Section 21
PRINCIPLES OF
REHABILITATION MEDICINE
71 PRINCIPLES OF CANCER
REHABILITATION MEDICINE
KRISTJAN T. RAGNARSSON, MD
DAVID C. THOMAS, MD
Medical advances in the diagnosis and management of cancer have
markedly increased survival rates. While the treatment for some
patients may now result in complete cure and no perceived physical
deficits, for others, an aggressive definitive treatment may result in
significant physical impairment or disability. To ensure quick restora-
tion of optimal function, early and continued aggressive rehabilitation
interventions should be provided, including physical and occupational
therapy, prosthetic and orthotic devices, and assistive equipment.
Application of rehabilitation techniques frequently results in a swift
functional improvement and a reduction of subjective complaints,
even when the prognosis for life is considered poor. It has always been
difficult to predict with a degree of certainty the life expectancy of an
individual with cancer. Modern diagnostic techniques and effective
treatment of malignant neoplastic diseases have invalidated old statis-
tics and dogmas regarding life expectancy and thus made accurate
prognostication even more difficult for the clinician. No cancer
patient, even one with widespread metastases, should be denied the
benefits of aggressive treatment, including appropriate surgical inter-
vention, chemotherapy, radiation, and comprehensive rehabilitation.
These interventions, when offered in an integrated and timely fashion,
prolong life, protect organs and residual healthy tissue, reduce pain,
and maximize self-care and mobility skills, and thereby help to reduce
the stigma of cancer and physical impairment while providing dignity
and a better quality of life for the cancer patient.
Early referral for rehabilitation services and good communication
among the oncologist, the surgeon, the physiatrist, and the other mem-
bers of the cancer rehabilitation team are essential to the patient’s suc-
cessful return to optimal function. Every effort should be made to
coordinate the rehabilitation treatment with other types of interven-
tion. A comprehensive and well-coordinated rehabilitation approach
that concurrently deals with the physical, psychologic, and social
problems caused by the malignancy and the consequent disability usu-
ally yields the best results. Most important for success, however, is the
patient’s personal interest and ability to participate in the rehabilitation
program and to pursue the established functional goals, supported by
family and friends.
APPLICATION OF REHABILITATION CONCEPTS
Many persons afflicted by cancer develop some form of functional
impairment or disability that will interfere with self-care, mobility,
and a smooth transition to their former life style. These patients should
be identified early and referred for rehabilitation treatment. Cancer
rehabilitation can be broadly defined as the maximum restoration of
physical, psychologic, social, vocational, recreational, and economic
functions within the limits imposed by the malignancy and its treat-
ment. To make a significant and timely impact on such a wide variety
of functions and needs, the efforts of a well-coordinated and goal-ori-
ented multidisciplinary cancer rehabilitation team are required (Table
71.1). Because of the patient’s often uncertain prognosis, most cancer
rehabilitation programs focus on quick gains in mobility and self-care
skills, and the provision of psychosocial support to the patient and
family. Flexibility in goal setting is unavoidable because of the
patient’s changing needs, stamina, and medical status.
Despite the potential benefits, referrals of cancer patients for
rehabilitation services are often made needlessly late or not made at
all. Clinical problems amenable to rehabilitation interventions are
often identified too late or not at all. Pessimistic prognostication by the
oncologist and the rehabilitation specialist may hinder rehabilitation
referrals, as cancer patients are inappropriately compared with
patients disabled by trauma or other relatively static medical disorders.
Fortunately, the prognosis for most types of cancers has improved, and
consequently the demand for rehabilitation services for cancer patients
with disabilities has grown.
Several studies have shown that cancer rehabilitation programs
result in measurable benefits when individualized, specific, and real-
istic goals are set.1 Comprehensive inpatient rehabilitation services
Table 71.1. Interdisciplinary Cancer Rehabilitation Team
Physician (physiatrist) Speech-language pathologist
Rehabilitation nurse Social worker
Physical therapist Psychologist
Occupational therapist Chaplain
Prosthetist-orthotist Vocational counselor
Nutritionist Recreational therapist
972 SECTION 21 / Principles of Rehabilitation Medicine
Table 71.2. Activities of Daily Living*
Eating and drinking Moving in bed
Dressing and undressing Changing position
Bathing and grooming Walking
Toileting Climbing stairs
Managing bladder and bowel functions General wheelchair skills
Manipulating small objects Using a manual wheelchair
Caring for health and fitness Using a powered wheelchair
* Rehabilitation indicators: skill indicators.
may be economically provided for disabled cancer patients who are
considered “cured or controlled,” but precise short-term rehabilitation
interventions may enable even those with a poor prognosis to gain the
mobility and self-care skills that facilitate early hospital discharge.
The physical impairment experienced by cancer patients may result
from tissue destruction caused by the cancer itself, prolonged bedrest,
or inactivity, or from definitive treatment such as surgery, radiation, or
chemotherapy.The exact nature of the impairment may vary, but in
essence, it is no different from impairment caused by trauma or non-
cancerous disease and is customarily managed by the rehabilitation
team. A specific rehabilitation goal must be established for each patient
and an individualized program prescribed that is designed to obtain
measurable early results. The main rehabilitation goals for all people
with physical disabilities are, first, to develop maximum skills in the
activities of daily living (ADL) (Table 71.2) allowed by the disability
and, second, to obtain independent mobility with or without assistive
devices, such as wheelchairs, prostheses, orthoses, walkers, crutches,
or canes. To reach these goals, the therapist will utilize physical exer-
cise to improve muscle strength, endurance, joint flexibility, and self-
care skills, as well as apply physical modalities to decrease pain and
swelling. Prescription, fabrication, and fitting of prosthetic and orthotic
devices and other assistive equipment, followed by training in their use,
is essential for amputees and individuals with significant muscle weak-
ness, paralysis, or unstable skeletal structures.
It is essential to provide rehabilitation interventions that also aim
at the often profound psychological, sexual, social, and vocational
consequences of the cancer and the physical impairment. Preferably,
the anticipated psychosocial difficulties should be addressed when the
initial diagnosis is made and when treatment is begun. The goal of
cancer care is not just to eradicate or control the malignancy and
extend the patient’s life but to maintain or re-establish a life of quality.
While fatal or physically disabling consequences of cancer are quickly
recognized and usually well managed by the hospital staff, the psy-
chosocial effects of cancer, which frequently manifest after hospital
discharge, may remain unnoticed and therefore go untreated. As a
result, they may become more disabling than the physical impairment.
The rehabilitation goals of cancer patients may be broadly classi-
fied according to the different stages of the disease. (1) Preventive
rehabilitation therapy is started early after the diagnosis of cancer is
made, that is, before or immediately after surgery, radiotherapy, and/or
chemotherapy. At this stage no significant physical impairment exists,
but therapy is started to prevent functional loss. (2) Restorative reha-
bilitation therapy is directed at the comprehensive restoration of max-
imum function for patients considered “cured or controlled” but who
have a residual physical impairment and disability. (3) Supportive
rehabilitation therapy attempts to increase the self-care skills and
mobility of the cancer patient with growing cancer and progressive
impairment and disability by the application of quick, effective meth-
ods, for example, providing appropriate assistive devices and the
teaching of simple techniques for self-care.2 Supportive rehabilitation
therapy also includes physical exercises to prevent the effects of
immobilization, such as joint contractures, muscle atrophy, weakness,
and pressure sores. (4) Palliative rehabilitation therapy aims to
increase or maintain the comfort and function of patients with termi-
nal cancer by utilizing physical modalities, simple orthotic devices,
and assistive equipment to manage pain, joint contractures, and pres-
sure sores, and to provide at least partial self-sufficiency.2
THE CANCER REHABILITATION AND
ADAPTATION TEAM
Organized cancer rehabilitation programs can significantly
improve a patient’s physical function and community re-integration.1,3
An integral part of such programs is an interdisciplinary cancer reha-
bilitation and adaptation team (see Table 71.1). The exact composition
of the team may vary considerably, depending on the program’s phi-
losophy and size, the type of institution, and the range of disabilities
encountered. The team is led by a physician who is either an oncolo-
gist or, more commonly, a physiatrist.3 An oncology nurse, social
worker, psychologist, physical therapist, occupational therapist, voca-
tional counselor, chaplain, and nutritionist are present on most teams.
Other rehabilitation professionals may contribute to the rehabilitation
of cancer patients, depending on each patient’s specific physical
impairment, including prosthetist, orthotist, speech pathologist,
driver’s trainer, and recreational therapist. The roles of the various
team members are described below.
The physiatrist, the medical specialist who usually directs the can-
cer rehabilitation team, needs to be knowledgeable in oncology in
addition to having expertise in the field of physical medicine and reha-
bilitation. The physiatrist is the team’s primary link with other treating
physicians. To establish realistic goals and prescribe an appropriate
rehabilitation program, the physiatrist needs to know (1) details of the
cancer diagnosis with respect to organ site, histology, and grade of
anaplasia, (2) the cancer’s anatomic staging (primary site only,
involvement of regional nodes, or metastases), (3) the patient’s life
expectancy, that is, whether the patient is “cured or controlled,” and if
not, the anticipated rapidity of the cancer’s progression, and (4) the
definitive treatment plan for the cancer, that is, the timing of surgery,
chemotherapy, or radiation, and its anticipated efficacy and potential
side effects. The physiatrist discusses this information with the reha-
bilitation team as the basis for developing a specific and realistic plan
of preventive, restorative, supportive, and palliative therapies. The
physiatrist introduces the patient and family to the goals of the cancer
rehabilitation team and meets regularly with the team, as well as with
the patient and family, to direct and coordinate their efforts, while tak-
ing into account the patient’s progress and changing needs.
The rehabilitation oncology nurse serves primarily as an easily
accessible resource to the nursing staff giving care to the cancer patient,
as well as to the patient and the family. The nurse evaluates the patient’s
specific nursing needs, plans the patient’s care, helps to obtain nursing
supplies, educates other nurses, the patient, and his or her family about
nursing techniques and the principles of cancer treatment, facilitates
patient and family self-management, and monitors discharge plans and
assists in the discharge process. After discharge, the nurse may provide
advice to the caregivers in the home on the management of the differ-
ent and complex treatment problems that may arise.
The physical therapist teaches the patient to perform specific
exercises to strengthen muscles, to increase stamina, and to maintain
or improve joint range of motion and trunk flexibility. When indicated,
training is provided to improve balance and coordination, as well as
functional skills: transfers into and out of bed, wheelchair locomotion,
and ambulation with or without assistive devices. Instructions are pro-
vided on how to normalize gait patterns and to safely ascend and
descend stairs and curbs. Various physical modalities may be used by
the therapist to reduce pain, such as superficial and deep heat, cold,
transcutaneous electrostimulation (TENS), and massage, but the clin-
ician needs to stipulate that heat modalities and massage should not be
applied directly over or immediately adjacent to a site of cancer. Phys-
ical exercise is perhaps the most important therapeutic modality in the
rehabilitation management of physical disabilities. Muscle-strength-
ening exercises may be either isometric, isotonic, or isokinetic. Iso-
metric exercise does not involve joint motion, and so is prescribed for
painful or unstable body parts, whereas isotonic exercise involves joint
motion against variable resistance. Isokinetic exercise, a most effective
strengthening exercise, involves the use of specific devices (e.g., the
Cybex apparatus) to maintain constant speed of motion independent of
the force applied.4 Passive stretching exercises are done by the thera-
pist without the patient’s direct participation to maintain or increase
joint mobility. Task-oriented exercises, such as ambulation or training
in self-care, may improve function and safety by repetition and pro-
longed therapy.
