11.5 Cancer Rehabilitation & Oncologic Rehabilitation
Key Takeaways
- Cancer rehabilitation improves function, fatigue, pain, and quality of life across the cancer continuum (prehabilitation before treatment, during treatment, post-treatment survivorship, and end-of-life); early physiatric involvement is now a quality standard.
- Cancer-related fatigue is the most prevalent symptom and responds to moderate aerobic and resistance exercise—exercise is one of the few evidence-based interventions for it.
- Common rehab-relevant impairments include post-surgical deficits (mastectomy, neck dissection, thoracotomy), chemotherapy peripheral neuropathy (oxaliplatin, vincristine, taxanes), radiation plexopathy/fibrosis, lymphedema, bone metastases/pathologic fracture risk, and steroid myopathy.
- Exercise is safe in patients with bone metastases when modified to avoid high-load on affected sites; caution with thrombocytopenia, neutropenic precautions, and central lines guides activity prescription.
Cancer Rehabilitation & Oncologic Rehabilitation
Cancer rehabilitation is a Domain E topic (cancer, transplant, postinfectious). Physiatric involvement across the cancer continuum is an evolving quality standard: prehabilitation before treatment, rehab during treatment, survivorship, and palliative/end-of-life care.
The Cancer Rehabilitation Continuum
| Phase | Goals | Common Issues |
|---|---|---|
| Prehabilitation (pre-treatment) | Optimize baseline fitness, nutrition, psychological readiness | Deconditioning, anxiety, baseline deficits |
| During treatment | Maintain function, mitigate treatment toxicity | Fatigue, cytopenias, neuropathy, deconditioning |
| Post-treatment survivorship | Restore function, late-effect management | Lymphedema, radiation fibrosis, neuropathy, osteoporosis |
| Palliative / end-of-life | Maximize comfort and independence, caregiver training | Pain, weakness, transfers, dyspnea |
Treatment-Related Impairments
- Surgery: mastectomy/axillary dissection → shoulder ROM restriction, lymphedema risk; neck dissection → accessory nerve palsy, shoulder dysfunction; thoracotomy/laparotomy → respiratory and core impairments; limb-sparing resection or amputation → prosthetic/orthotic needs.
- Chemotherapy-induced peripheral neuropathy (CIPN): oxaliplatin (acute cold-triggered and chronic), vincristine, taxanes (paclitaxel, docetaxel), bortezomib, platinum agents; presents with sensory loss, paresthesias, proprioceptive deficits, and falls; managed with desensitization, balance training, AFOs for foot drop, and activity adaptation.
- Radiation: radiation fibrosis syndrome (contracture, lymphedema, weakness), brachial/lumbosacral plexopathy (often delayed, painless weakness distinguishing from tumor recurrence), osteoradionecrosis, radiation myelopathy.
- Steroid myopathy: proximal weakness from prolonged corticosteroids; improve with taper and progressive resistance.
- Hormonal therapy: aromatase inhibitors cause arthralgias; androgen deprivation causes osteoporosis and metabolic syndrome.
Cancer-Related Fatigue & Exercise
Cancer-related fatigue is the most prevalent cancer symptom and is one of the few conditions for which exercise has strong evidence. Moderate aerobic and resistance exercise improves fatigue, physical function, depression, and quality of life across many cancer types and stages.
Cancer + Treatment ──► Fatigue + Deconditioning ──► ↓Activity (Vicious Cycle)
│
└── Moderate Aerobic + Resistance Exercise ──► ↑Function, ↓Fatigue, ↑QoL
Bone Metastases & Safety Modifications
Patients with bone metastases can and should exercise, with modifications:
| Risk Consideration | Modification |
|---|---|
| Spinal/lower-limb lytic metastases | Avoid high-impact loading, heavy resistance on affected sites; substitute non-impact aerobics (cycle, aquatic), seated exercise |
| Pathologic fracture risk | Screen for pain on loading; avoid end-range rotation under load |
| Thrombocytopenia | Hold contact/impact exercise when platelets very low (< 20-50k depending on activity) |
| Neutropenia | Avoid group/public exercise during severe neutropenia; consider home program |
| Central venous catheters | Avoid upper-extremity heavy load; protect port site |
Lymphedema
Lymphedema—common after axillary/groin dissection and radiation—presents with unilateral swelling, pitting then non-pitting, stemmer sign. Management: complete decongestive therapy (manual lymphatic drainage, multilayer bandaging, compression garments, exercise, skin care). Modern evidence supports progressive resistance exercise (even after breast cancer axillary surgery) and does not show exercise worsens lymphedema when properly progressed.
Transplant & Postinfectious Rehab Adjuncts
Hematopoietic stem cell transplant recipients face profound deconditioning, graft-vs-host disease, cytopenias, and steroid myopathy; rehab is staged by engraftment status and immune reconstitution. Postinfectious rehab (post-COVID, encephalitis, polio/post-polio, Guillain-Barre sequelae) addresses residual weakness, dysautonomia, and cognitive impairment.
Cancer Prehabilitation & Survivorship Models
Prehabilitation—intervening between diagnosis and cancer treatment—optimizes cardiopulmonary fitness, nutritional status, psychological readiness, and baseline function to reduce post-treatment complications and length of stay. Survivorship rehabilitation addresses late and long-term effects: radiation fibrosis (often years later), chemotherapy-induced peripheral neuropathy, cardiotoxicity (anthracyclines, trastuzumab), endocrine effects (aromatase inhibitor arthralgia, androgen deprivation osteoporosis), and secondary cancers. The rehab plan adapts across the continuum and anticipates late effects rather than reacting to them.
Pain in Cancer Rehabilitation
Cancer pain is multifactorial: nociceptive (tumor invasion, bone metastases, surgical), neuropathic (plexopathy, CIPN, postsurgical nerve injury), and mixed. Management follows the WHO analgesic ladder (non-opioids → weak opioids → strong opioids; adjuvants for neuropathic/bone pain), with disease-directed therapy (radiation for bone metastases, systemic therapy), interventional options (nerve blocks, neuraxial, intrathecal pumps), and rehabilitation (positioning, modalities, desensitization, assistive devices). Bone metastases pain often responds to palliative radiation; pathologic fracture risk is managed with orthopedic stabilization (prophylactic fixation) and modified activity.
Palliative Rehabilitation
Palliative rehab maximizes comfort, dignity, and independence in advanced disease: positioning to prevent contractures and pressure injuries, breathing techniques and energy conservation for dyspnea, transfer and mobility training for safe caregiver-assisted care, splinting for edema and comfort, and management of lymphedema, secretions, and pain. The goals shift from restoration to symptom control and quality of life, but rehabilitation remains active—not abandoned—through end of life.
Exercise Prescription & Surveillance
Pre-treatment ──► During treatment ──► Survivorship ──► Palliative
Prehab Maintain function Late effects Comfort/positioning
Fitness ↑ Fatigue ↓ Neuropathy Transfers
Surveillance includes monitoring for recurrence, late treatment effects (cardiotoxicity, neuropathy, osteoporosis, second cancers), psychosocial health, and return to work. Exercise is prescribed across this continuum with stage-specific modifications (cytopenia precautions, central lines, bone metastasis loading limits), and is now recognized as standard supportive cancer care.
Which intervention has the strongest evidence for cancer-related fatigue?
A patient with breast cancer received axillary dissection and radiation and now has unilateral arm swelling with a positive Stemmer sign. Which management is most appropriate?
A survivor has oxaliplatin chemotherapy-induced peripheral neuropathy with foot drop and falls. Which rehabilitation approach is most appropriate?