INTRODUCTION:

A survivor is a person who remains alive and carries on to function during and after enduring a life-threatening disease, its diagnosis and treatment. In cancer, a person is considered to be a survivor from the time he is diagnosed, to the treatment, and until he remains alive¹. The number of survivors of cancer in India, already 2.25 million, is growing with improved cancer treatment and ageing of the population, and every year, over 11,57,294 new cancer patients are registered^2.Cancer survivors encounter innumerable adverse consequences of cancer diagnosis and treatment that add to or worsen the effects of existing comorbidities and diminishes the functional capacity^3.

The outcomes of cancer are minimal for some survivors; these patients can return to a normal life once the treatment is complete^4,5. However, many survivors do experience physical or psychosocial effects of cancer and its treatment⁶. The most common problems in cancer

survivors are depression, pain, and fatigue⁷. In general, the prevalence of late effects in cancer survivors is believed to have increased over time, likely because anticancer interventions have become more complex and intense with combinations of surgery, radiation, chemotherapy, hormone therapy, and targeted biologics⁸

Cancer rehabilitation is a program that helps people with cancer in maintaining and refurbishing the physical, emotional and social well-being⁹. Despite the growing burden of cancer, rehabilitation in India had been amongst the least priority areas. However, efforts by the Indian Cancer Society have been able to provide specific and comprehensive rehabilitation services to many cancer patients and their families every year. Several studies from India have highlighted the need and prospect of rehabilitative procedures, such as use of a prosthesis, screening procedure etc.¹⁰

Several studies have drawn attention to the benefit of rehabilitative measures in improving quality of life and symptoms of cancer survivors. Dolan LB et al (2018)¹¹ assessed the effectiveness of cardiac rehabilitation model in improving fitness, quality of life, and depression in 25 breast cancer survivors. The program consisted of 1 weekly supervised session for 22 group sessions. Results showed that cardiorespiratory fitness improved by 14% (21±6 to 24±7mL/kg/min, p < .001), with significant improvements in quality of life (p< .001) and depression scores (p = .019). Cherrier MM et al (2013)¹² conducted a randomized trial of 7-week cognitive rehabilitation in cancer survivors. Twenty-eight participants (mean age 58 years) with a median of 3 years (±6 years) adjuvant treatment and various cancer sites (breast, bladder, prostate, colon, uterine) completed the study. Compared to baseline, the treatment group demonstrated improvements in symptoms of perceived cognitive impairments (p < .01), cognitive abilities (p < .01) and overall quality of life with regard to cognitive symptoms (p < .01) as measured by the FACT-Cog. The treatment group also improved on objective measures of attention (p < .05) and a trend toward improvement on verbal memory. Results suggest that group based cognitive rehabilitation may be an effective intervention for treating cognitive dysfunction in cancer patients.

Cancer rehabilitation:

It is a speciality of physical medicine and rehabilitation that directs to meet physical and psychological needs of cancer survivors. It focuses on the assessment, evaluation, treatment and management of structural loss, functional loss, and pain disorders with the goal to rebuild maximal function and improve the quality of life. A multidisciplinary, competent and trained team including a physiatrist (i.e., physical medicine and rehabilitation clinician), physical therapist, occupational therapist, speech and language therapist, lymphedema therapist, cognitive psychologist, dietitian, vocational counsellor, rehabilitation nurse, orthoptist, prosthetist, and recreational therapist takes care of rehabilitation needs of the patient.

Models of rehabilitation:

Cancer rehabilitation is often grouped into four categories as per Dietz Classification¹³

· Preventative rehabilitation:

The emphasis in preventative rehabilitation (sometimes referred to as prehabilitation or prospective surveillance) is on the use of early intervention and exercise to prevent or delay complications related to cancer or its therapies.¹⁴

· Restorative rehabilitation:

For patients in whom a fully functional recovery is expected, restorative rehabilitation envisions full reintegration of the patient back into society, community, school, or work.