The occupational therapist focuses in on upper-extremity exer-
cises and training in self-care activities. The exercises are designed to
improve strength, coordination, and skills in the various ADL (see
Table 71.2). Different adaptive equipment may be provided to make
the patient more proficient in self-care and activities related to work
and recreation. When indicated, the therapist fabricates simple orthotic
devices, such as hand splints for immobilization or to compensate for
weak muscles. When brain dysfunction is present, a gross assessment
of cognitive and visual perceptual skills is performed, and therapy is
initiated to compensate for deficits in these areas. The home and work-
place are evaluated and recommendations are offered to make these
sites more accessible and more conducive to complete self-sufficiency
and greater productivity. Working independently, or with a recreational
therapist, the occupational therapist strives to make a resumption of
leisure time activities easier for the patient.
The prosthetist/orthotist is called on to make artificial limbs (pros-
theses) or special braces (orthoses) for patients in need of such
devices. The prosthetist/orthotist should evaluate the patient with the
physiatrist and the therapist and help to select the proper components
and materials for the device, as well as determine its general design
and methods of fabrication on the basis of the pathology and biome-
chanics involved. After delivery, the physiatrist checks out the device
for comfort and fit, but it is the duty of the prosthetist/orthotist to mod-
ify and service the equipment as long as it remains in use.
The nutritionist evaluates the patient’s nutritional condition,
assesses the additional metabolic demands that the cancer places on the
body, and recommends the optimal diet with respect to specific clinical
condition, caloric intake, food ingredients of choice, optimal consis-
tency for easy swallowing, and the individual’s tastes. The nutritionist
judges total food intake by closely monitoring the patient’s weight and
counting calories and, if nutrition is inadequate, may recommend inter-
ventions to facilitate adequate intake in the presence of poor appetite and
swallowing disorders. The nutritionist should teach the patient and fam-
ily general and specific dietary principles and consult with the clinical
staff on the optimal parenteral nutrition when the need for that arises.
The speech-language pathologist evaluates and provides therapy
for impaired oral communication and works closely with the occupa-
tional therapist and nutritionist in the assessment and care of swallow-
ing disorders.
The social worker has many important roles in the rehabilitation of
the cancer patient, but especially with respect to discharge planning,
facilitating a smooth transition from the hospital to the community,
ensuring continuity of care, and securing appropriate follow-up ser-
vices after discharge. The social worker helps the patient to secure
financial resources, including health insurance coverage, and Social
Security and disability compensation, as well as to obtain authorization
and payment for necessary devices and home help. Before hospital dis-
charge, arrangements need to be made for transportation, attendant, or
nursing care, home modifications, and other appropriate posthospital
services. This may involve transfer to and placement in other health
institutions. The social worker often acts as a liaison among the patient,
the family members, and the various health care professionals.
The psychologist assesses the patient’s cognition and behavior,
including intelligence, personality (i.e., ideational, emotional, behav-
ioral, and character patterns), personal history, motivation, reaction to
the illness, and coping skills. Following the diagnosis of cancer and the
development of a disability, both the patient and family members may
experience reactive depression or grief, which often is expressed in
diverse ways, including denial, anger, anxiety, panic, fear, dependent
behavior, depression, and the unmasking of previously controlled psy-
chopathology. The primary role of the psychologist is to assist the
patient and the family in coping, as well as to counsel and consult with
the rehabilitation team members in managing the emotional reactions.
The effectiveness of psychosocial intervention has been successfully
demonstrated with cancer patients.5,6
A chaplain or religious counselor is often included in the cancer
rehabilitation team. This professional may be able to relate to the
CHAPTER 71 / Principles of Cancer Rehabilitation Medicine 973
patient and the family in a way that can help them use their faith to
adjust to the illness and disability.
A vocational counselor should participate in the care of physically
impaired cancer patients who have any potential of returning to work.
An initial interview should be conducted at the hospital and vocational
services continued after discharge. These services may include
detailed evaluation, counseling, testing, career exploration, and edu-
cational planning. The counselor will have to proceed to the extent and
at a pace that are sensitive to the patient’s need and readiness to resume
vocational activities, whether education or employment. At the proper
time, the counselor may make visits to work or school sites and con-
sult with employers and teachers to facilitate the transition from dis-
ability to productivity as a worker or student. For school-age children,
home tutoring may have to be arranged. Patients who are unemployed
may be taught skills to seek jobs successfully. The Office of Vocational
Rehabilitation (OVR) in each state can be a source of funding for var-
ious vocational rehabilitation services, that is, certain aspects of reha-
bilitation, education, training, job placement, and equipment and envi-
ronmental modifications, if these will enable the disabled person
eventually to return to school or work. The counselor makes the initial
referral to OVR and maintains a close cooperative and effective rela-
tionship with the OVR representatives.
The recreational therapist offers activities to meet the different
needs and interests of disabled individuals both in and out of the hospi-
tal, such as art therapy, music therapy, attending art shows and sports
events, going to theaters, eating at restaurants, and shopping. Family and
friends may join in these recreational activities, which serve to enhance
socialization, leisure-time activities, and positive attitudes. The trips into
the community may facilitate the institutional discharge for the physi-
cally disabled person and re-integration into community life.
FUNCTIONAL ASSESSMENT
A medical intervention should not be offered unless measurable
benefits will result. Unlike other fields of medicine, the outcome of
rehabilitation interventions cannot be measured by survival or by the
disappearance of symptoms. The effectiveness of rehabilitation inter-
ventions is judged by the patient’s degree of functional independence.
The terms impairment, disability, and handicap have been carefully
defined by the World Health Organization to clarify the impact of a
physical deficit.7 Impairment is “any loss or abnormality of psycho-
logical, physical, or anatomical structure of function,” for example,
paralysis. Disability is “any restriction or lack (resulting from an
impairment) of an ability to perform an activity in a manner within the
range considered normal for a human being,” for example, paralysis
resulting in an inability to walk. Handicap is “a disadvantage for a
given individual resulting from an impairment or disability that limits
or prevents the fulfillment of a role that is normal (depending on age,
sex, and social and cultural factors) for that individual,” for example,
the person is paralyzed and unable to walk and thus is unable to meet
the requirements of the job and so cannot return to work.
To assess and monitor function accurately, the performance in dif-
ferent activities of self-care, mobility, and communication must be
numerically rated according to the patient’s level of independence:
completely independent; independent with devices; requires assistance
(supervision, “spotting,” reminding, physical help); or completely
dependent. This requires the collection of numerous diverse data by var-
ious means, including physical examination, observation, and a review
of records and reports from the various rehabilitation team members, as
well as the gathering of information directly from the patient and fam-
ily. Several evaluation scales exist. Some are simple and easy to use but
provide incomplete information, whereas others are detailed but time
consuming, as they address a whole range of quality-of-life factors,
which include mobility, self-care, employment, income, education, fam-
ily activities, living arrangements, and transportation. Computer tech-
nology has made the gathering, analysis, and plotting of data easier and
has enabled clinicians to document the patient’s progress numerically,
during inpatient and outpatient rehabilitation care. The functional eval-
uation scale that currently is gaining the widest acceptance by rehabili-
974 SECTION 21 / Principles of Rehabilitation Medicine
tation professionals is the Functional Independence Measure (FIM)
(Table 71.3).8–10 but for cancer patients, the Karnofsky Performance
Status Scale has been most widely used (Table 71.4).11
A new scale developed specifically to measure quality of life and
functional outcome for patients with cancer, the Cancer Rehabilitation
Evaluation System (CARES) has been shown to be valid, reliable, and
sensitive to changes in status.12,13
THE REHABILITATION PROCESS
Rehabilitation services are frequently requested too late in the care of
the cancer patient. The physiatrist should be consulted as soon as it may
be anticipated that the cancer will result in a physical disability. The reha-
bilitation interventions may thus be planned and explained to the patient
before, during, or immediately following definitive treatment. Physical
and occupational therapy is initially provided at the bedside, but the
patient should be mobilized out of bed as soon as possible and escorted
to the rehabilitation area, where facilities and equipment are conducive to
better performance. Other members of the rehabilitation team become
involved in the care of the disabled cancer patient as deemed appropriate
by the physiatrist. If these interventions allow the patient to become self-
sufficient and ambulatory, he or she should be discharged home directly
from the acute service, when medically indicated, having received proper
instructions, equipment, and referrals for specific nursing interventions.
Table 71.3. Functioning Independence Measure (FIM)
Copyright 1990 Research Foundation - State University of New York.
A more comprehensive and intensive rehabilitation program on an
inpatient rehabilitation service is provided for physically disabled can-
cer patients who do not gain independence in ADL and mobility with
daily therapy on the acute service, who are medically capable of
actively participating in the program for at least 3 hours daily, and who
are motivated and mentally capable of following instructions and
learning the different tasks.
The inpatient rehabilitation unit should be in a hospital with an in-
house physician on call and the various medical and surgical consulta-
tion services available at all times. Here the disabled cancer patient is
re-evaluated by the physiatrist, who obtains a detailed medical and
social history and performs a careful physical examination to assess
the general medical and the precise musculoskeletal and neurologic
condition, as well as the current functional ability. The physiatrist
writes the routine medical orders, as for nursing care, medications, and
disability-specific diagnostic tests, including radiologic studies, uro-
logic evaluation, pulmonary function tests, electrodiagnostic studies,
and blood and urine analyses. The physiatrist at this time sets the gen-
eral rehabilitation goals and prescribes evaluation and interventions to
be undertaken. The physiatrist prescribes the specific exercises and
training methods to be given by the physical and occupational therapists,
as well as interventions by the psychologist, speech pathologist, voca-
tional and recreational counselors, and others when they are needed.
The rehabilitation program begins promptly after transfer to the
inpatient rehabilitation service. Initially, the actual participation of
patients on the program may be impeded by the physical decondition-
ing or by special evaluations and tests, but after the first few days, 4 to
6 hours each day are spent in an active therapy program in addition to
different ward activities, such as self-care training, management of
bowel and bladder dysfunction, and educational and recreational activ-
ities. When serious medical complications arise during the course of
rehabilitation that interfere with the patient’s ability to attend the reha-
bilitation program for at least 3 hours a day for more than 3 consecu-
tive days, the patient should be transferred to the appropriate medical
or surgical service for definitive care.
Within 1 week of admission, an initial team conference is held at
which the patient’s medical, functional, psychologic, social, voca-
tional, and recreational status, as well as the rehabilitation potential
and prognosis, are presented and discussed. More specific rehabilita-
tion goals are set, needs for equipment and personal assistance are
assessed, and a discharge date is predicted. Soon after this conference,
the physiatrist meets with the patient and the family, together or sepa-
rately, to discuss these issues and answer questions regarding the
patient’s medical condition and rehabilitation program. Team rehabili-
tation conferences are held biweekly to discuss the patient’s progress
and plans for discharge. While the patient is making continuous and
measurable progress toward the set functional goals of independence
in ADL and mobility, continued inpatient stay may be justified. Com-
munication among members of the rehabilitation team, a most critical
component, is facilitated through informal meetings during which spe-
cific concerns are shared and discussed. When a patient is discharged
home, it is most important to ensure that needed equipment and sup-
plies have been obtained, family members or home health aides have
been instructed and trained in the patient’s care, follow-up by the vis-
iting nurse service has been arranged, and referrals have been made for
continued therapy and visits with various physicians, including the
oncologist, surgeon, physiatrist, and family doctor.
