects of Immobility
 Prevention of Related Problems
 Contractures – Decubiti
 Muscle Atrophy – Deconditioning
 Role of Exercise & Mobilization

30. Common Rehabilitation Problems Seen in
Cancer Patients
 Chemotherapy/Radiotherapy Induced Side Effects
 Fatigue
 Myopathies
 Neuropathies & Plexopathies
 Pain
 Edema
 Immobility/Generalized Deconditioning
 Bone Destruction
 Depression
 System Specific Problems

31. Rehabilitation- Bone Destruction
 Evaluation
 X-Ray –Bone Scan – CT
 Management
- Pain
 Unweighting
 Assistive Devices
 Surgical Considerations
>50%
- Stability C o rtica l 3 cm
- Bracing Lo ss
> 60% of
B o ne
D ia me te r

32. Rehabilitation- Orthotics
 Splinting to Maintain Position
 Orthotics to Restore Function
 E.g. AFO to lock the knee during stance phase

33. “The important thing is not how many years in
your life but how much life in your years.”
~Edward J. Stieglitz

36. Rehabilitation of Lung Cancer
Patients with inoperable lung cancer now account
for a large group of patients who use this type of medical
intervention and can significantly improve the quality of
life and the method shows positive impact on the
survival rate.
Jastrzębski D, Ziora D, Hydzik G, Pasko E, Bartoszewicz A, Kozielski J,
Nowicka J.Pulmonary rehabilitation in patients with lung cancer.
Pneumonol Alergol Pol. 2012;80(6):546-554.

37. Abstract
M TH
E ODS:
twice-weekly sessions of aerobic exercise and weight training over an 8-
week period.
functional capacity, measured by the 6-minute walk test and muscle
strength, as well as quality of life, lung cancer symptoms and fatigue,
measured by the Functional Assessment of Cancer Therapy-lung and
Functional Assessment of Cancer Therapy-fatigue scales.
CONCL IONS
US :
Those who completed the program experienced an improvement in their
lung cancer symptoms. Community-based or briefer exercise interventions
may be more feasible in this population.
J Thorac Oncol. 2009 May;4(5):595-601.
A structured exercise program for patients with advanced non-small cell lung cancer.
Temel JS, Greer JA, Goldberg S, Vogel PD, Sullivan M, Pirl WF, Lynch TJ, Christiani DC, Smith
MR.

38. Abstract
Lung cancer survivors exhibit poor functional capacity, physical functioning,
and quality of life (QoL).
The primary outcomes focused on feasibility including eligibility and
recruitment rate, loss to follow-up, measurement completion, exercise
adherence, and program evaluation. Secondary outcomes addressed
preliminary efficacy and included changes in muscular strength (1 repetition
maximum), muscular endurance (repetitions at 70% of 1 repetition
maximum), body composition (DXA scan), physical functioning (6-minute-
walk-test, up-and-go, sit-to-stand, arm curls), and patient-reported outcomes
including QoL (SF-36, FACT-L), fatigue (FACT-F), PRET is a feasible
intervention with potential health benefits for a small proportion of lung
cancer survivors in the post-treatment setting.
Lung Cancer. 2012 Jan;75(1):126-32. Epub 2011 Jun 28.
Feasibility and preliminary efficacy of progressive resistance exercise training in
lung cancer survivors.
Peddle-McIntyre CJ, Bell G, Fenton D, McCargar L, Courneya KS.