· Supportive rehabilitation:

For patients in whom cancer treatment has resulted in permanent deficits, the goal of supportive rehabilitation is to restore functional autonomy as much as possible.

· Palliative rehabilitation:

If intensive rehabilitation is not possible or deemed clinically inappropriate, palliative rehabilitation may play a role in supporting the patient, especially if he or she is facing a terminal diagnosis. The goals are to improve quality of life, maximize comfort, minimise pain and improve caregiver support.

Setting:

Settings for delivery of rehabilitation services vary according to the clinical condition of the patient, overall disease course, goals of care and patient’s preferences. Settings include the acute care hospital, rehabilitation hospitals, skilled nursing facilities, outpatient clinics, hospice settings and in patient’s home.

Specific impairments of cancer survivors and rehabilitation measures:

Patients may face multiple clinical problems during treatment with cancer. Severity depends upon the type of cancer, stage of diagnosis, type of treatment course and existing comorbidities Common impairments are discussed below.

i. Upper extremity pain:

Cancer survivors, in particular those treated for breast cancer, face a myriad of upper extremity impairments. Two common conditions seen include issues related to the shoulder and the axillary web syndrome. Upper extremity surgery and radiation therapy may induce painful scar tissue formation and nerve damage. Axillary web syndrome or "cording" is a clinical entity characterized by formation of palpable cord-like subcutaneous tissue that extends from the axilla to the medial arm and sometimes may extend up to the palm. The cords can limit the range of motion of the shoulder.

Rehabilitative measures:

These include exercise interventions i.e. active ROM (AROM), active-assisted ROM (AAROM), passive range of motion (PROM)/manual stretching, stretching exercises, and strengthening or resistance exercises. Therapy is usually directed at maintaining shoulder range of motion and reducing edema through manual lymphatic drainage. Therapy can begin with gentle, gravity-assisted pendulum exercises and can gradually progress to wall walking and active assisted range of motion.

ii. Post-mastectomy pain syndrome:

Post-mastectomy pain syndrome (PMPS) is characterized as any pain persisting beyond the period of healing post-mastectomy, although it is also seen post-lumpectomy. The pain may be characterized as burning, stabbing, paraesthesia, numbness or as an "electric shock" at the operative site.

Rehabilitative measures:

This includes modalities such as desensitization techniques, transcutaneous electrical nerve stimulation (TENS), and the application of cold packs topically. The approach also includes pain management, including neural stabilizers (pregabalin or gabapentin), serotonin-norepinephrine reuptake inhibitors ([SNRIs]; e.g., duloxetine), or topical agents (e.g., lidocaine or non-steroidal anti-inflammatory drugs). Interventional techniques such as intercostal or paravertebral nerve blocks or ablation can be used in the usual manner to treat regional pain syndromes. Botulinum neurotoxin type A (BoNTA) injections are administered into hyperirritable muscles such as the pectoralis major and serratus to treat refractory PMPS.

iii. Lymphedema:

Lymphedema is the collection of protein-rich fluid into the interstitial spaces due to disruption of lymphatic flow.

Rehabilitative measures:

It includes decongestive therapy. In early stages of lymphedema, external compression is used to diminish ultrafiltration and is achieved with repetitively applied, multilayered padding materials and short-stretch bandages. For more severe disease, compression bandaging is applied to the affected limb after manual lymphatic drainage is performed and is worn around the clock during the treatment phase of complete decongestive therapy. In addition, for patients referred to rehabilitation, the application of Kinesio tape may be an additional modality for treatment¹⁵. Kinesio taping is a specific type of modality that involves the use of an elastic adhesive tape applied to a patient’s skin to facilitate proper fascial plane alignment. It is theorized that re-aligning such fascial planes will enhance tissue healing and serve to alleviate pain. Once the lymphedema reaches its nadir, compression garments (lymphedema compression sleeve or hosiery) are used to provide maintenance therapy to prevent fluid reaccumulation.

iv. Neuropathy:

Chemotherapy-induced neuropathy (CINP) may result from direct toxic effects on the nervous system or indirectly from drug-induced metabolic derangements or cerebrovascular disorders.