CANCER OF THE BRAIN
Brain damage may result from primary tumors of the brain, from
metastatic disease, or from treatment of the cancer—surgery, radiation,
or, more rarely, chemotherapy. The symptoms and disability that may
result vary extensively but, in essence, are similar to those that are seen
in patients who have sustained traumatic brain injury or a stroke involv-
ing different parts of the brain (Table 71.5). The main difference, how-
ever, is the potentially progressive or recurrent nature of the brain can-
cer and its uncertain prognosis. The greatest deficits are frequently seen
immediately after surgery or during radiation and chemotherapy, after
which remarkable improvement may occur. Late brain injury from radi-
ation with infarction or necrosis also may occur, but the resulting dis-
Table 71.4. Karnofsky Performance Status Index
General Index
Able to carry on normal activity, no special care needed 100
90
80
Unable to work, able to live at home and care for most personal 70
needs, varying amount of assistance needed 60
50
Unable to care for self, requires institutional or hospital care or 40
equivalent, disease may be rapidly progressing 30
20
10
0 Dead
ability has a less favorable prognosis for recovery. All patients with
brain cancer and impaired function in mobility or ADL should be
referred for rehabilitation services. The majority can be helped with
simple rehabilitation measures, whereas others may require compre-
hensive inpatient rehabilitation, which should be provided when longer
life expectancy allows. Following definitive treatment of primary brain
tumors in children, it has been shown that rehabilitation significantly
improves outcome in self-care activities, transfers into and out of bed, and
locomotion by a wheelchair or walking.14
Most commonly, the rehabilitation intervention starts after surgi-
cal resection or removal of the brain tumor. When medically stable, the
patient should be helped to sit up, get out of bed, and start on an active
restoration program that is designed according to the patient’s general
condition. The location and size of the cerebral lesion clearly deter-
mine the clinical symptoms encountered. The variability of the symp-
toms precludes a standard rehabilitation approach but demands an
individual evaluation and treatment plan. Broadly, the problems of
patients with cancer of the brain are physical, psychological, social,
and vocational. Table 71.5 gives a detailed list of problems that are
most commonly found and are briefly discussed below.
Paralysis, often in the form of hemiplegia, can be a conspicuous
consequence of brain cancer. While the paralysis is most profound just
after the brain surgery, a certain return of motor power is common and
may continue for several weeks or months. As a rule, the earlier the
return, the greater the recovery. However, muscles that are still totally
paralyzed 4 to 8 weeks postoperatively generally remain so. At this
point, functional improvement can still occur through physical train-
ing and provision of appropriate assistive devices (orthoses or canes).
When the medical condition is unstable, the patient is kept in bed, rest-
ing on a firm mattress with a soft surface, such as sheepskin, to pre-
vent pressure sores. He or she should usually lie in the extended posi-
tion with the affected arm abducted, externally rotated, and slightly
elevated. Joint range-of-motion exercises should be applied to the par-
alyzed parts and active exercises to the uninvolved parts twice a day.
Mobilization training starts when the patient is ready to be trans-
ferred out of bed. Depending on the extent of the paralysis, the patient
may be taught to ambulate with assistive devices or to maneuver a
wheelchair. When the motor dysfunction is severe, the patient is first
placed on a tilt table to decrease orthostatic hypotension and fear of the
upright position, to stimulate antigravity muscles, and to improve body
balance. Upon regaining some degree of body balance and lower-
extremity strength, the patient is stood up between parallel bars for
balancing exercises and early ambulation training. At this stage, the
knee extensors on the affected side may be weak and require stabiliza-
tion with a temporary knee-ankle-foot orthosis (KAFO), which locks
the knee in extension for weight bearing. As the body balance
improves and the patient has learned to lean consistently to his or her
good side, ambulation outside of parallel bars can begin, with the
patient using a broad-based cane carried in the unaffected upper
extremity. Usually, some knee extensor strength returns, allowing the
patient adequate knee support, but the ankle dorsiflexors and invertors
still may be weak. Here a plastic ankle-foot orthosis (AFO) may be
prescribed to prevent foot dragging during the swing phase of gait. This
Specific Criteria
Normal, no complaints, no evidence of disease
Able to carry on normal activity, minor signs or symptoms of disease
Normal activity with effort, signs or symptoms of disease
Cares for self, unable to carry on normal activity or to do work
Requires occasional assistance from others, but able to care for most needs
Requires considerable assistance from others, needs frequent medical care
Disabled, requires special care and assistance
Severely disabled, hospitalization indicated; death not imminent
Very sick, hospitalization necessary; active supportive treatment necessary
Moribund
orthosis is easily inserted into most shoes. It is cosmetically superior to
the old metal orthoses and usually provides equal or better function. If
knee extensor strength does not return, fabrication of a KAFO may be
considered, but the prognosis for functional ambulation with such a
device is poor.
Training and elevation activities, such as climbing and descending
stairs, ramps, or curbs, are started when a good gait pattern on level
ground has been achieved. Patients with severe neurologic deficits
may require a wheelchair, either for mobility at all times or only when
ambulation endurance or safety is impaired.
The major goal in the rehabilitation of the patient with cancer of the
brain is independence in ADL, which may be obtained through train-
ing, prescription of proper assistive devices, and possibly modification
of the patient’s clothing and the architecture of the patient’s home.
Spasticity frequently interferes with mobility and performance of
ADL. Factors that may aggravate the spasticity (e.g., skin lesions,
infections, and anxiety) need to be identified and treated. Thorough
stretching of all joints should be performed daily. Medications—
dantrolene sodium, baclofen, or diazepam—may be of some benefit
but should be used sparingly in view of their potential side effects.
Selected nerve blocks with dilute solutions of phenol or motor point
blocks with botulinum toxin are usually effective in reducing local
spasticity, but surgical procedures for reduction of spasticity in
patients with cancer of the brain are rarely indicated.
Joint contractures, whether due to muscle imbalance, spasticity,
poor nursing care, improper bed positioning or an inadequate exercise
program, may change the rehabilitation prognosis significantly. A 10-
degree flexion contracture of the knee, for example, will greatly
increase oxygen consumption during ambulation and thus markedly
reduce endurance. Knee contractures that exceed 15 degrees will usu-
ally make functional ambulation impossible for the patient with brain
cancer and hemiplegia. Development of a frozen shoulder may make
independent dressing impossible. Prevention of contractures by proper
joint range-of-motion exercises is imperative from the onset of the dis-
ability, since treatment of contracture is relatively ineffective.
Pain in different parts of the body may be experienced in patients
with neurologic deficits caused by cancer of the brain. Dysesthetic
thalamic pain is notably refractory to treatment, although various cen-
trally acting agents may be helpful. Pain with motion of the hemiplegic
shoulder is common, perhaps due to muscle imbalance at the shoulder
girdle and recurrent minor trauma to the periarticular structures.
Table 71.5. Rehabilitation Problems Associated with Cancer of the
Brain
Paralysis Dysarthria
Spasticity Aprosodia
Joint contractures Dysphagia
Pain Ataxia
Sensory deficits Visual-perceptual deficits
Visual field deficits Cognitive and behavioral deficits
Diplopia Psychosocial-vocational problems
Aphasia
976 SECTION 21 / Principles of Rehabilitation Medicine
Shoulder support by an arm sling or a lap board, administration of
analgesics, application of heat or cold modalities, and gentle range-of-
motion and strengthening exercises may all help to reduce the pain and
improve shoulder function. Complex regional pain syndrome, for-
merly known as reflex sympathetic dystrophy, may occur and requires
similar treatment, but more effective relief may be obtained by simply
administering oral steroids, for example, prednisone 5 mg four times a
day for 2 to 3 weeks.15 Sympathetic nerve blocks may be performed
when symptoms are more persistent.
Sensory deficits of varying degrees are commonly seen in patients
with brain cancer, either in the distribution of the cranial nerves or on
one or both sides of the body. Cancer affecting the parietal lobes of the
brain may cause severe sensory loss with little muscle weakness. This
may interfere with balance and mobility since the patient who cannot
feel motion is unable to control it. Although physical exercise cannot
decrease the sensory loss, training with adaptive gait aids (i.e., canes,
crutches, or a walker, and wearing of proper shoes) may help the
patient to ambulate functionally again.
Visual deficits, such as double vision or visual field deficits, are
commonly seen as a result of cancer in the lower brain or above the tento-
rium, respectively. While double vision may improve spontaneously, the
use of unilateral or alternating eye patches or special prism glasses may be
helpful. The value of exercises for retraining the eye muscles is uncertain.
Homonymous hemianopsia—blindness to the affected side of the body
due to a contralateral brain tumor—rarely resolves spontaneously. While
a patient with a left brain lesion usually learns easily to compensate for
hemianopsia through scanning of the environment, the patient with right
brain lesion may experience severe difficulties owing to accompanying
anosognosia, that is, lack of awareness of the affected left side of the body
and of the surroundings. Specialized programs of cognitive remediation
have been found to be effective with these patients.16
Aphasia may be seen in patients with cancer in the left dominant
hemisphere of the brain. This is an impairment of the central language
process, with reduced capacity for interpretation and formulation of
the symbols for communication. Although all components of lan-
guage—listening, speaking, reading, and writing—are usually
affected, they are not affected to an equal extent, and thus several types
of aphasia are recognized.17,18 Expressive or nonfluent aphasia is
caused by lesions in the Broca area of the brain and is characterized by
reduced language production, vocabulary and use of grammar. The
patient is well aware of these difficulties and becomes very frustrated.
Less well known is receptive or fluent aphasia, which is caused by
lesions in the Wernicke area of the brain. Here, the patient primarily
has difficulty in understanding language, both his or her own, and that
of others. The patient thus may be able to speak continuously at nor-
mal speed and with normal intonation without giving any pertinent
information or being aware of the errors. Most aphasic patients, how-
ever, understand nonverbal sounds and enjoy listening to music, and
frequently some automatic speech is retained.
Different objective tests can be performed to assess the patient’s
language and communication skills, but many patients perform better
during a conversation than on such tests, since they may be able to
grasp certain key words and successfully make guesses, as well as
understand gesticulations, facial expressions, the tone of voice, and
other situational clues. The efficiency of speech therapy is debated
since most patients will have a degree of spontaneous improvement.
Nonetheless, speech therapy is indicated, whenever available, not only
for psychological support but also to provide the necessary stimulation
for the patient to utilize his or her maximum speech ability, to adjust
to new circumstances, and to instruct the family in proper communi-
cation with the patient by using short simple sentences at a normal
voice volume, gestures and facial expressions, always with respect,
optimism, patience, and encouragement.
Dysarthria is a motor disturbance of speech, which implies weak-
ness, slowness, or incoordination of the muscles that produce speech.
Understanding written or spoken language is, therefore, never a prob-
lem. Articulation is usually the main problem, but speed, rhythm,
sound, and intonation may also be disturbed. Mild dysarthria accom-
panies many brain cancers that involve cranial nerves and cerebrum
and affect the facial musculature, but dysarthria is particularly promi-
nent in brainstem tumors. Management, which is often successful,
emphasizes teaching the patient to use the remaining speech muscles
more effectively or to bypass the effects of disturbed function. First,
the patient is guided in producing sounds, then words, and finally
whole sentences. If speech still remains completely unintelligible,
other communication methods are introduced, such as writing, typing,
sign language, or pictures.
Aprosopia is a little-known communication disorder that is seen
with lesions of the nondominant right hemisphere.19 This condition
relates to the inability to express and comprehend variations in pitch,
rhythm, and stress, which give emotional meaning to speech. These
patients may speak in a relatively flat voice and are often unable to rec-
ognize the emotional tones of speech, including the meaning of non-
language speech sounds, such as grunts or sighs. It is important for the
clinician and the family to understand this deficit and to communicate
with the patient strictly by words, since specific therapy does not exist.
Considerable improvement usually occurs with time.
Dysphagia, or impaired swallowing, is frequently seen in patients
with brain cancer, especially when the brainstem is involved. In its
most severe form, the patient may be totally unable to swallow, but in
milder cases, there may only be difficulty with the swallowing of liq-
uids. Aspiration with resulting pneumonia may occur, which demands
careful evaluation of the condition and proper intervention. Serial
radiographic swallowing studies should be done for proper monitoring
of the condition until it is resolved or until other safer means of nutri-
tion are established. A swallowing training program may be instituted
by the speech or occupational therapist where the patient attempts to
swallow food of different consistency using different techniques and
positions. A nasogastric tube can be used for several weeks while wait-
ing for spontaneous recovery, but a more persistent dysphagia war-
rants insertion of a gastrostomy tube for prolonged feeding.
