Physical Therapists Make Life Worth Living: Physiotherapy in Oncology
By: Nataliya Zlotnikov, HBSc, MSc

On February 17, 2021, Embodia was fortunate to host a webinar with Marize Ibrahim, a physical therapist in cancer rehabilitation.

The continuing education physiotherapy webinar was presented as an informal dialogue with oncology expert, Marize, discussing the needs of cancer patients to help apply skilled interventions, which are vital for patients’ independence, functional capacity and quality of life.

The webinar accomplished this by taking us through 3 cancer-related cases from Marize's own clinical practice showcasing the importance of physiotherapists’ involvement in cancer care.

Today's blog is based on this webinar.

This Blog Discusses:

1. Worldwide cancer statistics
2. Canadian cancer statistics
3. The need for rehabilitation in cancer care
4. The 4 pillars of oncological rehabilitation
5. Three case presentations showcasing the importance of physiotherapy in oncology
6. A review of what happens to the body systems with exercise
7. Benefits of exercise for cancer patients 
8. Exercise guidelines for cancer
   
   

1. Let’s Talk Cancer

2. Cancer Canada

In Canada, about 1 in 2 Canadians will develop cancer in their lifetime. Globally, we are ranked 11 with our global cancer cases of 334 cases per 100,000.

The chart below indicates the share of the population with cancer by Country (4.63% in Canada); this value has steadily increased over the past few decades.

Share of World's Population with Cancer (2017)

• About 1 in 4 Canadians will die from the disease
• Lung, breast, colorectal and prostate cancer account for half of all new cancer cases
• 60% of Canadians will be alive 5 years post-diagnosis

Reference: cancer.ca/en/cancer-information/

3. Why Do We Need Rehab?

As we alluded to in the previous section, more and more people are now surviving cancer. Cancer survival rates are now greater than 50%. Simply surviving cancer however does not equate to a good quality of life (QoL) of these survivors. 

Cancer treatment regimens are often found to be more toxic than the disease itself leaving survivors with a multiplicity of problems to deal with following treatments.

The goal(s) of rehabilitation depend on the individual needs of each patient and how the treatment has affected one's ability to carry out daily activities.

4. Pillars of Oncological Rehabilitation 

(Dietz, 1981, Okamura, H., 2011)

• Preventative: Prevention starts soon after cancer diagnosis and is performed before and after surgery, radiotherapy and chemotherapy. The goal of this stage is to prevent impairments before they can occur. 
• Restorative: Attempts to maximize functional recovery in patients who have impairments to their function and decreased abilities.
• Supportive: Increases the patients' self-care ability and mobility using effective methods (e.g., mobility devices). Preventing disuse such as atrophy, decreased function, etc. 
• Palliative: Designed to relieve symptoms. Enables patients in the terminal stages of their lives to have the quality of life physically, psychologically, and socially while respecting their wishes. Preserves one's dignity up to the end of life.
  

5. Case Presentations Showcasing the Importance of Physiotherapy in Oncology

The following three cases are dedicated to therapists who keep believing in rehab, listen to their gut, and are not afraid to challenge others when necessary. These, are for you!

Case 1: Dedicated to all the therapists who believe that nothing is impossible with rehabilitation.

Case 2: Is dedicated to therapists in the private sector who question and go with their gut if something feels a little bit “off."

Case 3: Is dedicated to therapists who are not afraid to challenge other healthcare professionals to help their patient make a much more informed and educated decision.

Case 1: Nothing is Impossible with Rehab

The patient: 

• Male, 70 years old.

Presentations and diagnosis: 

• Diagnosed with left pelvic osteosarcoma.
• Was offered systemic treatment which he refused on multiple occasions.
• At the initial onset of the disease, the patient presented with left leg lymphedema and left hip pain. The lymphedema progressed significantly because of the tumour compression. Only then did he decide to do the treatment as it was now affecting his mobility.

