The BIG C and Physical Therapy
Not a week goes by without a patient asking me why an oncology physical therapist isn’t an automatic part of their cancer team from the beginning. They relay frustration about why it “took so long” for them to be referred to a specialist. Severe muscle loss seems to be a given. Cancer patients who work with a specialized physical therapist from the start of treatments fare better than those who try to regain strength after treatments leave them exhausted and unmotivated.
Appropriate, early intervention can help prevent physical decline, reduce inflammation and improve patient outcomes. What’s more, exercise during and after cancer treatments reduces and manages side effects, such as chronic pain, lymphedema severity, fracture risk and decreased balance from neuropathy. Early treatment of these issues can also reduce the financial burden of patients, insurance payers and hospital systems. Cancer patients should request physical therapy before, during and after treatments.
Research shows that tailored exercise and physical fitness also can improve the length and quality of life for people diagnosed with cancer. The American Cancer Society recommends physical therapy to improve function, reduce risk of recurrence and improve cancer survival. Ginsburg was diagnosed with pancreatic cancer in 2009; the vast majority of patients do not survive five years. She lived for another 11. While no one can say for certain how she beat the odds, it is my opinion that exercise played a role.
Richard Briggs, physical therapist, coined end-of-life exercise as, “rehab in reverse.” The more usual pattern in hospice and an unfamiliar concept for the therapist to apply is that of “rehabilitation in reverse” as identified by Briggs,[29] which includes exploring the process of functional adaptation and occupational engagement on a daily basis. Throughout each phase of decline during the dying process, new or adapted skills and abilities must be learned by the patient, as well as the care givers, to maximize functional independence and safety. The therapist has the knowledge and skill to assess current status; teach appropriate techniques such as transfers, bed mobility and positioning to decrease pain; collaborate with patients on relaxation techniques; adapt activities of daily living and mobility; and instruct in the use of needed equipment. Other team members may provide some basic instruction but the therapist should be consulted for further care. Therapists provide skilled therapy service that achieves the hospice goal of promoting safety, independence, meaning and quality of life, despite the physical and mental decline which is expected.
For example, the physical therapist might have a patient who has a brain tumor and is unsteady. The patient has been walking without a cane, and now the therapist has to teach him how to use a cane and teach family members to assist with balance. Then, a week or two later, the therapist need to fit him with a walker and teach him to use it. A month later, therapist needs to teach transfers from bed to a wheelchair. And one week later, the therapist might be positioning for pressure relief. As the patient’s health is declining, there is always some level of skilled care that the therapists can provide.[3]
What he meant was that appropriate physical therapy helps reduce the risk of falls, fractures and hospitalizations, all too common with frail patients. Physical therapists teach patients about safety, equipment and swelling management when patients are still walking, different guidance when patients become more sedentary and updated recommendations when patients are bed-bound. Studies show that when pain and other symptoms of a terminal illness are managed, people can work and live longer, just like Ginsburg.
REWARDS
While there is great opportunity for more physical therapists to make a difference in the hospice setting, this is clearly an area of practice that is not for everybody. Becoming involved in a family’s grief process can certainly be emotionally draining. But physical therapists with experience in this area of practice overwhelmingly report that the rewards of hospice care are indeed rich.[3]
Says Steve Gudas, “The spirit, the strength, the courage, the resiliency, and the determination that people have toward the end is amazing to witness. And it is a privilege to play a role in the process. It is actually life affirming.”[3]
Adds Nicole Gergich, “It is gratifying to connect with a person at this time in his or her life. We can offer the patient control, independence, and dignity. Yes, it is sad that the person is dying. But if I am the one who can help, Iam glad to have been part of it. It is rewarding and reinforces to me how very important my job is.”[3]
The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue.
Overall findings retained the conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should "avoid inactivity." Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life. Implications for other outcomes, such as peripheral neuropathy and cognitive functioning, remain uncertain.
