Cancer Rehabilitation Serves a Critical Role in Patient Care

Oncology nurses serve as a critical access point to those services and must understand rehabilitation and its indications. To better highlight cancer rehabilitation’s benefits and importance in clinical practice, ONS members Grace Campbell, PhD, MSW, RN, CNL, CRRN, and Beverly Reigle, PhD, RN, shared a conversation about the finer points of cancer rehabilitation specialty practice.

The Physical Activity Conversation

Grace Campbell (CG): Cancer rehabilitation has become a routine part of the cancer care conversation. The popular press is full of stories recommending walking and fitness programs for individuals with cancer, referring to these as “rehabilitation.” Exercise and rehabilitation are actually two related but distinct concepts, and patients may be confused about the indications for each. Can you help clarify?

Beverly Reigle (BR): Cancer rehabilitation is delivered by trained rehabilitation professionals whose scope of practice includes diagnosing and treating physical, psychological, and cognitive impairments to maintain or restore function, aid in symptom management, maximize independence, and improve quality of life (https://www.ncbi.nlm.nih.gov/pubmed/26314705). Fitness instructors do not diagnose and treat impairments, but they do provide general exercise recommendations (https://www.ncbi.nlm.nih.gov/pubmed/23856764) to improve cardiovascular fitness, strength, and flexibility. Oncology nurses can assess survivors for functional impairments, and if identified, should refer them to rehabilitation prior to recommending exercise participation.

GC: This is key. Fitness exercise has a place in the cancer rehabilitation discussion, but its goals are different. It can certainly improve function and quality of life, but exercise and rehab have some important differences.

BR: Exercise is a subtype of physical activity that focuses on repetitive bodily movement to improve or maintain physical fitness (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424733/). However, if survivors have cancer- or treatment-related impairments, the recommended 150 minutes of moderate intensity exercise per week (https://www.ncbi.nlm.nih.gov/pubmed/22237782) could place the survivor at risk for injury. In this case, rehabilitation is indicated prior to any fitness exercise program.

GC: As oncology nurses, we’re urged to encourage patients to exercise, but functional limitations may make exercise unsafe or impractical. Referral to a physiatrist (i.e., rehabilitation physician) is indicated. The physiatrist can order physical therapy (PT) and occupational therapy (OT) to ameliorate cancer- and treatment-related impairments so that exercise is safe. PT and OT providers can also modify exercise programs for individuals with pre-cancer physical impairments, such as from arthritis or a stroke.

The Differences Between Prehabilitation and Rehabilitation

GC: Now let’s talk about prehabilitation. How is it different from rehabilitation?

BR: Prehabilitation involves rehabilitation prior to cancer treatment to establish a functional baseline, identify impairments, and intervene to decrease the occurrence or severity of impairments (https://www.ncbi.nlm.nih.gov/pubmed/23856764). Most prehabilitation research involves the surgical oncology population using a multidisciplinary and multimodal approach, including nutritional supplementation and conditioning exercise regimens (https://www.ncbi.nlm.nih.gov/pubmed/30025745).

GC: An example of rehabilitation aimed at improving function for treatment-related impairments is PT and OT for post-mastectomy shoulder dysfunction. Women who undergo axillary dissection and postmastectomy radiation are at increased risk for lymphedema (https://journals.lww.com/ajpmr/Citation/2019/02000/Integrated_Rehabilitation_for_Breast_Cancer.10.aspx) and range of motion (ROM) limitations.

BR: Presurgical functional assessment is critical and should include arm circumference measurements. Postoperatively, progressive upper-body ROM exercises are recommended, with early referral to rehabilitation after full axillary dissection plus radiation or with limited shoulder abduction.

GC: Rehabilitation services can help patients before and during curative treatment, but survivors with long-term and late effects of treatment can also benefit. Survivors with persistent limitations can improve their function with rehabilitation intervention (https://www.ncbi.nlm.nih.gov/pubmed/31046719). Research suggests that each phase of the survivorship trajectory can have appropriate rehabilitation goals.

BR: Dietz, a pioneer in cancer rehabilitation (https://www.sciencedirect.com/science/article/abs/pii/S014702728080002X), advocated for early referral to rehabilitation services. He promoted rehabilitation for all survivors regardless of prognosis as well as rehabilitation goals that are preventive, restorative, supportive, and even palliative. Today, the same goals are the bedrock of cancer rehabilitation and are employed throughout the cancer care continuum.

Cancer rehabilitation benefits patients and families throughout the survivorship trajectory. Oncology nurses can conduct functional screening in cancer survivors and recommend appropriate referrals throughout the cancer care continuum.

To do this, an understanding of the difference between cancer rehabilitation and conditioning exercises is critical. Collaboratively, oncology and rehabilitation nurses can advocate for the role of both rehabilitation and fitness exercise in the survivor population. For more information, see the Association of Rehabilitation Nurses’ Rehabilitation of People With Cancer (https://rehabnurse.org/about/position-statements/rehabilitation-of-people-with-cancer) position statement, which ONS has endorsed.