Medical (chemotherapy and surgery) intervention: 

• He completed neoadjuvant chemotherapy but had a very poor response to treatment. 
• He underwent extensive surgery that essentially left him with a floating femur.
• The initial surgery was complicated by wound necrosis, which sent the patient back to the operating room and resulted in the removal of a large portion of the residual ilium and extensive muscle debridement including iliopsoas and gluteus maximus.
• The second surgery was not followed by postoperative chemotherapy because of severe infectious complications that he had.

Introduction of physiotherapy:

• He was hospitalized between May and September of that same year and during that period there were two therapists involved, Marize who was consulted for the lymphedema and her colleague (the in-patient physiotherapist).

Initial physiotherapy evaluation:

• Bed mobility: He needed 1-2 people for rolling in bed.
• Transfers: Supine to sit - needed 2-3 people to help him. Sit to stand - unable. Bed to chair - unable.
• Gait/ambulation/stairs: Completely unable.
• Lymphedema affect on ADLs/IADLs: Prevents. The left leg, thigh and calf were 142%, 126% and 154% percent bigger than the right respectively. 
• Ability to handgrip: Difficult.
• Shoes fitting: Able on right, unable on left.

 

Could this man ever walk again?

Surgeon uncertainty: 

• The surgeon expressed uncertainty regarding this patient's ability to walk again because half of his femoral head was floating around and her inability to attach it to the non-existing acetabulum to form a hip joint at the time of the surgery.

The patient's family: 

• The family was extremely supportive and didn’t leave his bedside. It was just wonderful for the patient to have this support.
• They wanted to be very involved in the patient's care in any capacity.

Unsuccessful candidate: 

• After the patient was sent to the rehab center he was deemed an unsuccessful candidate and discharged home after a short admission.

Stubborn spouse and community for the win: 

• The patient's wife refused to believe that he would never walk again, so she hired a private physiotherapist 2x/day at home for him and as a result of the financial costs and burden the extended family and the community came together to help with the cost of treatment.
• After 4 months of intensive therapy at home, the patient came back for his lymphedema follow-up and walked into the clinic (walked in using a walker and a left leg AFO) and this was unreal – no one expected this! 
• He was so proud of his accomplishments.

Moral of the story: 

Be stubborn like his patient’s wife and never give up on your complicated patients!

Case 2: Always Go With Your Gut

The patient: 

• Male, 55 years old. 

Presentations and diagnosis:

• Frozen shoulder (referred to Marize. She is the third physiotherapist he is seeing). 
• He was already treated for the frozen shoulder for one year prior to this referral. 
• Initial MRI: Radiologist wrote capsulitis in the report.

The physio continues:

• Marize treated him like a typical frozen shoulder patient for one month, but her gut told her something felt off. 
• Capsular pattern was present, but there was a strange blockage of the left shoulder she had never felt before.

First referral:

• Marize referred him to a sports doctor. 
• His response was "Marize, it's just a frozen shoulder, continue physio..."  
• Yet...her gut was still not convinced.

The physio continues some more: 

• Another month of physio, still no change. 
• And the patient's pain is worse, his ROM is also worse despite following protocol for frozen shoulder.

Second referral: 

• Orthopedic surgeon specializing in upper extremity. 
• Orthopedic surgeon also felt that something was off, so he ordered another MRI. 
• The MRI showed that the first radiologist missed a small mass that has now grown to 8.3 x 5.2 x 8.2 cm.

Third referral:

• Orthopedic surgeon specializing in oncology. 
• Biopsy taken revealed: Left shoulder desmoid tumor!

Moral of the story: 

If your gut is telling you "something feels off" investigate further, the probability is that there is something else going on.

 

Case 3: Don't Be Afraid to Challenge

The patient: 

• Female, 57 years old, painter. 

Presentations and diagnosis:

• Right breast cancer diagnosis, triple-negative.