Neuropsychological changes may be prominent when cancer
affects the cerebral hemispheres. Reduced memory and judgment fre-
quently make successful rehabilitation impossible as the patient may
be unable to remember instructions. Severe agitation may need treat-
ment with a major tranquilizer, such as chlorpromazine or haloperidol.
Visual perceptual deficits, caused by a central disturbance in organiz-
ing visual stimuli from the environment, frequently accompany right
brain damage even when visual field and acuity are normal. These
patients may experience difficulty in recognizing the three dimen-
sions: depth and distances, the relationship of lines and objects, and
vertical and horizontal lines. This may, in turn, affect different func-
tions, including reading, understanding maps, recognizing familiar
objects, and driving vehicles safely. Similarly, these patients may be
unable to recognize the emotional significance of facial expressions,
adding to the communication problems caused by the frequently
accompanying aprosopia. There is a tendency to be impulsive and
careless, to minimize or even ignore the problems in functioning, to
make frequent mistakes, and often to neglect the left environment
(anosognosia). Patients with lesions in the left hemisphere, on the
other hand, usually act and learn slowly, make few mistakes, and are
aware of their deficits, which frustrate them severely. In recent years,
neuropsychological training programs designed to help patients over-
come the visual, perceptual, and cognitive deficits have been reported
as being successful.20 In addition, repeated neuropsychologic evalua-
tions have been found to be sensitive indicators of recurrence.21
CANCER OF THE SPINE
While primary tumors of the vertebrae (e.g., multiple myeloma)
are uncommon, metastases to the spine are frequent. The spine is the
most common site for skeletal metastases.22 At autopsy, 70% of
patients who die from cancer demonstrate vertebral metastases,23 and
more than 5% have evidence of metastatic compression of the spinal
cord.24 This is usually an extradural anterior mass that involves bone.
Intradural extramedullary tumors are usually histologically benign
meningiomas or neurofibromas. Gliomas (i.e., ependymomas, astro-
cytomas, and medulloblastomas) are usually intramedullary, although
occasionally they are also found in an extramedullary site. Although
the response to treatment is quite different for all of these histologi- CHAPTER 71 / Principles of Cancer Rehabilitation Medicine 977
cally distant tumors, the neurologic symptoms, signs, and rehabilita-
tion interventions are quite similar.
Injury to the spinal cord and peripheral nerves is a recognized risk of
therapeutic radiation that may not become manifest for many months, or
even years.25 A transient radiation myelopathy primarily involving sen-
sory neurons may occur in 10 to 15% of patients receiving mantle radia-
tion for Hodgkin’s disease.26 This condition is usually associated only
with sensory symptoms, such as paresthesias and Lhermitte’s sign, and
resolves in 1 to 9 months.26 Delayed radiation myelopathy is an irre-
versible and progressive neurologic condition that may affect motor, sen-
sory, and sphincter functions and has a reported incidence of 1 to 12%.27
CLINICAL PRESENTATION By far the most frequent presenting symp-
tom of a tumor of the spine is pain. The pain may be localized, diffuse,
or radicular in nature. It is characteristically made worse by activity
and by straining. Different from more benign back pain, the pain
caused by tumors tends to be persistent, to be present or even worse at Figure 71.1. Halo-orthosis. (Reproduced with permission from Rag-
night, and is not relieved by rest. Additional symptoms at presentation narsson KT. Orthotics and shoes. In: Rehabilitation medicine: principles
may be weakness of the legs, difficulty in walking, and urinary sphinc- and practice. Joel A DeLisa, editor. Philadelphia: J.B. Lippincott; 1988).
teric problems leading to incontinence.
Neurologic deficits may develop insidiously or occur suddenly,
depending on the tumor’s rate of growth and location, or on the occur- part of the spine is stabilized inherently by the rib cage. Lesions in the
rence of a sudden pathologic fracture. Slowly progressive neurologic more mobile lower thoracic and lumbar spine are often associated with
dysfunction is often seen with tumors of the lower spine that encroach severe pain. An adjustable thoracolumbar sacral (TLS) orthosis (Fig.
on the cauda equina, whereas tumors of the thoracic spine may cause 71.3) with posterior stays may provide sufficient support for less
the sudden collapse of a vertebral body with direct compression of the severe lesions, decrease pain, and allow greater mobility. The soft
spinal cord or of its blood supply. Although only half of all tumors of anterior portion of the corset, the apron, should fit snugly over the
the spine are located in the thoracic region, these cause 70% of all entire abdomen for optimal support. Larger lesions and postoperative
spinal cord compressions that result in paraplegia. Such paraplegia conditions may require fabrication of a custom-molded plastic TLS
may be neurologically complete, that is, with total paralysis and sen- brace, a two-piece removable orthosis (Fig. 71.4) that firmly grabs the
sory loss below the level of the lesion. More frequently, however, the pelvis below and the chest above.
neurologic lesion is incomplete, with sensation and motor function When neurologic loss has occurred, the rehabilitation therapy must
preserved to varying degrees, as may be rated by the ASIA Impairment be carefully individualized, on the basis of the extent of the neurologic
Scale,28 which is a modified version of the Frankel Scale.29,30 dysfunction, the medical/surgical condition, and the patient’s life
Impaired bladder and bowel control at first may present clinically as expectancy. Spinal cord dysfunction with severe or complete paralysis
urinary urgency or hesitancy, but with progressive cord compression, and sensory loss, and perhaps bladder and bowel dysfunction, warrants
urinary retention or bowel and bladder incontinence may occur. a comprehensive but relatively short-term rehabilitation program
TREATMENT Proper rehabilitation management planning and inter- involving as many members of the rehabilitation team as judged
vention depend on an accurate diagnosis and staging of the tumor, just appropriate by the physiatrist. The rehabilitation programs should be
as does the medical and surgical management. Most patients with designed to address each of the many clinical complications and con-
spinal metastases can and should be managed nonsurgically with radi- ditions that may be seen in individuals with spinal cord dysfunction of
ation, chemotherapy, and orthotic stabilization of the spine, since it has traumatic origin (Table 71.6). Early intervention should include bed-
been demonstrated that radiation alone provides results that are simi- side physical and occupational therapy, establishment of bowel and
lar to those of surgery followed by radiation.31 In general, laminec- bladder training programs, and the application of nursing principles to
tomy with decompression has been found to be of limited use as com- prevent complications, such as pressure sores and joint contractures,
pared with radiation, since the compressive lesion is usually located that increase morbidity, worsen the functional prognosis, and prolong
anteriorly to the cord, and the surgical procedure itself contributes to the rehabilitation phase. Proper positioning of the patient in bed and
spinal instability. However, profound neurologic deficits, especially turning at least every 2 hours is of paramount importance in this
when occurring rapidly, may warrant surgical decompression, which regard. The patient and family are given emotional support and are
preferably should be done by an anterior approach followed by surgi- educated in the medical aspects of spinal cord dysfunction and man-
cal stabilization of the spine. Surgical decompression of the spinal
cord is not very effective once the patient has become completely para-
plegic. Surgical stabilization may often be indicated when gross spinal
instability is present, as two of the three “columns” (anterior, middle,
and posterior) of the spine have been destroyed by the tumor.32 The
extent of surgical stabilization varies, depending on the patient’s antic-
ipated life expectancy. Patients with short life expectancy (less than 1
year) benefit most from a relatively simple procedure employing
methylmethacrylate, which allows immediate spinal stability and
rapid mobilization of the patient, whereas patients with a more favor-
able prognosis may be better served by vertebrectomy, spinal instru-
mentation, and bony fusion in conjunction with methylmethacrylate.32
Spinal metastases and myelomatous lesions, even when accompa-
nied by compression fractures and minor or modest spinal instability,
can be successfully managed by spinal orthotic support and radiation.
Both modalities may significantly decrease pain. Lesions in the cervi-
cal spine are most rigidly immobilized by a halo brace (Fig. 71.1) but Figure 71.2. Sternal-occipital-mandibular immobilizer (SOMI ortho-
also may be adequately supported by a SOMI brace (sternal-occipital- sis). (Reproduced with permission from Ragnarsson KT. Orthotics and
mandibular immobilizer) (Fig. 71.2). When such lesions are present in shoes. In: Rehabilitation medicine: principles and practice. Joel A.
the upper thoracic spine, spinal orthoses may not be necessary, as this DeLisa,editor. Philadelphia: J.B. Lippincott; 1988).
978 SECTION 21 / Principles of Rehabilitation Medicine
Figure 71.3. Thoraco-lumbo-sacral orthosis (TLSO, Knight-Taylor
brace). (Reproduced with permission from Ragnarsson KT. Rehabilitation
of patients with physical disabilities caused by tumors of the muscu-
loskeletal system. In: Tumors of the musculoskeletal system. Michael M.
Lewis, editor. New York: W.B. Saunders Co.; 1991).
agement. If the prognosis is poor (i.e., less than 6 months) the patient
is instructed early in the ADL skills, which he or she can quickly learn
to perform, and provided with the necessary assistive devices, such as
a wheelchair, nursing supplies, and personal assistance. As soon as
medically appropriate, discharge from the hospital to the home or a
nursing facility can be accomplished. When life expectancy is greater
and the general criteria for admission to the inpatient rehabilitation
service are met, the patient may be transferred there for a more com-
prehensive and intensive rehabilitation program.
CANCER OF THE HEAD AND NECK
Definitive treatment of cancer that arises from the skin of the face
and neck or tissues of the nose, mouth, throat, and larynx may result in
impairments in cosmesis, oral communication, feeding, and respira-
tion, as well as affect the senses of sight, hearing, taste, and smell.
These functional deficits may have major psychological, social, and
vocational consequences if not adequately addressed early and man-
aged properly. Surgical excision and reconstruction are frequently fol-
lowed by radiation, which by itself may produce clinical problems,
including skin erythema, blistering and peeling, edema, delayed wound
healing, muscle atrophy and fibrosis with reduced mobility, nerve dam-
age with weak muscles and sensory deficits, dry mouth, and bad or lost
taste. Sensory deficits and radiation-induced skin changes require care-
ful grooming and hygiene to prevent further skin damage, by using
nonirritating soaps and cosmetic products, an electric razor instead of a
Figure 71.4. Custom molded thoraco-lumbo-sacral orthosis (TLSO), a
two-piece removable plastic orthosis (“body jacket”). (Reproduced with
permission from Ragnarsson KT. Rehabilitation of patients with physical
disabilities caused by tumors of the musculoskeletal system. In: Tumors of
the musculoskeletal system. Michael M. Lewis, editor. New York: W.B.
Saunders Co.; 1991).
blade, lukewarm water for washing, loose-fitting garments, and similar
measures. Meticulous oral hygiene is essential, and the patient should
frequently use diluted mouthwash with 3% hydrogen peroxide but
avoid all irritating agents (i.e., alcohol, tobacco, and astringent tooth-
paste) and should limit denture wear. A sense of noxious taste and dry
mouth may be reduced by the use of artificial saliva and by increasing
fluid intake. Mobilizing exercises for the mouth, jaw, neck, and shoul-
ders should be emphasized to prevent adhesions and contractures.
Cosmetic defects of the face are primarily treated by surgical
reconstruction, but different types of maxillofacial prostheses may be
custom-made from plastic materials to closely match the facial con-
tours and complexion. Surgical resection of cancer involving the
mouth, pharynx, and larynx may result in impaired functions of chew-
ing, swallowing, and speaking in different proportions. Following
resection of the tongue and mandible, physical exercise of the residual
muscles may improve chewing and swallowing, and special tubes or
utensils may help to place the food into the pharynx or esophagus and
thus ease the swallowing process. Defects in the palate may be cor-
rected by a prosthetic device, an obturator, placed between the oral and
nasal cavities.