Rehabilitative measures:

Physical therapy and/or occupational therapy, may be useful to work on deficits such as decreased balance, gait abnormalities, muscle weakness, and difficulties with performing activities of daily living. Nerve conduction studies (NCS) and needle electromyography (EMG) studies are often used to characterize the location and severity of nerve damage. They may strengthen the working diagnosis based on the history and physical exam

v. Spinal accessory nerve palsy:

For patients with head, neck or spine tumours, the spinal accessory nerve can be damaged directly or indirectly from surgery, radiation. Rehabilitative measures: These include preserving range of motion of the shoulder, strengthening of alternate scapular elevators and retractors, neuromuscular retraining of shoulder girdle muscles, postural modification, and using electrical stimulation. Patients with complete spinal accessory nerve palsy can be fitted with an orthosis to reduce pain¹⁶. For patients experiencing spasm or tightness of a specific muscle group, a combination of PT as well as botulinum toxin injections into the sternocleidomastoid muscle to decrease painful spasms¹⁷. Integrative techniques, such as acupuncture, may also be helpful^18.

vi. Dropped head syndrome:

Patients with history of radiation to head and neck can develop neck extensor weakness secondary to myopathy and atrophy leading to dropped head syndrome, or inability to keep the head up for a prolonged period of time.

Rehabilitative measures:

Physiotherapy can improve patients' quality of life by improving core muscles as well as neck strength, posture, body mechanics, proprioception, and endurance with emphasis on a lifelong home exercise program. A cervical collar or a similar device can be used for functional assistance in elevating the neck, energy conservation, and improving quality of life.

vii. Trismus:

Trismus (locked jaw) is a common complication of head and neck cancer and is usually due to a combination of factors, including direct tumour invasion, surgery, and radiation.

Rehabilitative measures:

Includes assessment by a speech and swallow specialist, dentist to evaluate issues in speech and dysphagia. Physiotherapy should be initiated for oromotor tongue and jaw exercises such as jaw stretching to conserve range of motion¹⁹. Botulinum toxin injections to the masseter or pterygoid by themselves can help with muscle pain and decrease dynamic muscle spasm. Pain medications, including muscle relaxants, analgesics, can be used to make jaw opening devices and therapy beneficial by decreasing the pain and spasm.

viii. Speech and swallowing dysfunction:

This should be evaluated in every head and neck cancer patient and should be treated appropriately.

Rehabilitative measures:

Electrolarynges and esophageal speech are commonly used modalities. Electrolarynges are battery operated devices that are placed in the mouth or against cheek or neck. This external source vibrates to produce sound. A person can move his tongue and mouth in particular way to make words. Video fluoroscopy is used to evaluate swallowing and helps to decide interventions such as botulinum toxin and dilatation for treatment of dysphagia. Exercises to strengthen specific muscles such as tongue base are used. Education regarding use of stoma, manual suctioning, stoma covers, pulmonary rehabilitation should be provided to the patients. Correct use of ryles tube for feeding should also be demonstrated.

ix. Cognitive dysfunction:

Cognitive dysfunction is associated not only with intracerebral malignancies, but is also secondary to cancer treatments. Although "chemo brain" is commonly used, cognitive dysfunction is usually multifactorial in nature, and the treating clinician should rule out other concomitant factors such as anxiety, depression, fatigue, and sleep disturbances. Cognitive dysfunction can include memory impairment, auditory and visual processing, mental cloudiness, difficulty concentrating, slower processing speed, difficulty with executive functioning and problem with non-verbal learning.

