PHYSICAL REHABILITATION FOR PATIENTS WITH CANCER�BROWN UNIVERSITY/LIFESPAN HOSPITALS�CANCER PREVENTION AND SURVIVORSHIP ELECTIVE�FEBRUARY 2025

Scott Capozza, PT, MSPT

Board-Certified Clinical Specialist in Oncologic Physical Therapy

scott.capozza@ynhh.org

SM: @scottcapozza

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Learning Objectives

• Define the professional roles of rehabilitation professions and their role in oncology care
• Identify the ways in which rehabilitation professionals can address sequelae of cancer treatment throughout the care continuum
• Analyze opportunities to engage rehabilitation services in oncology care

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�Who are we?�

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-- American Physical Therapy Association

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-- American Occupational Therapy Association

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Physical Therapists are experts in movement and function, especially when movement involves changes in “normal” movement patterns. Physical Therapists are dedicated to promoting health and wellness of all Americans through preventing functional decline and the development of certain conditions.

As an inclusive profession, occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living.

OTs and PTs Can Screen For:

• Decrease in Range of Motion
• Decreased Strength
• Decreased Balance
• Decreased Energy
• Scar Tissue Management
• Peripheral Neuropathy
• Lymphedema
• Special Certification (CLT); can be either PT or OT
• Board Certification/Specialization in Oncology Physical Therapy
• First class: 69 in the US

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So…who gets the automatic referral?

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www.rheumatology.com/patients/jointreplacementsurgery; www.yalemedicine.org/conditions; www.cancer.org

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When should we refer someone with cancer to PT?

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IT DEPENDS…

Oncology Rehab through the Cancer Continuum

Prehabilitation

• Occurs after cancer diagnosis but before surgery
• Establish patient’s baseline
• Strength/ROM/arm circumference
• Identify and treat current morbidities of the shoulder complex as well as validate/establish consistent exercise program
• Physically and mentally prepared for surgery

• Promote risk reduction for future impairments
• Decreased range of motion
• Decreased strength
• Pain
• Balance
• Initiates communication with Oncology team

Ideally 4-6 weeks of prehab or at least 1-2 sessions

Preventative/�Prehabilitation

Benefits

• Preoperative Optimization
• Increase tolerance to treatment
• Enhancement of treatment efficacy
• Decreased Hospital length of stay
• Potentially decreases rate of mortality
• Patient empowerment

Emphasizing shoulder strengthening, core strengthening, diaphragmatic breathing

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Squats

Lunges

Rows

Lat Pull-downs

Isometric abdominal exercises (planks)

Aerobic exercise

Diaphragmatic breathing

During Active Treatment

Early vs. Delayed ROM

• Early post-op exercises
• Breathing
• Posture
• Gentle AROM (shoulder below 90 deg)
• Neck ROM
• Desensitization
• Mid- 2 weeks and beyond
• Regain ROM and strength
• Progressive return to functional activities
• Plans for radiation?
• Plastic surgery restrictions (some limit to less than 90 for 4 weeks)

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Range of Motion: Muscle Energy Techniques

Photo: Physio Body and Sole

CORDING: LOW LEVEL LASER TREATMENT

SCAR TISSUE MANAGEMENT/LYMPHEDEMA: PHYSIOTOUCH/LYMPHATOUCH

Balance Training for Chemotherapy-Induced Peripheral Neuropathy (CIPN)

Hurdles

Uneven surfaces

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Rehabilitation for HNC

• Immediate Post-op:
• Head of Bed (HOB) elevated 30 degrees
• Drain management
• WBAT for FFF, placed in CAM boot, AD as needed
• NWB/no pronation/supination to donor arm for radial FF reconstruction
• NO NECK EXTENSION OR ROTATION UNTIL CLEARED BY SURGEON FOLLOWING FF GRAFTING

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SCAPULAR STABILIZATION EXERCISES

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Potential PT session in the presence of bone mets

• w/u on nu-step (no arms if spinal tumors)
• Sit 🡪 stands from elevated mat table
• Wall push-ups
• Closed chained lunges
• Scapular retraction/lat pull-downs w/ therabands
• Isometric abdominals
• Gait training/AD training if needed
• Reinforce education (how are you getting out of the car? How are you getting out of bed?)

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Campbell 2019

Chemotherapy-�Periodization �Exercise

• CFR and CIPN are cumulative
• Progressive peaks and valleys; will continue past completion of chemo
• Corresponds to decrease in steady state exercise oxygen consumption

Kirkham 2020; Photo courtesy of K. Sturm, PT, DPT, CLT-LANA

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Chemo-Periodization

• Need to adjust dose of exercise based on chemotherapy cycle
• Mindful of blood counts (Hg, HCT, Absolute neutrophils)
• Timing is everything…

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SURVIVORSHIP – WHAT’S NEXT?!?

