01 Mar Physical Therapy From Diagnosis and Beyond
Written by Lisa M. Miller, DPT
From the time of initial cancer diagnosis, there are things you can do to help your quality of life and outlook for each day throughout your cancer treatment plan. Many people have either heard of or experienced physical therapy and rehabilitation. Whether it be after surgery for a knee replacement, after a stroke, or even for common back pain or shoulder pain, physical therapy is frequently prescribed. There are multiple ways that therapy or exercise has the ability to help with a diagnosis of head, neck, or oral cancer. Physical therapy was significantly underutilized in the fight against cancer until now. It is now not only recommended but considered best practice to have regular exercise embedded into the treatment plan for every patient no matter what type of cancer. All members of the multi-disciplinary cancer team should promote physical activity and help their patients adhere to exercise and mobility guidelines. The most expected treatments after a cancer diagnosis include chemotherapy, radiation, immunotherapy, or surgery. Both the cancer itself and any combination of the curative treatments for cancer can take a toll on your body with multiple side effects. The side effects, referred to as toxicities, can include but are not limited to pain, fatigue, balance deficits, difficulty swallowing, peripheral neuropathy, and orthopedic injuries. Changes in posture can greatly affect how the body functions during movement, and these changes can decrease independence in your day to day activities including dressing, bathing, getting in and out of bed, driving, walking, climbing up and down stairs, cleaning, and working. It is important to be aware of what mobility options are available to help fix or manage unavoidable after effects of cancer treatment. Awareness is the most important element when being your own advocate. It is helpful to know there are providers like myself who specialize in helping to regain and maintain your functional independence, movement, and quality of life no matter what stage of your treatment plan you are in. In my current practice, I work with a multidisciplinary rehab group which includes physical therapy, speech pathology, and lymphedema specialists. Our rehabilitation group provides a well-rounded approach and unique treatment plan for each individual patient who is undergoing treatment for head, neck, or oral cancer and the patients who have previously undergone treatment needing further rehabilitation. Whether the individual is newly diagnosed or has been out of treatment for several years, there are many areas I focus on from a physical therapist perspective.
Exercise is defined as any physical activity of the body that improves or maintains health and wellness. These activities can include aerobic, strength, flexibility, and balance exercises. Physical activity has been shown to reduce side effects both physically and psychologically, to improve cardiovascular endurance, increase metabolic and immune system efficiency, help reduce inflammation, lower health-care costs, and improve quality of life. Typically, I encourage my patients to start small and build up exercises slowly as their endurance builds. It is recommended to build up to 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week. This can easily be broken down to just 30 minutes a day for 5 days of the week.
Have you noticed difficulty with just getting through the day? Does getting dressed or preparing a simple meal feel like running a marathon? This could be due to low endurance and weakness causing fatigue. Fatigue is experienced by up to 90% of patients treated with radiation therapy and up to 80% of those treated with chemotherapy; it may already be present in 40% of patients at time of diagnosis. One of the simplest ways to combat fatigue is by working on your endurance with incorporating a walking program into your daily routine. A walking program doesn’t require you to be an athlete, but rather helps slowly increase your endurance and as a result decrease daily fatigue throughout your normal routine. Walking is a safe low impact way to keep up strength both in your muscles as well as your cardiovascular system. In my practice, we strive to discuss a walking program with every patient as close to diagnosis as possible. Having these discussions at the beginning of the treatment plan, we can empower patients to build up endurance and tolerance prior to the start of any cancer treatments. Of course, walking is just one of the many ways to reduce fatigue and improve endurance. A skilled therapist can help you find a safe starting point for reduction of fatigue as well as implement a plan to progress safely without falls or injury.
Balance can be affected many ways throughout treatment as well. Some people have bad balance even prior to cancer treatment due to decreased activity with weakness and fatigue. Our balance system is made up of multiple things including our vision, strength and sensation in our legs as well as our vestibular system. During chemotherapy, both fatigue and chemotherapy induced peripheral neuropathy can affect your stability and balance. Peripheral neuropathy is damage to the nerve endings in your feet and/or hands that decreases the sensation needed for fine motor coordination and balance. Chemotherapy induced peripheral neuropathy affects approximately one third of people. It can take anywhere from 18 months to 5 years to recover from peripheral neuropathy caused by chemotherapy, but sometimes this decreased sensation can be permanent. What can be done to help recover your stability is balance specific physical therapy. Balance therapy acclimates your body to stabilize with increasing strength and creating awareness of how to maintain your balance.
Posture is another key point I focus on with patients from the very beginning of treatment. No matter what treatment is planned or in process to treat your cancer, you want to work on correcting and maintaining posture. Posture is affected by a combination of things throughout treatment for head, neck, or oral cancer. Whether it be from fatigue with decreased mobility or from post-surgery and radiation treatment, posture is often weakened, and the inevitable downward pull of gravity has shortened muscles and skin pulling you out of alignment because of scar tissue and radiation fibrosis. It is important to work on posture from the start to aid in swallowing, improve breathing, decrease pain, increase range of motion, and aid in good functional mobility. Good or correct posture is positioning the body in alignment where there is no stress on the spine. This position where the spine has no stress is called spine neutral. Spine neutral not only helps to decrease muscle tension that can lead to pain and headaches, but it also can help other structures such as the windpipe and throat to work properly for swallowing and opening the airway to improve oxygenation. Postural alignment is also beneficial for improving range of motion for both the neck and shoulders. This can help with function, checking your blind spot, scanning the room, as well as reaching things over head, behind your back, and out to the side with efficiency. Making these movements more efficient and normal will greatly help with decreasing pain. There are specific muscles that work to help maintain your posture. These muscles can be evaluated and pinpointed with exercises to help you obtain and maintain good posture throughout the day.