Total laryngectomy results in a complete loss of voice and a per-
manently open tracheostomy.33 Preoperatively, a speech pathologist
should meet with the patient to explain ways to communicate postop-
eratively. Communication is initiated postoperatively by using writing
materials, communication boards, or electronic typing gadgets, but as
early as possible the patient is instructed in the use of an artificial elec-
trolarynx. Here, a hand-held battery powered “diaphragm” is placed
firmly against the neck to transmit sound waves through the tissues
into the mouth, where it resonates and may be articulated with relative
ease as comprehensible speech. Greater training, however, is required
to become proficient in the so-called esophageal speech, which is gen-
erated by trapping air in the upper esophagus by the tongue and releas-
ing it suddenly into the pharynx, thus producing a “burp-like” low-
pitched sound that may be articulated into words. Other patients may
prefer pharyngeal speech, which is produced by capturing air within
the mouth or pharynx. In some cases, a tracheopharyngeal shunt may
be surgically reconstructed to restore a more normal voice.34 Due to
the open tracheostomy, the laryngectomized patient is unable to strain
during lifting, pushing, or defecation, except by manually closing the
stoma. The permanent tracheostomy requires not only good local care,
but also inhalation of humidified air through a stoma cover made of a
piece of gauze that acts as a sieve for dust and other foreign materials.
Certain laryngeal cancers may be treated with partial resection of
the larynx, that is, hemilaryngectomy or supraglottic laryngectomy.
Hemilaryngectomy removes one vocal cord, while supraglottic resec-
tion removes the epiglottis. The former is associated with a voice
change that may be improved with voice therapy, whereas the latter is
associated with impaired deglutition, which is restored with appropri-
ate therapy. Aspiration pneumonia is a possible complication of laryn-
geal dysfunction. In paralysis of a vocal cord, autologous cartilagenous
transcervical implant can restore phonation and diminish aspiration.
Radical neck dissection may involve the removal of several neck
muscles and temporary or permanent damage of the spinal accessory
nerve that supplies the sternocleidomastoid and the trapezius muscles.
Table 71.6. Conditions and Complications Associated with
Spinal Cord Dysfunction
Loss of motor power Metabolic disturbances
Loss of sensation • Negative calcium balance
Pressure sores • Negative nitrogen balance
Urinary dysfunction • Hormonal imbalance
Bowel dysfunction Circulatory disturbances
Sexual dysfunction • Orthostatic hypotension
Autonomic hyper-reflexia • Edema
Pain • Deep vein thrombophlebitis
Spasticity Respiratory disturbances
Joint contractures Psychological problems
Heterotopic ossifications Social problems
Vocational problems
This is likely to result in gross asymmetry of the neck and shoulders,
restriction of motion, overstretching of remaining muscles, and persis-
tent pain if not treated early. During the rehabilitation of these patients,
it is of primary importance to unload the shoulder immediately post-
operatively, reduce shoulder and neck pain, and prevent stretch fibro-
sis of the trapezius and contracture of the unopposed pectoralis mus-
cles, as well as to provide strengthening exercises for the residual
muscles in the neck and shoulder girdle to compensate for lost mus-
cles.35 The patient is instructed to maintain good posture, both while
sitting and standing, and to pull back the shoulders frequently. Sleep-
ing on the back is preferable, with proper support provided by pillows
placed between the scapulae and under the posterior neck. Lying on
the affected side is to be avoided, and when lying on the unaffected
side, the affected arm should be slightly raised and supported on a pil-
low. Occasionally, it may be helpful to wear a sling, or even a shoulder
orthosis, to compensate for trapezius paralysis. Therapeutic exercises
are initially passive but gradually progress to active-assistive and even-
tually resistive exercises as tolerated by the patient. Strenuous physi-
cal activities, such as lifting, carrying, pulling, and pushing, should be
avoided initially but may be resumed in the course of time as the phys-
ical condition improves.
CANCER OF THE LUNG
The physical disabilities associated with lung cancer and its treat-
ment include respiratory insufficiency, shoulder pain and stiffness,
scoliosis, and the remote effects of certain lung cancers that cause a
neuromuscular disorder that becomes manifest as weakness and inco-
ordination. However, the functional limitations associated with lung
cancer frequently do not receive adequate attention and intervention
because of the high mortality and short life expectancy associated with
the disease.
Reduced respiratory capacity after lung resection or pneumonec-
tomy, especially when combined with pre-existing chronic obstructive
pulmonary disease (COPD), may result in respiratory complications and
insufficiency during both the postoperative period and the long-term
follow-up. These may best be prevented by preoperatively teaching the
patient deep-breathing exercises, segmental breathing, effective means
of coughing, and the principles of postural drainage. On the first post-
operative day, these activities are resumed with a physical or respiratory
therapist to eliminate mucus, which otherwise might plug the bronchi
and cause atelectasis and pneumonia. As the patient recuperates and
becomes ambulatory, shoulder range-of-motion, general strengthening,
and endurance exercises, as well as postural training, are added to the
therapy program to increase strength and stamina and to prevent post-
thoracotomy scoliosis and scapulohumeral displacement.36
CANCER OF THE BREAST
Breast cancer is usually treated with mastectomy or with lumpec-
tomy followed by radiation, and often with chemotherapy. This treat-
ment not only may result in considerable physical disability, but the
woman’s self-image and emotional well-being may be adversely
affected. The cosmetic impact of the loss of the breast, a symbol of fem-
ininity, is profound and adds to the emotional turmoil created by the can-
cer diagnosis and the uncertain prognosis of the disease. Radical mas-
tectomy with removal of the pectoralis muscles, although now rarely
performed, may cause shoulder weakness and, together with axillary
node dissection, may produce swelling of the ipsilateral arm. Stiffness of
the shoulder and hand may limit reach and manual dexterity. Fortunately,
the recent trend of performing modified radical mastectomies or
lumpectomies and routinely providing proper postoperative rehabilita-
tion therapy has reduced the frequency and severity of these problems.
Postoperative rehabilitation has three main goals: prevention of phys-
ical disability, restoration of cosmetic appearance, and psychosocial and
vocational re-adjustment. Physical rehabilitation aims at improving mus-
cle strength and mobility at the shoulder, minimizing arm swelling, and
facilitating resumption of all functional activities—ADL, recreation, and
work. Following radical mastectomy, the arm should be kept slightly ele-
vated, with the shoulder abducted to 80 to 90 degrees and externally
rotated, keeping the elbow free.37 The entire arm is compressed by a well-
wrapped elastic Ace bandage, which is reapplied every 8 hours to reduce
CHAPTER 71 / Principles of Cancer Rehabilitation Medicine 979
the swelling. Substantially less physical rehabilitation is necessary fol-
lowing modified radical mastectomy and axillary dissection, an operation
that spares the pectoralis major and usually the pectoralis minor. Lumpec-
tomy with axillary dissection requires even less physical and psychologi-
cal rehabilitation, which may proceed at a more rapid pace. Depending on
the extent of the mastectomy, physical exercises may be started within 2 to
5 days postoperatively. The nurse or therapist first instructs the patient in
deep-breathing and relaxation exercises, and in how to move about in bed
comfortably, and to get up and perform light self-care tasks using primar-
ily the unaffected arm. Gentle exercises are started at this time, with the
patient actively moving all the unaffected limbs, as well as the elbow,
wrist, and hand on the affected side, and isometrically contracting the dis-
tal muscles (hand squeezing) while supine and with the affected arm ele-
vated. When the drains have been removed from the surgical site, the exer-
cises may become more demanding. The patient starts performing gentle
active exercises of the affected shoulder while still in a supine position.
Approximately 10 days postoperatively, when the sutures are removed,
active or active-assistive shoulder exercises in the upright position are
begun, that is, “wall climbing” exercises using the uninvolved arm or an
overhead pulley system to ease the task. Upon discharge, the patient
receives a series of exercises to perform at home to ensure that full shoul-
der mobility and maximum strength will be regained.
Cosmetic restoration following mastectomy involves either surgi-
cal reconstruction of the breast or provision of a prosthesis. During the
initial postmastectomy period, a temporary Dacron-filled prosthesis
may be provided, but a more definitive prosthesis can be furnished
when the surgical incision is well healed, usually 1 or 2 months fol-
lowing the surgery.38 Reconstruction is usually done several months
after surgery, following the completion of chemotherapy and radia-
tion, although immediate reconstruction at the same operation after
mastectomy and axillary dissection has many advocates. Reconstruc-
tion is particularly indicated in younger women who have good life
expectancy but whose self-image has suffered due to the mastectomy,
although neither age nor an uncertain prognosis should be a con-
traindication to this procedure. Simple and temporary fillings of soft
materials may be inserted into the brassiere initially for cosmetic
effect, but a permanent prosthesis is ordered 2 to 3 months postopera-
tively, or after completion of the radiation therapy.
Lymphedema of the arm after radical mastectomy is seen in
approximately 10 to 15% of patients, although relatively mild or mod-
erate arm swelling is much more common, especially in the early post-
operative days. Lymphedema is less common after modified radical
mastectomy, and rare after lumpectomy, even though both procedures
do have axillary dissection. When lymphedema is severe, it may result
in both a significant disability and a disfigurement. While surgical
removal of lymph nodes and lymph vessels or their destruction by radi-
ation undoubtedly is the major etiologic factor, a number of other con-
tributing factors may play a role, including infection, inflammation,
scar formation, obesity, thrombophlebitis, arm dominance, and habit-
ual dependent position of the arm. The greatest incidence of lym-
phedema has been noted among those who received high-dose radia-
tion or had a history of one or more infections.39 Prevention of
lymphedema with proper postoperative care and initiation of an exer-
cise program, as outlined above, is most important because treatment
of persisting lymphedema is relatively ineffective. Such treatment usu-
ally involves different physical interventions: performing, several
times a day, sets of isometric exercises of all the arm muscles while the
arm is maintained in an elevated position, and using sequential pneu-
matic compression with a multi-compartmental inflatable sleeve.40
These modalities help to pump the fluid from the hand and distal arm
toward the body. Many hours of pump use may be required each day to
reduce the edema significantly. Compression therapy by manual mas-
sage of both the edematous41 and the contralateral arm42 has also been
advocated but is considered by some to be time-consuming and ineffi-
cient.43 Between periods of use, the arm should be carefully wrapped
with elastic bandages, and when maximum reduction of the edema has
been obtained, a custom fitted elastic support sleeve should be fabri-
cated and worn continuously. The entire limb should be guarded
980 SECTION 21 / Principles of Rehabilitation Medicine
against even trivial trauma, which may be caused by constricting gar-
ments and excessive heat or exercise, to minimize swelling. Treatment
with these physical modalities has been shown to benefit the majority
of patients with postoperative lymphedema and is more effective than
diuretics, salt-restriction diets, benzopyrones, or surgical proce-
dures.42–44 Benzopyrone has been reported to cause a slow but safe
reduction of high-protein lymphedema of the extremities by stimulat-
ing proteolysis by macrophages.45
CANCER OF THE GASTROINTESTINAL TRACT
The cancer rehabilitation team is involved in the care of the patient
who has cancer limited to the gastrointestinal tract when the definitive
surgical treatment has resulted in an ostomy. The enterostomal thera-
pist (ET nurse) plays a major role in helping the cancer patient with an
ostomy (i.e., colostomy, ileostomy, or urostomy) to understand the
principles of ostomy care, to learn the different aspects of ostomy man-
agement, and to adjust to the altered self-image. After surgery, the
patient is placed on a diet of clear liquids, which is followed by full flu-
ids, and later solid food. What constitutes a well-balanced diet and the
importance of a high-fiber, low-fat diet are discussed. It is best to
increase the diet’s fiber content gradually to avoid gas formation and
bloating, by adding fruits, vegetables, and whole-grain food in slowly
increasing amounts.