Rehabilitative measures:

Cognitive rehabilitation for cancer patients is not yet based on solid evidence-based research and oftentimes uses the guidelines approached for traumatic brain injury and stroke patients²⁰. Goals usually involve maximizing functioning, coping, and quality of life through the use of compensatory strategies and reliance on residual abilities²¹. Compensatory strategies include making changes in the patient’s home or hospital environment to increase structure, decrease demands for planning and decision making, and enhance orientation. External memory aids such as checklists, planners or memory books, wall calendars, and alarms can be used. Pharmacological interventions (eg, cytokine antagonists, anti-inflammatory agents, stimulants, and anticholinergics) have also been used in conjunction with formal rehabilitation. Exercise has not yet been studied for cognitive dysfunction in cancer patients, but it has shown improvement in cognitive recovery among patients with acquired brain injury²²

x. Cardiotoxicity:

Cancer survivors are at increased risk for cardiovascular disease-related to direct effects from cancer treatment, development of cardiovascular risk factors, and lack of cardiorespiratory fitness during or after treatment.

Rehabilitative measures:

A multimodality approach based on principles of cardiovascular rehabilitation, including exercise, nutritional counselling with dieticians who specialize in cancer, and modification of cardiovascular risk factors. In addition, PT and/or occupational therapy may be appropriate in cancer patients with musculoskeletal impairments, neurologic or cognitive issues, bone loss, lymphedema, ostomy, or risk factors for infection, and in those currently receiving cancer therapy.

Rehabilitation of cancer survivors with psycho-social issues:

· Psychoeducation:

Psychoeducation refers to providing education and information to the patients and their family members who are receiving mental health services those seeking or receiving mental health services. Interventions include adaptive coping strategies, relieving worry, encouraging patient for emotional expression etc. Sexual side effects of cancer have been assessed using this method.

· Cognitive behavioral treatment:

Cognitive behavioral treatment (CBT) trains survivors to reframe experience to more positive interpretations, reduce maladaptive thoughts, and provides training in active coping strategies and setting goals for oneself.

· Multidimensional rehabilitation and return to work programs:

Rehabilitation programs with physical and psychosocial components seem particularly well suited to the multidimensional needs of survivors.

· Physical activity:

Physical activity is safe and improves distress and depression in cancer survivors along with enhancing numerous aspects of physical health, emotional well-being, body image, and overall quality of life.

· Mind-body interactions:

Activities such as yoga have been the subject of evaluation and consistently show that they can improve quality of life. Relaxation and other mindfulness training is an emerging area of interest. Mindfulness-based relaxation techniques teach individuals to focus their attention and awareness in their everyday life as a way to manage their emotions and aspects of cognition.

· Intimacy-enhancing treatment:

IET consists of communication training and encourages couples to share their thoughts and feelings about cancer to promote emotional intimacy. Patients with lower marital satisfaction and higher distress levels reported improved functioning after treatment. These interventions can be as short as one-half of a day and still result in improvements in sexual health²³

· Novel methods for outreach:

Phone, videoconference, and internet methods are particularly suitable to provide support for cancer survivors because they can provide access to those with distance barriers to care. Phone methods have been most conveniently and widely used amongst all and are found to be helpful in delivering services²⁴

· Brain-training programs:

Brain-training computer-based programs (sometimes referred to as neurobics) aim to use repetitive mental exercises to increase the brain’s performance. These are commercially available and may be quite expensive.

· Occupational therapy:

This is usually referred to as cognitive rehabilitation, which is typically done by some speech therapists, occupational therapists, and neuropsychologists.

· Electroencephalography (EEG) biofeedback:

This technique, also termed neurofeedback results in improvement in cognitive measures, fatigue, psychological scales, and sleep. These improvements are maintained at atleast four weeks posttreatment.

CONCLUSION:

Cancer rehabilitation is a speciality of physical medicine and rehabilitation that aims to make cancer survivors physically, psychologically and socially independent. Cancer rehabilitation plays a role from diagnosis to the time a patient is alive. With growing burden of cancer in India, there is a need to train professionals in the field of cancer rehabilitation in order to enhance the quality of life and personal independence of cancer survivors.

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Received on 25.02.2020 Modified on 21.03.2020

Asian J. Nursing Education and Research. 2020; 10(3): 365-369.

DOI: 10.5958/2349-2996.2020.00077.4