Stretching and manual therapy is another method used with exercise during rehab to help correct posture, increase range of motion, return functional movement, decrease pain, and decrease tissue restriction from radiation fibrosis. Radiation fibrosis is residual damage caused by radiation. Radiation therapy side effects are varied based on the strength and the number of treatments received. However, 10% of patients who receive radiation to soft tissue of the neck end up with radiation fibrosis leading to pain or discomfort with restrictions of motion. This radiation fibrosis coupled with scar tissue from surgery can cause significant tightness and discomfort. Tightness, pain and neck spasms are patient-reported experiences that can be evaluated by a cancer rehab specialist using established quality of life assessment tools. The good news is there are stretching and skilled massage techniques that can reduce the pain or discomfort. One of the first things I work on with my patients is the ability to lay flat with knees slightly bent to protect the lower back. This is sometimes more difficult than it sounds after significant surgery and radiation. Muscles in the front and sides of the neck can get very tight all the way into the chest area causing it to be uncomfortable to lay flat. Sometimes a wedge is needed to accomplish this based on other needs for breathing positionally. The wedge assists with “neutral” spine as we have already discussed its importance. With a vigorous stretching routine, a combination of soft tissue, deep tissue and myofascial release, we can soften the radiation fibrosis, provide decrease in pain or discomfort and improve movement of the neck and shoulders. A skilled therapist can also provide mobilizations of the neck, shoulder, and jaw to assist with pain reduction as well as increasing movement. Often, I teach my patients some of the massage techniques in addition to scar mobilization after surgery to provide self-management for pain reduction and improving movement.
Lymphedema is something that I monitor with my patients, but I am not a lymphedema specialist, so I typically refer to my colleagues in our multidisciplinary team who specialize in lymphedema care. Sheri Puglielli,OT, CLT, who is a lymphedema specialist with Advocate Aurora Healthcare, has provided the following information in regard to lymphedema because it is a common occurrence from a tumor after surgery, chemotherapy, or radiation for head, neck, or oral cancer:
Have you noticed firmness, fullness or tightness under your chin, along your jaw or neck? Do your cheeks or eyelids feel puffy making it difficult to see? Do you have that stuck feeling in the back of your throat when you try to swallow? Does your tongue or lips feel swollen making it difficult to speak and eat? Are you are having a more difficult time breathing? You may be experiencing symptoms of lymphedema. Lymphedema is a condition in which excess lymph fluid collects in tissue spaces due to an overload in the lymphatic transport system. The lymphatic system is part of your circulation and immune system. It consists of vessels which collect and take lymphatic fluid from tissues to the lymph nodes that filter our wastes and toxins. When this fluid remains in the tissue (lymphostatic), it leads to inflammation and a decreased localized immune response. This allows for increased risk of infection in the area. In head and neck cancer, the tumor itself, surgery, radiation and chemotherapy can interfere with drainage of the lymphatic system. The overload of fluid can cause internal or external tissue changes. This can cause increased pressure on nerves, blood vessels and structures creating a feeling of heaviness, tightness and pain. The restriction in tissue mobility from the excess fluid, scar tissue and radiation changes can decrease your head, shoulder, and facial motion. This can then limit your activities of daily living, for example, with having difficulty turning your head while driving or lifting your head back to drink from a cup. Fluid buildup in your neck can make it difficult to wear a button up shirt or tolerate wearing a necklace. Internally, the swelling can affect the inner mouth and throat structures that affect speech, breathing, and swallowing. Swelling can change appearance, therefore affecting self-esteem and involvement in social activities. Early intervention is key, but therapy will help in all stages of lymphedema. How does a certified lymphedema therapist help? An extensive evaluation is completed, which includes reviewing past medical history, cancer treatment history, questions about your past and current activities of daily living performance, social/emotional status/appearance and how the swelling has changed this. The therapist will take measurements of the face and neck, assess head and neck tissue for mobility, firmness, color and temperature, assess the range of motion of neck and shoulders, and facial movement. The therapist will look and gently feel inside the mouth to assess the tongue and cheeks for swelling and restrictions in movement. Treatment includes:
- Manual lymphatic drainage (MLD) which is a special manual technique that gently stimulates lymphatic node areas and pathways to redirect the lymph fluid to reduce the swelling
- Instruction on skin care, infection prevention and lymphedema precautions
- Manual techniques to improve scar and radiation tissue mobility for improved lymph drainage and motion
- Compression garment recommendations to decrease the refill of the tissue
- Sleep positioning education to improve lymph drainage
- Instruction on lymphatic drainage exercises to pump the fluid internally and stretches to improve the length and movement of the tissue and muscles
- Home program education to help you successfully move to self-management of your lymphedema
Physical therapy and other rehabilitation services are there for you as a support system to help maintain or recover quality of life. A cancer rehab specialty physical therapist will evaluate and guide you on the path to self-management to give you freedom and independence to move better and decrease pain. I cannot stress enough to you as a patient to advocate for yourself. From the point you are told you have cancer until many years after treatment you can always request therapy and discuss with your doctor if you feel your everyday function is being affected by pain or limited movement. Requesting therapy for guidance throughout your recovery journey is encouraged to ensure safety and a goal driven program to help maximize efficiency for your time spent. Your doctor will let you know if you are cleared to participate with physical therapy or if you have any restrictions for exercise.
Editors Note: Lisa M. Miller, DPT obtained her Doctorate in Physical Therapy from Clarke University located in Dubuque, IA in 2011. Her certifications include LSVT protocol and PWR!! Program for Parkinson’s clients, Cancer Rehabilitation Specialist, and Ekso skeleton for retraining gait. She has been working with Advocate Aurora Healthcare in outpatient physical therapy for 8.5 years.