By Christine Rhodes
Interview with Jennifer Baima, MD
Studies show there is no one-size-fits-all approach to rehabilitation from cancer surgery. Each type of cancer requires a different approach to achieve adherence, and lessen pain while working to restore physical function and other post-treatment challenges.
Physical and occupational therapy are important components of recovery for many cancer patients, especially those who have had surgery. Too much rest can lead to loss of body function, muscle atrophy, and reduced range of motion.
“Patients with different types of cancers and comorbidities have different impairments,” Jennifer Baima, MD, told Practical Pain Management, commenting on the unique needs of patients rehabilitating from treatment of breast, brain, prostate, and lung cancers from a presentation at the Association of Academic Physiatry annual meeting in Las Vegas, Nevada.
Exercise Interventions Prevent Shoulder Pain
In women treated for breast cancer, shoulder pain and diminished range of motion are common problems after treatment with surgical resection, even in the absence of prior shoulder disorders. This dysfunction can last from months to years and is particularly common in breast cancer patients who have undergone axillary lymph node dissection or mastectomy with adjuvant radiation.1 The evidence support the efficacy of postoperative exercise in treating upper arm pain and impaired shoulder range of motion following surgery.2
“In breast cancer patients,” said Dr. Baima, an assistant professor at the University of Massachusetts Medical School, “shoulder dysfunction is a common problem that may appear prior to surgery and persist for some time. Exercise interventions can be helpful both before and after treatment to lessen shoulder pain and improve motion.”
Dr. Baima presented results of a pilot study that explored the feasibility of teaching women how to perform shoulder exercises for one month prior to surgery in an effort to prevent postsurgical pain and seroma formation, which can lead to lymphedema.1
In the study, 1 group was given in-person instruction, as well as an information sheet and a link to an instructional video.1 A control group was given only the instruction sheet and the link to the video. The reseachers found that no difference between in-person teaching and video instruction among the patients, and reported no added risk of seroma formation when patients followed prehabilitation exercises.
Walking Program Fosters Strength and Balance
Patients treated for brain tumors typically suffer from weakness and balance impairments due to radiation, chemotherapy, and other therapies that continue beyond the active cancer care period. Resistance and endurance exercises have been shown to reverse muscle atrophy and weakness, and that exercise behavior is a strong predictor of survival.3
“Patients have a preference for exercise information after treatment either in the outpatient setting or at home, as compared to during chemotherapy or radiation,” Dr. Baima told Practical Pain Management.
Dr. Baima presented preliminary research on one option for home-based independent exercise in patients with high-grade brain tumors.4 In this study, patients watched an exercise video and received an in-person demonstration of strength exercises that targeted muscles used in walking, a balance exercise, and recommendations for a walking plan.
Patients were instructed to perform the exercises once daily for 1 month. Among those who started the program, 64% continued to exercise regularly during the 4 weeks. In these patients, a higher frequency of exercising was associated with higher quality of life measures. As such, the authors reported that a novel independent exercise program designed with the particular needs and limitations of the brain tumor population appears feasible and safe to implement at home.
Men Who Play Soccer Regain Control
In men who were treated for prostate cancer, androgen deprivation therapy that depletes male hormones typically reduces muscle strength, too. While exercise-based rehabilitation offers improvement in physical capacity and quality of life, recruitment and persistence among male cancer patients in attending rehabilitation and physical activity appear low.
In patients who have not demonstrated a willingness to change their behavior upon diagnosis as readily as patients with other types of cancer patients, 12 weeks of supervised soccer presented a welcome opportunity to regain control and acquire a sense of responsibility for their own health without assuming the patient role.5 Soccer training legitimized and promoted mutual caring behavior in a male-oriented context.
The authors concluded that soccer, due to its cultural representation of masculine ideals, might offer a potent and unique strategy for increasing recruitment and adherence to physical activity following prostate treatment.5
Presurgery Aerobic Exercise Improves Function
Following treatment for lung cancer, aerobic exercise rather than strength training is the usual focus of rehabilitation to improve lung function. In a review of physiotherapy interventions,6 presurgical exercises based on moderate-intensity aerobic exercise in patients undergoing lung resection offered improved functional capacity and reduced postoperative morbidity. Conversely, interventions performed only during the postoperative period did not seem to reduce pulmonary complications or length of hospital stay following surgery.
Exercise that is tailored to the individual—and can be completed at home— may lessen pain and enhance recovery in patients who have cancer, especially those preparing for surgery and/or following surgery. The type of cancer and individual preferences should be considered in tailoring an exercise program to encourage adherence and achieve optimal recovery. This is particularly true in less well-studied cancers.
For patients who need treatment for pain, weakness, and deconditioning associated with less well-studied cancers, the best course is to consider referral to a physiatrist who can apply general rehabilitation principles and as needed, thinking outside the box, in finding an exercise protocol that will meet individual needs.
- Baima J, Reynolds SG, Edmiston K, Larkin A, Ward BM, O’Connor A. Teaching of independent exercises for prehabilitation in breast cancer.J Cancer Educ. November 6, 2015. [Epub ahead of print]
- De Groef A, Van Kampen M, Dieltjens E, et al. Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review.Arch Phys Med Rehabil. 2015;96(6):1140-1153.
- Ruden E, Reardon DA, Coan AD, Exercise behavior, functional capacity, and survival in adults with malignant recurrent glioma.J Clin Oncol. 2011;29(21):2918-2923.
- Omer ZB, Yunus S, Varlotto J, Moskowitz J, Hildebrand L, Baima J.Feasibility and safety of a home exercise program for patients with high grade brain tumors. Poster presentation at: 2017 Association of Academic Physiatrists Annual Meeting; February 7 – 11, 2017; Las Vegas, Nevada.
- Bruun DM, Krustrup P, Hornstrup T, et al. “All boys and men can play football”: a qualitative investigation of recreational football in prostate cancer patients.Scand J Med Sci Sports. 2014;24(Suppl 1):113-121.
- Rodriguez-Larrad A, Lascurain-Aguirrebena I, Abecia-Inchaurregui LC, Seco J. Perioperative physiotherapy in patients undergoing lung cancer resection.Interact Cardiovasc Thorac Surg. 2014;19(2):269-281.