Assessing for all of it…����

• Increase self care and mobility, prevention of functional loss, management of late and long-term side effects
• Screen/Assess/Treat for
• CV disease risk
• Fatigue
• Hormone related symptoms
• Pain
• Sexual Dysfunction
• Cognitive function
• Anxiety, Depression
• Return to work/leisure activities 🡪 QOL

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Cancer Related Fatigue

Defined by the National Comprehensive Cancer Network (NCCN) as a “distressing, persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”

CRF is reported more frequently than any other symptom of cancer and cancer treatments

CRF affects 70-80% of cancer survivors at all stages of disease and recovery – during treatment, in advanced disease, and in remission

Compared to fatigue experienced by healthy individuals, CRF is more severe, more distressing, and less likely to be relieved by rest.

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Campbell 2019

Fear of Recurrence

• Important to know exercise/rehab history
• Potential scenarios
• Never exercised (I still got cancer, so why bother now?)
• Always exercised (I did everything right, and my body still betrayed me)
• Why bother resuming exercise?
• I want to resume exercise, but I don’t know how to restart or what’s safe

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Campbell 2019

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Campbell 2019

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Furthering Oncology Rehab

• APTA – Academy of Oncologic Physical Therapy
• EDGE Task Force
• Oncology Residencies
• Board Certification in Oncology
• APTA Oncology Student/New Professionals Group
• Mentor List/Mentor-Mentee pairing program
• Oncology Special Interest Group (SIG): state-level, campus-level
• American Society of Clinical Oncology + National Cancer Coalition Network
• American College of Surgeon’s Commission on Cancer (CoC)
• Rehabilitation Care Services (4.6)
• Survivorship Guidelines (4.8)

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Oncology Rehab on SoMe

• Twitter
• Nicole Stout: @NicoleStoutPT
• Kathryn Schmitz: @fitaftercancer
• David Mizrahi: @davemiz_EP
• Dan Steventon (peds): @TheKidsCancerPT
• Instagram
• APTA Oncology SNP: @aptaoncologysnp
• Kelly (Reed) Strum (lymphedema): @CancerRehabPT
• Alexandra (Alex) Hill (pelvic health): @oncopelvicpt
• Brianna DeWitt (PT/breast cancer survivor): @bri.d.pt
• Podcasts
• TheOncoPT (@theoncopt)
• PTPintCast (@PTPintCast)

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Selected Resources

• APTA Oncology EDGE Task Force. EDGE-Annotated-Bibliography-8.19-update-1.pdf (oncologypt.org). Accessed January 4^th, 2023.
• American College of Surgeons Commission on Cancer Survivorship Standards. https://www.facs.org/-/media/files/quality-programs/cancer/coc/optimal_resources_for_cancer_care_2020_standards.ashx. Accessed January 2^nd, 2023..
• APTA CPG+. Cancer Related Fatigue Screening and Assessment Clinical Practice Guideline (CPG+) | APTA. Accessed January 12^th, 2023..
• Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023 Jan;73(1):17-48. doi: 10.3322/caac.21763. PMID: 36633525.
• Doherty DJ, Wilson CM, Boright LE, eds. Oncology Rehabilitation: A Comprehensive Guidebook for Clinicians. 1^st ed. Elsevier; 2022.
• Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, Ligibel JA, Cheville A, Galvão DA, Alfano CM, Patel AV, Hue T, Gerber LH, Sallis R, Gusani NJ, Stout NL, Chan L, Flowers F, Doyle C, Helmrich S, Bain W, Sokolof J, Winters-Stone KM, Campbell KL, Matthews CE. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019 Nov;69(6):468-484. doi: 10.3322/caac.21579. Epub 2019 Oct 16. PMID: 31617590; PMCID: PMC7896280.
• Patel AV, Friedenreich CM, Moore SC, Hayes SC, Silver JK, Campbell KL, Winters-Stone K, Gerber LH, George SM, Fulton JE, Denlinger C, Morris GS, Hue T, Schmitz KH, Matthews CE. American College of Sports Medicine Roundtable Report on Physical Activity, Sedentary Behavior, and Cancer Prevention and Control. Med Sci Sports Exerc. 2019 Nov;51(11):2391-2402. doi: 10.1249/MSS.0000000000002117. PMID: 31626056; PMCID: PMC6814265.
• Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, Zucker DS, Matthews CE, Ligibel JA, Gerber LH, Morris GS, Patel AV, Hue TF, Perna FM, Schmitz KH. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019 Nov;51(11):2375-2390. doi: 10.1249/MSS.0000000000002116. PMID: 31626055; PMCID: PMC8576825.
• Kuderer NM, Desai A, Lustberg MB, Lyman GH. Mitigating acute chemotherapy-associated adverse events in patients with cancer. Nat Rev Clin Oncol. 2022 Nov;19(11):681-697. doi: 10.1038/s41571-022-00685-3. Epub 2022 Oct 11. PMID: 36221000.
• Groeneveldt L, et al. A mixed exercise training programme is feasible and safe and may improve quality of life and muscle strength in multiple myeloma survivors.BMC Cancer. 2013 Jan 24;13-31

THANK�YOU