12.5 Cancer Rehabilitation: Physical, Occupational & Pelvic Floor Therapy
Key Takeaways
The prospective surveillance model measures shoulder motion, strength, limb volume, and function before surgery and at intervals afterward so impairments are caught early.
Physical therapy addresses shoulder range of motion, axillary web syndrome, post-mastectomy pain, lymphedema, neuropathy-related balance problems, and exercise prescription.
Occupational therapy helps with daily activities, energy conservation, fine motor deficits from neuropathy, cancer-related cognitive impairment, and return to work.
Pelvic floor physical therapy treats dyspareunia, pelvic floor muscle tension, and urinary incontinence related to estrogen deprivation and is part of sexual health rehabilitation.
Since January 1, 2024, the Lymphedema Treatment Act has required Medicare coverage of medically necessary compression garments and supplies.
Why Rehabilitation Is on the Exam
Many breast cancer survivors live with treatment-related impairments for years: limited shoulder motion, arm and chest wall pain, lymphedema, neuropathy, fatigue, cognitive changes, and sexual dysfunction. These impairments are often under-recognized and under-referred. The CBCN outline lists rehabilitation with physical therapy, occupational therapy, and pelvic floor therapy as examples, and nurses are usually the ones who notice the problem and make the referral.
The Prospective Surveillance Model
The prospective surveillance model for breast cancer rehabilitation recommends:
- A preoperative baseline of shoulder range of motion, strength, arm circumference or volume, and function.
- Scheduled reassessment after surgery and during and after chemotherapy and radiation, often at about 1 month, 3 months, and then every few months in the first year.
- Early intervention at the first sign of impairment, rather than waiting for severe disability.
- Ongoing education on exercise and self-monitoring.
This model finds lymphedema at a subclinical stage and treats shoulder stiffness before adhesive capsulitis develops.
Common Impairments and Who Treats Them
| Impairment | Typical cause | Rehabilitation approach |
|---|---|---|
| Reduced shoulder flexion and abduction | Surgery, drains, radiation fibrosis, pain avoidance | PT: progressive range of motion, stretching, strengthening |
| Axillary web syndrome (cording) | Lymphatic and venous cords after axillary surgery | PT: stretching, soft tissue work; usually resolves in weeks to months |
| Post-mastectomy pain syndrome | Nerve injury (intercostobrachial) | PT desensitization, activity modification, with medication management |
| Lymphedema | Axillary surgery and nodal radiation | Certified lymphedema therapist: decongestive therapy, compression, exercise |
| Radiation fibrosis and chest wall tightness | Radiation | PT: myofascial release, stretching, posture work |
| Neuropathy with balance problems | Taxanes | PT: balance and gait training, fall prevention; OT: fine motor strategies |
| Fatigue and deconditioning | Chemotherapy, radiation, endocrine therapy | Supervised aerobic and resistance exercise |
| Cognitive changes ("chemo brain") | Multifactorial | OT and speech-language cognitive strategies |
| Dyspareunia, pelvic pain, incontinence | Estrogen deprivation, surgery, stress | Pelvic floor PT |
Physical Therapy
Physical therapists restore mobility and strength after surgery and reconstruction. After autologous flaps, protocols protect donor sites (for example, limiting abdominal strain after a DIEP flap or shoulder strain after a latissimus dorsi flap). Exercise with bone metastases requires fracture-risk assessment and weight-bearing precautions.
Evidence-based exercise guidance from the 2019 ACSM roundtable: moderate-intensity aerobic exercise at least 3 times a week for about 30 minutes plus resistance training twice a week improves fatigue, anxiety, depression, physical function, and quality of life, and slowly progressive resistance training is safe for women with or at risk of lymphedema.
Occupational Therapy
Occupational therapists focus on performing daily roles:
- Energy conservation for fatigue: planning, pacing, prioritizing, and positioning.
- Fine motor and sensory strategies for neuropathy: adaptive utensils, button hooks, safe temperature checks.
- Cognitive rehabilitation: memory aids, routines, single-tasking, and environmental adjustments for cancer-related cognitive impairment.
- Return to work: job analysis and accommodation requests.
- Compression garment donning aids and upper-extremity task adaptation.
Pelvic Floor Physical Therapy
Estrogen deprivation from aromatase inhibitors, ovarian suppression, chemotherapy-induced menopause, or risk-reducing oophorectomy causes vaginal atrophy, pain, and protective pelvic floor muscle tightening. Pelvic floor therapists use education, relaxation and down-training, manual therapy, graduated vaginal dilators, and biofeedback to reduce dyspareunia and treat urinary urgency or incontinence. Combining pelvic floor therapy with moisturizers, lubricants, and sexual counseling works better than any single measure.
Referral Triggers for Nurses
- Shoulder motion still limited 4 to 6 weeks after surgery, or a painful cord in the axilla or arm.
- Any sign of lymphedema: heaviness, tightness, visible swelling, or a rising bioimpedance or tape measurement.
- Falls, unsteady gait, or trouble with buttons and writing.
- Fatigue that limits daily activities after other causes are addressed.
- Pain with intercourse, pelvic pain, or leakage.
- Trouble returning to work or managing home roles.
Access and Coverage
Barriers include cost, visit limits, travel, and lack of specialized therapists. The Lymphedema Treatment Act, effective January 1, 2024, requires Medicare Part B to cover medically necessary compression garments and related supplies for lymphedema, a benefit many private insurers also follow. Nurses help with prescriptions, documentation, and finding certified therapists.
Recovery Expectations After Surgery
Most patients regain near-full shoulder motion within weeks to a few months after sentinel node biopsy or lumpectomy; recovery after axillary dissection, mastectomy with reconstruction, and radiation is slower. Warning signs that need referral include shoulder flexion or abduction that plateaus or worsens, night pain, or a feeling of a "frozen" shoulder, which can progress to adhesive capsulitis if ignored.
Exercise Precautions During and After Treatment
| Situation | Precaution |
|---|---|
| Severe neutropenia | Avoid crowded gyms and public pools; prefer home or outdoor activity |
| Low platelets | Avoid contact sports and heavy resistance or high-impact activity at very low counts |
| Anemia with dyspnea or dizziness | Lower intensity until evaluated |
| Bone metastases | Fracture-risk assessment; avoid heavy loading or twisting of affected bones |
| Peripheral neuropathy | Choose stable options such as a stationary bike; check feet daily |
| Lymphedema | Slowly progressive resistance training is safe; wear compression if prescribed |
| Recent surgery or reconstruction | Follow surgeon-specific lifting and motion restrictions |
Most survivors can exercise safely with these adjustments, and inactivity carries its own risks, including worse fatigue and deconditioning.
Which practice best reflects the prospective surveillance model for breast cancer rehabilitation?
Waiting to refer to physical therapy until the patient reports she cannot lift her arm to shoulder height
Measuring shoulder motion, strength, and arm volume before surgery and reassessing at scheduled intervals afterward
Referring only patients who had axillary dissection, never those with sentinel node biopsy
Performing a single functional assessment 5 years after treatment ends
A 49-year-old on anastrozole reports pain with intercourse despite using a lubricant, and she describes tightening and burning at the vaginal opening. Which referral would most directly address the muscular component of her symptoms?
Pelvic floor physical therapy
Cardiac rehabilitation
Speech-language pathology
Occupational therapy for fine motor skills
A survivor with persistent taxane-induced neuropathy drops objects, struggles with buttons, and feels exhausted by midday. Which referral best matches these needs?
Pelvic floor therapy
Radiation oncology for a boost dose
Occupational therapy for fine motor strategies, adaptive equipment, and energy conservation
Genetic counseling
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