COLOSTOMY The surgical treatment of cancer of the rectum usually
mandates the creation of a colostomy, using the sigmoid colon. A can-
cer higher in the colon can frequently be resected and the bowel recon-
nected by anastomosis. Before undergoing a surgical procedure for
cancer that will result in a colostomy, the surgeon needs to discuss the
plans carefully with the patient. Subsequently, the ET nurse should
meet with the patient and family members to explain in simple but
clear terms the nature of the colostomy, for example, where the stoma
will be located on the abdominal wall, how it will look, what coverings
and collection appliances will be needed, how evacuation will occur,
and so on. A positive attitude on the part of the medical and nursing
staff is important at this time, although the patient’s fears and concerns
regarding function, appearance, and sexual activity need to be
acknowledged and discussed. Detailed and explicit explanations, par-
ticularly regarding the surgical procedure and subsequent care, should
be based on a patient’s individual needs. Too much information that the
patient is not ready to absorb may do little except increase anxiety. A
visit by a person who is successfully managing his or her colostomy
may be very helpful. Good preoperative preparation reduces the
patient’s fears and builds confidence, both of which will facilitate
postoperative rehabilitation.
Postoperatively, protecting the skin and collecting the drainage
should be the primary goals. This is accomplished by a properly fitted
appliance. Modern appliances with protective skin barriers cut to fit
the exact size of the stoma will avoid postoperative peristomal skin
excoriation and keep the patient dry and odor-free. A person with a
colostomy has a choice of allowing the bowels to function normally or
to irrigate as a method of attempting to control bowel movements.
Often, the bowel habits return to normal patterns, and a well-fitting
appliance may be emptied or changed as needed. Proper fit of an appli-
ance by an ET nurse allows the patient to make an informed choice, as
the appliances are odor-proof and disposable, and have protective
pectin skin barriers attached to keep the peristomal skin healthy and
free of irritating discharge.
The patient may choose to learn irrigation techniques, but these
cannot always be taught in the hospital setting, given the current pres-
sure for early discharge. Outpatient ET services and/or visiting nurses
often teach or continue to teach irrigation in the home after discharge.
The purpose of the irrigation is to establish a bowel routine, with the
goal of evacuating only after the irrigation, rather than spontaneously
or at inopportune moments. However, this is not always possible.
Therefore, the patient should always be instructed in the care and use
of a properly fitted appliance. This may help the patient to avoid the
frustrations that usually are experienced when bowel discharge con-
tinues between the irrigations. Irrigation of the colostomy may be done
daily, every other day, or even every third day, at the time of the
patient’s preference. Initially, a full hour should be allocated for the
irrigation and evacuation, although later 30 minutes may suffice to
complete the task. The first irrigation is an important event that
requires both sensitivity and technical skills on the part of the ET
nurse. The irrigation should be done in private, preferably with the
patient sitting by the toilet on a comfortable soft chair. A lubricated
cone is gently inserted into the stoma and 1 liter of lukewarm tap water
is instilled over a period of approximately 10 minutes from an enema
bag placed no higher than at shoulder level, similar to administering an
enema. The water distends the bowel, causing peristalsis and expulsion
of stool. Following evacuation, the skin is cleansed with warm water
and patted dry. The pouch is re-applied. A family member may want
instructions in colostomy care, both to understand the patient’s plight
and to be able to assist or take over the care during periods of illness.
The patient and the family are provided with information on the
United Ostomy Association, and its local chapters and publications, as
a resource for further information
Numerous clinical problems may arise at any time after the cre-
ation of a colostomy. Constipation is often due to inadequate intake of
fluids or dietary fiber but may be successfully managed by increasing
dietary fiber and fluid intake. Diarrhea may be caused by different
foods (spicy, greasy, or fried foods; certain vegetables, fruits, and
juices) or anxiety but small amounts of liquid stools may indicate
incomplete evacuation or the presence of impacted feces. Excessive
gas formation also may result from the ingestion of certain foods
(baked beans, onions, greasy food) or other factors which need to be
identified and treated appropriately. Noxious odor may be increased
by various foods and liquids (cabbage, eggs, onions, garlic, beer, cof-
fee). Each person must experiment with different foods. What may
adversely affect one person may not affect another. Deodorant tablets
placed in the disposable colostomy pouch may help to diminish odors.
Skin excoriation and maceration will usually respond to appropriate
local care by gentle washing with soap and water and applying a prop-
erly fitted appliance. Skin infections may be caused by fungi or bacte-
ria. Fungal infections should be treated with mycostatin (Nystatin)
powder and bacterial infections by administering topical or, occasion-
ally, oral antibiotics. Stomal bleeding in small amounts is usually of
little concern, but if persistent, mixed with stools, or in large amounts,
it will require proper diagnostic evaluation and intervention. Sexual
dysfunction after abdominoperineal resection is common, not due to
the colostomy per se but due to damage to the autonomic nerves in the
pelvis sustained during extensive surgery. The altered self-image often
associated with the colostomy can cause temporary sexual dysfunc-
tion. Men may become impotent and women anorgasmic, while sexual
desire is not lessened.46 Sexual counseling for both partners, good
communication, and the teaching of new techniques for mutual grati-
fication can do much to restore successful sexual activity. The
colostomy patient will normally experience a reactive depression or
grief and subsequently go through the different stages of adaptation
that are associated with any kind of major personal loss. The
colostomy’s negative influence on the patient’s self-image is best coun-
teracted by the physician and the ET nurse when they are able to make
an accurate assessment of the patient’s complaints and condition, plan
actions and interventions accordingly, and provide supportive coun-
seling on an individual basis.47
ILEOSTOMY The principles and techniques of ileostomy care are sim-
ilar to those of colostomy. The stools are of a loose consistency and
drain continuously from the ileostomy. It is, therefore, necessary that
the collecting pouch be worn at all times and that it be properly fitted
by an ET nurse. Small bowel contents contain active digestive enzymes,
which can cause severe peristomal skin excoriation if leakage occurs.
The collecting pouch must be emptied as needed, usually every 3 to 6
hours, by releasing the clamp from the bottom of the pouch and emp-
tying the contents directly into the toilet. Since the fluid loss through
ileostomy is greater than with colostomy, fluid intake must be increased
to prevent dehydration. There are no dietary restrictions except to avoid
corn and peanuts, but the food should be eaten slowly and chewed well
to prevent food blockage. A greater loss of electrolytes and certain vita-
mins, especially B12, may also be experienced, thus requiring regular
monitoring and supplementation. Certain coated medications and time-
release capsules may pass through the gut without being digested, a fact
to be considered whenever physicians prescribe medications for indi-
viduals with ileostomy. In general, the psychosocial adjustment and
rehabilitation outcome for an individual with ileostomy are similar to
those after any surgery that requires alteration of elimination habits and
results in living with a stoma.
CANCER OF THE GENITOURINARY SYSTEM
Invasive cancer of the bladder frequently requires radical cystec-
tomy and the creation of a new outlet for urine. More than 40 years
ago, Bricker developed the ileal conduit procedure by connecting the
ureters to an isolated segment of ileum, which is surgically closed at
one end but opens at the other as a stoma on the abdominal wall, allow-
ing free elimination of the urine. This procedure has become the tradi-
tional form of long-term urinary diversion. The management princi-
ples of ileal conduit stoma care are similar to those of colostomy and
ileostomy. Since urine flows continuously from the stoma, the collect-
ing system must be well fitted and watertight to prevent leakage. The
collecting pouch must have a drain valve for easy emptying and for
connecting to a night-time urine collection bag. Skin or stoma prob-
lems from the urine are not uncommon and may be caused by alkaline
urine. Many physicians prescribe vitamin C, 1,000 mg daily, to keep
the urine slightly acid. The intake of 8 to 10 glasses of fluid daily is
important. In recent years, the continent urostomy has gained consid-
erable popularity when used with compliant patients. The Kock pouch
and the Indiana pouch, with several modifications of both procedures,
result in an internal reservoir.48–53 The patient inserts a catheter into
the stoma every 4 to 6 hours to empty the internal pouch contents. This
procedure eliminates the need for external devices.
GENITAL CANCER Members of the cancer rehabilitation team may
occasionally be asked to provide care for a patient with cancer involv-
ing the genital organs, or when the cancer and its treatment have caused
sexual dysfunction. Rehabilitation interventions usually involve care-
fully planned reconstructive surgery and psychological and sexual
counseling. The form of surgical reconstruction varies, depending on
the type of the cancer and the extent of the surgical resection but also
on the specific needs of the patient. The woman who has undergone
radical gynecologic surgery with resection of the vagina may benefit
from vaginal reconstruction that allows resumption of sexual inter-
course.54 The man who is unable to achieve penile erection can be pre-
scribed sildenafil, taught intrapenile injection of vasodilating drugs to
cause erection when desired, or rarely nowadays have a penile prosthe-
sis implanted.55 The choice of prosthesis is between semirigid silicone
rod implants and a system of inflatable cylinders implanted into the
shaft of the penis, with the scrotal pump and fluid reservoir placed in
the abdominal wall.56–58 The implantation of the semirigid rod is a rel-
atively simple surgical procedure with few mechanical problems, but
the penis stays semierect permanently. The inflatable prosthesis pro-
vides a more normal appearance of the penis both when flaccid and
erect, but mechanical problems with the system arise quite often.
Cancer of the testes is usually treated with prompt surgical exci-
sion of one or both of the testicles, followed by radiation and/or
chemotherapy. Surgical implantation of a prosthetic testicle at a later
date may be gratifying for patients concerned about their appearance
and self-image.
Sexual rehabilitation obviously is not limited to those who have
cancer affecting the genital organs, but should be available for anyone
who experiences sexual dysfunction for physical or psychological rea-
sons due to cancer and its treatment. Different members of the reha-
bilitation team collaborate in providing sexual counseling for patients
with different forms of cancer, both on an individual basis and by orga-
nizing courses and seminars on the physiology and anatomy of sexual
function, on human sexuality, and on ways of adjusting to sexual dys-
function. Male sexual impotence compounds the reactive depression
associated with the diagnosis of cancer and adds to the stigma of any
physical disability. This condition is frequently met with prejudice and
poor understanding on the part of both the patient and his sexual part-
ner. Sexual rehabilitation emphasizes that sexuality is considered part
of the whole person and cannot be lost due to an illness or injury. Phys-
CHAPTER 71 / Principles of Cancer Rehabilitation Medicine 981
ical disability, in contrast to a physical illness, does not decrease sex-
ual drive, although it may affect sexual function both physically and
psychologically. The anatomy and physiology of sexual function
should be carefully explained to the disabled patient and his partner
and general guidelines for success given. Good communication and
strengthening of relationships between sexual partners are empha-
sized. The different physical aspects of sexual performance are
explained in order to make expectations compatible with performance
capability. For most cancer patients with a physical disability, impair-
ment of mobility, sensation, continence, and erection should not inter-
fere with building a solid personal relationship, with having sensitiv-
ity to the partner’s desires, or with being able to please and enjoy.
Sexual rehabilitation is built on the concept that if sexual comfort is
taught, sexual competence may result.59 Manual and oral sexual acts
may be appropriate for both sexes. No treatment or rehabilitation of the
patient with cancer can be considered complete until the clinician has
adequately addressed the impact of the condition on sexual function.
Sexual health cannot be separated from total health. The extra time
spent considering sexual adequacy and providing guidelines for help
can benefit the patient for years.
CANCER OF THE LIMBS
Primary malignant tumors of the limbs require surgical treatment.