Medical (chemotherapy & surgery) intervention: 

• Neoadjuvant chemotherapy 
• Followed by right  total mastectomy and axillary lymph node dissection 
• Followed by radiation to the chest wall (complicated by a second-degree burn post-radiotherapy). 
• Right arm swelling developed post-operatively and worsened post-radiotherapy.
• Doppler was done: negative for deep vein thrombosis. 

Reconstruction: 

• Underwent deep inferior epigastric perforators (DIEP) breast reconstruction surgery which was complicated by severe necrosis of the reconstruction leaving a large concave chest wall, with increased fibrosis from the failed reconstruction procedure.  
• After the failed DIEP flap, the plastic surgeon suggested a latissimus dorsi flap from the right (affected) side. The patient was not sure if this was the best solution considering her first failed reconstruction procedure.

Physiotherapy consult:

• Marize saw the patient for a lymphedema consult. 
• Severely necrotic right chest wall from failed DIEP flap, adhesive tissue ++, pec contracture and significant ROM limitations of the right shoulder.
• Lymphedema: Right arm is 60% greater than the left (volume difference), UA = 52%; LA = 69%.
• PT’s goal: reduce lymphedema, go back to painting with right arm, advice for reconstruction surgery (surgeon pushing her +++).

Marize asked Herself: 

• Is the patient aware of what a lat dorsi flap looks like and the additional right shoulder implications it can have on her already compromised right arm/shoulder/chest wall?
• Perhaps she would benefit from a second opinion prior to jumping into another surgery with such limitations?
• Education should always guide an informed decision…doesn’t this patient deserve more knowledge before deciding?

Challenge for second opinion: 

• So Marize challenged her surgeon and helped her get a second opinion.
• Following a consultation with the second surgeon, he informed Marize that he agreed with her professional opinion and recommended that the patient should not do the proposed lat dorsi flap as she already has significant impairment due to the ++ fibrotic chest wall, irradiated skin, and right shoulder joint limitations.
• Any additional surgery will likely fail and leave her with further debilitating right arm dysfunction.

Moral of the story:

Don’t be afraid to challenge other healthcare professionals to guide patients into making a more informed decision!

6. What Happens to the Body With Exercise? 

Now, let's switch our gears over to the importance of exercise for the human body. Of course, we have all studied this already, however, Marize organized it in such a concise and enjoyable way that it was hard not to include it! 

And the list of benefits goes on. 

7. Can Cancer Patients Benefit From Exercise Like "Healthy People?"

A definite yes. 

While pharmaceuticals are constantly improving, are you able to name one drug that has all the positive effects that exercise has? 

8. Exercise Guidelines for Cancer

American College of Sports Medicine (ACSM) guidelines for adults with cancer include (Schmitz et al., 2011): 

• 150 minutes of moderate-intensity aerobic exercise
• 2-week sessions of resistance exercise/week

Take Pride in Being a Therapist, for the Pill You Prescribe Surpasses All the Rest  

Cancer treatment is very difficult due to various complications and side effects that develop from the treatment. Rehabilitation is an integral component for recovery and management of treatment-related sequelae.

Successful outcomes depend upon timely recognition of functional problems and prompt referral for rehabilitation.  

We - physical therapists, are essential members of the multidisciplinary team! Our role as experts in function and mobility greatly improves the quality of life of cancer patients.

 

More and more people are now surviving cancer with the help of doctors and modern medicine.

If doctors save lives, then physical therapists make them worth living.

 

Further Reading and Viewing 

We invite you to take a look at another of our case-study-based oncology blogs, Do You Know How to Treat and Assess Complex Cancer Cases?, based on Jodi Steele’s – physiotherapist and founder of Cancer Rehab Inc., Canada’s first not-for-profit cancer rehabilitation centre – online healthcare course on Embodia, Complex Case Studies in Oncology.  

To see additional oncology courses from Embodia, follow the yellow button below:

Click Here for More Oncology Courses