Review Of Safety Considerations In Cancer Rehabilitation
This article was reviewed by Pooja M, MSPT.
Cancer and its treatment have various adverse effects that affect a survivor’s physiological, psychological and cognitive function. Frequently, activity and exercise tolerance are both affected.
Rehabilitation does mitigate loss of function and disability, however pt’s with cancer are amongst the most medically complex patient population that rehab providers treat.
Safety consideration with multidrug therapies cyclically administered over a period of time contribute to multisystem dysfunction and influence rehabilitation outcomes. Knowing side effects of chemotherapeutic agents /drugs is imperative for implementing rehabilitation interventions.
Hematological compromise – Myelosuppression is a common side effect with chemotherapy and immunosuppressive agents, in particular corticosteroids which affect rehab. Interventions.It can result in cytopenia which increases risk of infection, compromises metabolic function and alters physiological response to exercise in certain severe circumstances.
Anemia is a frequent complication of cancer and cancer treatment including chemotherapy and radiation, worsening anemia reduces exercise tolerance and endurance leading to fatigue, dizziness and hemodynamic instability. Precaution should be taken while administering resistive exercises in people with Hbg ≤8g/dL.Low intensity exercises may be beneficial to promoting improved blood counts.
< 11 g/dL (anemia): Establish baseline vital signs; may be tachycardic or present with orthostatic hypertension; symptom-based approach to intervention, monitoring self- perceived exertion < 8 g/dL (severe anemia): Close monitoring of symptoms and vital signs with intervention; transfusion may or may not be indicated based on individual presentation; short periods of intervention, symptom-limited; education for energy conservation. Thrombocytopenia occurs with myelosuppression therapies and affects red blood cell counts. Individuals with platelet counts below 10,000 k cells/uL are at risk of spontaneous hemorrhage and per guidelines will receive prophylactic transfusion. Individuals below 20,000 cells/uL should be restricted to walking and Activities of daily living. Individuals with counts >20,000 cells/uL can complete exercise program with close symptom monitoring. In general blood pressure should be maintained below 170/100 mm Hg . with counts >30,000 cells/uL can engage in moderate and light exercise program within tolerance.
Chemotherapy Induced Neutropenia typically occurs 3-7 days after chemotherapy, neutropenia predisposes to infection. Primary sites of infection- GI tract, sinuses, lung and skin. Neutropenic infections are major cause of mortality and morbidity in individuals undergoing cancer treatment. common infections- sepsis, pneumonia and colitis
Clinicians must practice hand hygiene and wash hands with antimicrobial soap during every patient encounter. There is no compelling evidence that rehabilitation is contraindicated in patients with neutropenia, but rehab interventions should be self-limited based on patient preferences.
Cardiopulmonary toxicity-malignant tumorsinvolve lungs more than heart -either as primary or metastatic disease. There is severe pulmonary compromise in patients with advanced cancer. Radiation to chest wall can significantly affect cardiac and pulmonary function and it may be progressive overtime.
Cardiac changes can manifest 6-12 months after radiation and also up to 20 years after completion of radiation therapy impacting long term morbidity and function. Hence, monitoring vital signs is imperative with these individuals. .Implementing use of Borg scale would be helpful to monitor patient’s self-report to exercise tolerance.
Neurotoxicity -CIPN-chemotherapy induced peripheral neuropathy is a common side effect in taxane and platinum based chemotherapeutic agents. Sensory affection include glove and stocking ( distal extremities) kind of presentation and may have motor involvement as well.
Fall risk is higher in population receiving neurotoxic chemotherapeutic agents and may necessitate intervention to improve balance deficit and enhance gait and stability.
Lymphedema is commonly seen after lymphadenectomy or radiation therapy. Individuals with lymphedema are encouraged to perform exercises with some of compression, to improve mobility and prevent fluid accumulation.
Frailty is a clinical syndrome characterized by loss of physiologic reserve secondary to reduced physiological capacity, weight loss, weakness, slow walking speed, self-reported exhaustion and low physical activity, frailty is associated with falls, hospitalizations, poor rehabilitation outcomes and increased mortality.
Osseous Fragility – Osteoporosis and bone loss affect bone health in cancer survivors, osteoporosis worsens with prolonged exposure to hormonal therapies increasing fracture risk with increased duration of treatment.
Weight bearing exercise may have protective effect in mitigating bone density depletion during hormonal therapy interventions. Of importance are fall prevention strategies, education with activities that require lifting and carrying heavy objects, restricting excessive resistive ,compressive or rotational torque -like forces on involved limb/ region.
Assessment for home modifications, adaptive equipment evaluations should be considered to reduce risk of falling and improve safety in home, education for compensatory strategies, using assistive devices, orthotics and wheelchairs improve safety of individuals while promoting function.
Patients with advanced cancer should be seen for adverse effects like cachexia and sarcopenia, nutritional support is imperative in this population. In general care should also be taken for contraindications while applying manual therapy and modalities.
To conclude- “cancer rehab” is not an oxymoron, rehabilitation in oncology patients is generally safe; Overall tolerance to treatment and functional outcomes in a variety of cancer types are improved when exercise is initiated before/during cancer treatment
Oncology directed therapies and protocols are constantly advancing and therapists need to keep up to date in order to ensure the safety of patients they treat.
Maltser S et al.A focused review of safety considerations in cancer rehabilitation. PM&R 2017;S415-428.