The main surgical goal is to remove the tumor, either by an excision with
wide margins through a site well clear of any malignant growth, or by a
radical removal of the entire bone or the compartment afflicted by the
tumor. A subsequent surgical goal is to reconstruct the resulting defect
for optimal function and cosmesis. Although limb amputation has been
practised for centuries, in recent years, limb salvage by extended local
or regional excision and reconstruction has been the principal goal. The
survival and disease-free survival after both types of surgical approaches
are similar and have been vastly improved in recent years by the use of
chemotherapy, radiation, or both. The return to optimal function can best
be assured by a multi-disciplinary rehabilitation team approach that
includes the surgeon, the medical and radiation oncologists, the physia-
trist, and all the members of the rehabilitation team.60
Skeletal metastases are more common than primary bone tumors.61
Metastases to the limb bones are less common than those to the spine.
While some patients may complain of localized pain, others are essen-
tially asymptomatic until a pathologic fracture occurs. Such fractures
occur in approximately 10 to 15% of patients who have radiographic
evidence of skeletal metastasis. Pathologic fractures are most debilitat-
ing and often result in diminished survival for otherwise stable
patients.22 At particular risk are women with metastatic breast cancer,
patients with advanced metastatic disease, and those with a large single
lytic lesion eroding the bony cortex.62 Active rehabilitation and physi-
cal mobilization do not seem to increase the fracture risk significantly.
When prognosis suggests many months of anticipated function, pro-
phylactic surgery for impending fracture of the femoral neck or shaft
often diminishes the total disability consequent to pathologic fracture
and more difficult surgical repair. Prophylactic surgery is otherwise
generally not warranted but radiation may have some effect in reducing
pain and limiting tumor growth.63 If pathologic fracture occurs, open
surgical treatment with adequate internal fixation and conjunctive use
of methylmethacrylate may be employed successfully to relieve pain,
restore mobility, ease nursing care, and provide psychological reassur-
ance.64 Postoperative immobilization should be brief, and aggressive
physical therapy should be started early to return the patient swiftly to
previous function, as well as to minimize hospitalization.
PREOPERATIVE REHABILITATION Rehabilitation care should start
immediately after the diagnosis of primary cancer of a limb is estab-
lished, regardless of whether amputation or limb-sparing surgery is
planned for cancer removal, or whether chemotherapy and radiation
are to be instituted pre- or postoperatively. The implications of surgery
and the postoperative course should be discussed at this time with the
patient and family. Simultaneously, an appropriate physical exercise
program should begin. These interventions during the emotionally
stressful preoperative days may ease the patient’s adjustment and reac-
982 SECTION 21 / Principles of Rehabilitation Medicine
tion to the postoperative course. Emotional support is best given by
recognizing the patient’s fear and anxiety and by providing in a posi-
tive way some practical information and explicit factual instructions
that can be easily understood and followed. While it is important that
the positive aspects of the surgical treatment be explained (i.e., that it
is a swift, life-saving technique, and that modern technology and train-
ing allow significant restoration of function), it is best for the physi-
cian to resist overly optimistic predictions and to discourage unrealis-
tic hopes until postoperative rehabilitation success has been ensured.
On the other hand, pessimistic statements as to what the patient will
never be able to do are needless and are usually inaccurate. A time
frame is provided for postoperative rehabilitation efforts and possible
return to various functional activities, taking into consideration the
extent of reconstruction, level of amputation, general physical and
mental status, age, athletic ability, and lifestyle. Peer counseling by a
successful rehabilitated amputee may further help the patient to antic-
ipate postoperative events and function.
When amputation or limb-sparing surgery is planned, the exact
level of amputation and the surgical approach should be thoughtfully
chosen, taking into account not only the location and type of cancer
but also the probability of good wound healing and the successful fit-
ting of a prosthesis, when required. It may be helpful for the surgeon
to consult with the physiatrist and prosthetist for this purpose. Preop-
eratively, strengthening exercises should be started for muscles in the
uninvolved extremities and the trunk, as well as for muscles to be
spared in the affected limb. Specifically, the patient should learn to
perform isometric exercises for the quadriceps and gluteal muscles.
Strengthening exercises for the unaffected limbs should focus specif-
ically on shoulder depressors and elbow extensors, which are critical
for ambulation with crutches or walkers. Trunk-strengthening and
balancing exercises may further ensure postoperative ambulation suc-
cess. Ambulation with a walker or a pair of crutches, non–weight
bearing on the affected limb, should be practised preoperatively while
the patient has no fear of falling because of lack of limb support and
is not impaired by incisional pain, medications, or postoperative com-
plications. Such preoperative therapy not only will help the patient
succeed swiftly in postoperative ambulation and self-care activities,
but a quick restoration of function will ease the emotional adjustment
to the disability, whether it be amputation or limb sparing with an
internal prosthesis.
LIMB AMPUTATION Limb amputation for cancer at one time was dis-
couraged, as the prevailing opinion was that poor life expectancy did
not justify the expense of surgery and prosthetic fitting. However, the
5-year survival for patients who have undergone amputations for limb
cancer (49%) compares favorably with the survival of patients with
amputations for limb ischemia,65 and the functional skills of cancer
amputees are reportedly better than the skills of those patients who
have had amputations for other reasons.66
Until recently, amputations for cancer were done in a radical fash-
ion and left little, if any, residual limb, except when amputating for
very distal limb tumors, since the basic clinical rule was to amputate
proximally to the joint immediately above the tumor site. Lower-limb
amputations for cancer involving the knee joint or thigh thus were fre-
quently performed by a hip disarticulation or hemipelvectomy, and
upper-limb amputations by shoulder disarticulation or interscapu-
lothoracic (forequarter) amputations. These radical limb operations
were believed to be mandatory due to the high risk of metastasis, espe-
cially metastasis to the lungs. Modern diagnostic techniques now can
demonstrate the presence or absence of metastases with a high degree
of accuracy. According to a recent survey, since the use of adjuvant
chemotherapy, sarcomatous metastases are not as common as was pre-
viously thought.67 Thus, less extensive amputation techniques can now
be employed, such as cross-bone amputations with 3 to 4 inches of nor-
mal bone left as the margin. Greater residual limb length thus results,
and functional outcome is better for most patients. Accordingly, pri-
mary cancer in the distal femur now permits an amputation through the
proximal femur, a cancer in the proximal tibia permits amputation in
the mid or distal femur, and cancer in the distal tibia allows a below-
knee amputation (BKA). Analogous amputation levels may be appro-
priately considered for cancer of the upper limbs.
While maximum preservation of limb length compatible with
eradication of the cancer is desirable, certain amputation levels may
result in residual limbs that are difficult to fit and, therefore, best
avoided, such as the hind foot, the distal third of the leg, and the
femoral supracondylar region. It is critical to preserve the knee joint,
if possible, to ensure smoothness of gait, lower energy cost, and better
function. Whenever possible, 12 to 18 cm of tibia should be retained
for optimal prosthetic fitting, but even a very short BKA that retains
the tibial tubercle will preserve knee extension by the quadriceps mus-
cle, and preservation of the knee joint will provide the needed position
sense. This amputation level is, therefore, better than amputating
above the knee. When the fibula is retained, it should be cut slightly
shorter than the tibia. Disarticulation at the knee is also preferable to
above-knee amputation (AKA), as it provides a wide weight-bearing
surface, long lever arm, and proprioception. Unfortunately, this level
often cannot be chosen due to intra-articular spread of cancer located
in the mid or proximal tibia. It is preferable to have the AKA stump as
long as possible to preserve maximal adduction power. Prosthetic knee
joints can accommodate any length of femur. A residual femoral
length that is less than 8 cm from the greater trochanter to the tip func-
tions poorly. As a rule, hip disarticulation is preferred to an amputation
level above the lesser trochanter. Hip disarticulation and hemipelvec-
tomy need reconstruction with a long posterior flap in order to create
a proper sitting area on the prosthesis.68 When provided with a well-
fitting plastic laminated socket and an endoskeletal modular-design
prosthesis, persons with hip disarticulation are able to stand, walk, and
sit quite comfortably. Hemicorporectomy (translumbar amputation)
has been performed on rare occasions on patients with widespread
cancer of the pelvis, but without metastases elsewhere. This procedure
is a challenging alternative to the nonsurgical approach and has been
shown to have a good rehabilitation outcome.69 Cancers in the upper
limbs unfortunately are primarily found in the proximal humerus and
require shoulder disarticulation or interscapulothoracic amputation.
Here, it is important to retain quality skin and maximum muscle mass
for padding the shoulder, but retention of the humeral head, if possi-
ble, will result in better prosthetic fitting.
Successful prosthetic use depends to a large extent on proper sur-
gical techniques of amputation.70 It is not adequate only to provide a
long residual limb, although this is important for both leverage and
large total contact area for weight bearing. Optimally, the residual limb
should be firm and tapered or cylindrical in shape, with all bone ends
well padded. The skin must have good innervation and vascular supply
and not be adherent to bone or have sensitive scars.
Postoperative care should ensure optimal wound healing, mini-
mize limb swelling, prevent joint contractures, and improve muscle
strength and function. Application of appropriate dressing and exter-
nal pressure on the residual limb is very important.71 Wrapping with
the customary elastic bandages must be done skillfully with frequent
re-applications to maintain maximum sustained pressure and to avoid
a tourniquet effect. Different forms of semirigid dressings have been
used, such as Unna paste dressings, custom-made elastic “stump”
socks, plastic films, and inflatable air splints, each of which has dif-
ferent advantages and disadvantages. Inflatable and removable air
splints, recently popularized, are made of clear plastic and have a zip-
per, which allows easy inspection, attachments, and removal.
An elastic plaster bandage may be applied to the residual limb
immediately after the amputation. This immediate postsurgical fitting is
a rigid form of dressing that can effectively reduce edema and postoper-
ative pain. A prosthetic pylon and foot can be attached directly to the
plaster to allow standing within 2 days postoperatively. Initially, only
minimal weight bearing is allowed, but progressive ambulation is con-
tinued and full weight bearing may be possible in 3 to 4 weeks.72 Sev-
eral disadvantages of this technique have made it difficult to implement.
A removable rigid dressing provides for easier inspection of the residual
limb, dressing change, and adjustment for progressive shrinkage and
may even allow attachment of a temporary adjustable prosthesis.73,74
POSTOPERATIVE EXERCISE PROGRAM Physical and occupational
therapy should be initiated within 2 days after the amputation. The pre-
operative exercise program is resumed for muscle strengthening and
joint mobilization. Knee flexion contractures may easily develop after
BKA, whereas hip flexion and abduction contractures are frequently
seen with short AKA. Mobilization is started at the bedside, but within
a few days, the patient is taken by wheelchair to the therapy area, and
ambulation in parallel bars or with a walker is started. The skillful
amputee is subsequently provided with a pair of crutches; however,
when prosthetic fitting has been completed, a single cane will usually
suffice. Different types of ready-made or prefabricated temporary
prosthetic devices exist for the earliest ambulation efforts, but a cus-
tom-fitted provisional prosthesis should be provided as soon as the
surgical incision has healed. The amputee, however, may be dis-
charged from the hospital even without a prosthesis, if the patient is
ambulating safely with assistive gait devices and is independent in
ADL. Transfer to the inpatient rehabilitation unit for more intensive
therapy may be advisable at any time before these two goals are
reached if the amputee is otherwise medically stable.
PRESCRIPTION OF AN ARTIFICIAL LIMB The physician needs to con-
sider multiple factors when prescribing a limb prosthesis. The ampu-
tation level and limb condition clearly are of primary importance, but
prosthetic candidacy may be affected by numerous other factors,
including associated medical conditions, other physical disabilities,
life expectancy, muscle strength and coordination, stamina, various
psychological factors (i.e., motivation, emotional adjustment, and cog-
nition), and individual lifestyle factors (i.e., age, weight, family sup-
port, recreational interest, environment, and type of work). The extent
of prosthetic usage is to some degree predictable, since each symp-
tomatic medical problem adversely affects functional prognosis. The
ability of the patient to ambulate with a walker or a pair of crutches,
but without a prosthesis, strongly suggests prosthetic candidacy. After
carefully considering these different factors, the physiatrist may have
to choose between a prosthesis that provides relatively greater safety
with stability and one with greater function and mobility, between
durability and low prosthetic weight, besides considering differences
in cost and cosmesis. When new or advanced designs are chosen, the
skill and expertise of the prosthetist are crucial factors, and the pros-
thetist must be easily accessible to the patient as well.
Most prostheses are currently fabricated from metals and plastics.
The customary below-knee (BK) prosthesis consists of a socket,
shank, and ankle-foot components, as well as a suspension system.
The socket usually has a patellar tendon-bearing (PTB) design and
total contact with the residual limb for maximum pressure distribution.
Soft liners inside the socket add comfort by absorbing shocks. Several
layers of socks may need to be worn to accommodate a shrinking
residual limb. The shank is either of an endoskeletal design with an
internal metal pylon or an exoskeletal structure made from laminated
plastic. The solid ankle cushioned heel (SACH) foot is simple,
durable, lightweight, and cosmetic and is still most commonly pre-
scribed despite the arrival of a variety of new energy-storing prosthetic
feet, such as the Seattle and the FLEX feet designs. The prosthesis is
usually attached to the residual limb by a supracondylar cuff, although
several other alternatives exist. The above knee (AK) amputee tradi-
tionally obtains a prosthesis with a rigid quadrilateral socket and a pos-
terior ischial seat for additional weight bearing. More modern socket
designs promise greater comfort in sitting and better control during
ambulation.75 The popular single-axis knee joint with constant friction
is simple and durable, whereas the more costly and complex polycen-
tric or hydraulic knee units can provide better function for young,
physically active amputees. Stability of the knee joint during stance
may be increased by posterior placement of the knee axis, but for max-
imum safety, manual or automatic knee locks may be added. The AK
prosthesis optimally is suspended by total suction, or by partial suction
and a Silesian bandage or a pelvic band. An endoskeletal pylon con-
nects the knee unit above to the prosthetic foot below. After a hip dis-
articulation, the amputee receives the Canadian-type prosthesis, which
has a plastic laminated socket encircling the pelvis. This provides a
resting surface for the ischial tuberosity for weight bearing. With
proper molding, it is suspended from the iliac crest. A similar prosthe-
sis is worn after hemipelvectomy, with the rib cage providing the
weight-bearing surface.
CHAPTER 71 / Principles of Cancer Rehabilitation Medicine 983
Cancer in the upper limb frequently requires shoulder disarticulation
or interscapular thoracic amputation, both of which make fitting the
patient with a functional body-powered prosthesis difficult or impossible.
Myoelectrically controlled and externally powered prostheses may pro-
vide some gross function, but such prostheses are relatively expensive,
are heavy, and require repair more often than body-powered prostheses.
In recent years, prosthetic techniques for all types of amputations
have advanced significantly, especially with respect to evaluation
methods, socket design, ankle-foot components, and cosmesis.76
PROSTHETIC FITTING AND TRAINING Before completion of the pros-
thesis, the amputee needs to visit the prosthetist several times to ensure
optimal fit, function, and comfort. When fabrication has been com-
pleted, the prescribing physician checks the prosthesis for fit and com-
fort, socket stability, joint motions, appearance, and function. The
lower-limb amputee receives gait training, with or without gait aids,
depending on motor skills, instructions in attachment and removal
techniques, and exercises to increase muscle strength, joint range of
motion, balance, and posture. The upper-limb amputee learns to open
and close the terminal device, position the arm, manipulate objects,
and perform self-care tasks. Initially, a prosthesis may not be worn
comfortably for more than 15 to 30 minutes at a time. The amputee
thus requires frequent rest periods and short therapy sessions. After
each wear, the skin of the residual limb must be examined for signs of
excessive pressure or poor socket fit.
At the beginning of prosthetic wear, confrontational situations
may develop between the amputee and the health professional, espe-
cially when the patient’s expectations do not match the actual situation.
New and increased demands may produce discomfort at the prosthe-
sis–user interface and in other body parts. Disappointment with the
final appearance, weight, ease of wear, level of comfort, and func-
tional limitations of the prosthesis is common. The health professional
needs to understand the adjustment process and assist the amputee by
paying attention to legitimate complaints, providing encouragement,
and making judicious adjustment to the prosthesis. Poor communica-
tion may force the amputee to obtain a new, but often no better, pros-
thesis elsewhere. Various deviations of gait occur with lower-limb
prosthetic use due to problems with the residual limb, inadequate pros-
thetic fit, psychological reactions, and improper training. These need
to be carefully analyzed and proper intervention offered.
Lower-limb amputees ambulate at greater energy costs than do
nondisabled persons.77,78 The BK amputee expends 23 to 68% more
energy per unit distance than does an able-bodied person, and the AK
amputee expends 52 to 124% more.79 However, to save energy, most
amputees decrease their speed of ambulation, which is approximately
2.0 to 2.5 mph for BK and 1.0 to 1.5 mph for AK amputees, as com-
pared with a normal speed of 3 to 4 mph for nondisabled persons. The
lower energy cost and greater speed of ambulation for the BK amputee
clearly show the importance of sparing the knee joint whenever possi-
ble. Patients with hip disarticulation or hemipelvectomy ambulate
with lower energy expenditure if they use axillary crutches without a
prosthesis, as compared with prosthetic use.79
Various clinical problems may occur as the result of the amputa-
tion and consequent prosthetic wear, including pain, skin lesions,
swelling, joint contractures, and mental depression. Most amputees
experience phantom sensation, which is a painless awareness of the
amputated part. In contrast, phantom pain may be described as burn-
ing, crushing, cramping, or shooting sensations in the amputated
phantom limb. The reported incidence of phantom pain has varied
between 10 and 85%.80 This variation may be due to differences in
classification of the types of pain,81 the fear of presumed mental ill-
ness if a phantom pain is reported,80 and the time delay since surgery.82
The pain may be aggravated by limb contact and different physical
activities, but the exact cause remains unknown, as no detectable
pathology or premorbid emotional problems are usually discovered.
Phantom pain83 may be preventable or effectively managed by careful
preoperative explanations of the nature of the phantom phenomenon,
good surgical techniques, regular examinations postoperatively, and
frequent manual handling and good care of the stump, as well as by
984 SECTION 21 / Principles of Rehabilitation Medicine
effective treatment of stump infections and early provision of a func-
tional prosthesis. Definitive treatment, however, is difficult, but symp-
toms usually improve when a relatively normal situation has been
restored. Other beneficial interventions include desensitization by fre-
quent self-inspection and manipulation of the residual limb, applica-
tion of superficial heat or cold, deep heating with diathermy, massage,
vibration, TENS, imaginary exercises of the phantom limb, active
exercises of the entire body, local anesthesia, and psychological inter-
ventions. Analgesic medications are relatively ineffective, but agents
acting on the central nervous system may be helpful.
Actual and localized pain in the residual limb occurs frequently
after amputation for various pathologic reasons, such as infection, scar
adhesion, muscle spasm, or poor socket fit. Skin reactions occur fre-
quently under the prosthesis and require meticulous care. The limb
should be gently washed with soap and water and thoroughly dried each
evening rather than in the morning. The prosthetic socket should be
cleansed with a moist soapy cloth, and socks should be washed imme-
diately after removal and thoroughly dried before they are worn again.
The residual limb should be kept dry and free of trauma to prevent mac-
eration. Talcum powder is often used to keep the skin dry and smooth,
but cocoa butter may be applied to lubricate the scar. During early pros-
thetic wear, the amputee may frequently experience skin maceration,
abrasions, blisters, and infections of hair follicles and sweat glands,
each of which requires specific treatment. Open, draining, or painful
skin lesions require discontinuation of prosthetic wear until healing has
occurred. Gradually, the skin will toughen with regular prosthetic use,
and skin problems become fewer in the course of time.
Reactive depression and grieving the limb loss may be anticipated,
but these reactions are compounded by the cancer’s uncertain progno-
sis. Early restoration of function and psychological support provided
by the entire health care team may be the best intervention, although
psychiatric treatment may occasionally be indicated.
LIMB-SPARING SURGICAL RECONSTRUCTION Local resection of can-
cer with limb-sparing reconstruction may result in survival, disease-
free survival equal to that for amputation, and function which is supe-
rior.84,85 Amputation, however, is still a primary treatment for many
limb tumors since it may, at times, be impossible to perform a proper
resection while preserving key nerves and vessels and to reconstruct a
functional limb.
Limb-sparing reconstructive surgery obviously is an attractive alter-
native to amputation for both cosmetic and emotional reasons, but it
should only be undertaken if it will restore better and longer-lasting
function than amputation with subsequent prosthetic fitting.86 Depend-
ing on the location and size of the tumor, it may be a difficult procedure
where muscles, bone, and even joints are removed with the tumor. The
cancerous bone may be replaced by transplanting a fresh frozen cadav-
eric bone allograft or an autologous graft, but more commonly by
installing a synthetic metallic prosthetic implant.87–89 An expandable
and adjustable prosthesis may now be installed in growing children, who
formerly were felt to fare better with amputation.90 Just as when ampu-
tation is planned, all patients should be carefully told preoperatively
what degree of function to expect after the limb-sparing operation.
Rehabilitation interventions preferably should begin preopera-
tively when physical and/or occupational therapists should first teach
the patient the muscle-strengthening, range-of-motion, and ambula-
tion exercises that will be resumed postoperatively. Following lower-
limb-sparing surgery, the patient may begin exercising the uninvolved
limbs on the first postoperative day but the initiation, pace, and inten-
sity of exercises and the amount of weight bearing for the affected limb
depend on the exact mode of reconstruction and the postoperative
course. In general, continuous passive motion (CPM), active-assistive
exercises, and weight bearing as tolerated may be allowed 6 to 10 days
postoperatively, if no surgical complications occur and no specific
contraindications exist. During rehabilitation and a 2.5-year follow-up
of 17 children who underwent resection of malignant bone tumors in
the lower limbs with insertion of expandable prostheses, 7 of these
children walked without any assistive devices, but 10 required knee
orthoses, crutches, or both for ambulation.29 Following upper-
limb–saving surgery, active hand and isometric shoulder muscle exer-
cises are started on the first postoperative day, but if humeral resection
is performed, active elbow and shoulder exercises should not begin for
2 or 8 weeks postoperatively, depending on whether a metallic implant
or allo-/autografts, respectively, are used. It is thus of primary impor-
tance that the rehabilitation staff know exactly which muscles, nerves,
and bones were resected, and what the reconstruction entailed, to plan
a safe and effective rehabilitation program. Training in ADL is initi-
ated approximately 1 week postoperatively. Prior to discharge, a deci-
sion is made as to whether the patient requires a permanent orthosis or
other assistive devices to compensate for lost function. Following dis-
charge, most patients are referred for continued therapy and are given
specific instructions for exercise and other activities at home.
CONCLUSION
Management of cancer appropriately focuses on prevention, early
diagnosis, and cure, but following effective treatment, most cancer
patients experience some physical impairment that results in a physi-
cal disability or a handicap. As the prognosis for most types of cancers
improves, it becomes more important to ensure that all cancer patients
regain maximum function in the broadest sense to ensure return to all
former roles. Multi-disciplinary rehabilitation, therefore, is an integral
part of the total management of the cancer patient. The exact func-
tional deficits need to be identified for each patient and proper reha-
bilitation interventions started promptly or at the same time as other
treatments.
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