1. Post-surgical physical therapy
in patients with cancer
癌症病人術後物理治療
賴忠駿
臺大醫院物理治療中心

2. Contents
 General intervention in post surgical
patients
 Specific approach in different type of cancer
◦ Breast cancer
◦ Head & Neck cancer
◦ Lung cancer
◦ Gastrointestinal tumor
◦ Neurological tumor
◦ Musculoskeletal tumor
2013/1/2 2

3. Goal of surgery
 Debulking a tumor
 Diagnosing a tumor (biopsy)
 Removing precancerous lesion
 Resecting a tumor
 Correction of life-threatening conditions caused by
cancer
 Palliation
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4. Post-surgical complication
 Cardiopulmonary complications
◦ Restriction of lung capacities
◦ Atelectasis
◦ Airway clearance ↓
◦ Infection
 Other complications
◦ Muscle wasting
◦ Deconditioned status
◦ Malnutrition
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5. (Frownfelter D. 2006)
2013/1/2 5

6. Common rehabilitation themes
post surgical patients
 Early mobilization
 Pulmonary hygiene
 Gait training
 Training in ADLs
(Malone DJ, editors. Physical therapy in acute care:
A clinician’s guide 2006)
2013/1/2 6

7. Early mobilization & pulmonary hygiene
 Prevention of further immobility-related
complication
◦ Pneumonia
◦ Ileus
◦ Deep vein thrombosis
◦ Loss of lean body mass
 Pulmonary hygiene
◦ Splinted coughing
◦ Diaphragmatic & deep breathing exercise
◦ Postural education → prevent post-OP
pulmonary complication
2013/1/2 7

8. Gait & ADLs training
 Specific indication
◦ Status post amputation
◦ Weight bearing restriction
◦ Pain → limiting functional mobility
◦ Fatigue→ impeding mobility
2013/1/2 8

9. Physical activity post cancer treatment
 Beneficial effects of physical activity
◦ Optimize recovery of physical functioning and
quality of life
◦ Manage any chronic and late-appearing effects
of treatment
 Fatigue, lymphedema, fat gain, bone loss
◦ Reduce the likelihood of disease recurrence
◦ Reduce the likelihood of developing other chronic
disease
 Osteoporosis, heart disease, diabetes
(Courneya KS, editors. Physical activity and cancer. 2011)
2013/1/2 9

10. Breast cancer
 Various surgical method
◦ Sentinel node biopsy→ full axillary dissection
◦ Lumpectomy or partial mastectomy
◦ Mastectomy: remove breast tissue
 Simple mastectomy
 Modified radical mastectomy (MRM)
 Skin-sparing mastectomy
 Radical mastectomy
2013/1/2 10

11. Physical sequelae of treatment
 Shoulder mobility and strength ↓
◦ Cording
61% Internal rotation
◦ Stiffness in the tissue
41% Abduction
◦ Pain 34% External rotation
33% Flexion
 Pain and numbness (Joansson et al, 2001)
◦ Post-surgical pain → complex chronic pain
◦ Post-mastectomy neuritis
◦ 20% at 6 months (Versus et al, 2001);
◦ 25% at 6 months, 29% at 1 year (Karki et al, 2005)
2013/1/2 11

12. Physical sequelae of treatment
 Peripheral neuropathy
◦ Side-effect of C/T, surgery, spinal cord compression,
lymphoedema
◦ Demyelination of the nerve fibers
◦ Impact on mobility, dexterity, pain, hand function
◦ Symptoms
 Parasthesias, hyperarsthesias, clumsiness, loss of
proprioception
 Weakness and atrophy of intrinsic and extrinsic muscle
 Loss of palmar aches and decrease ROM of hand joints
2013/1/2 12

13. Physical sequelae of treatment
 Scar formation
 Lymphedema
◦ Obstruction of the lymphatic vessels
◦ Accumulation of lymph fluid In the tissue
 Abnormal posture (Karki at al, 2005)
◦ Prolonged protraction of the shoulder
◦ Tightness of the pectoral major muscles
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14. Pre-breast surgery
 Identification of risk factor for post-OP
◦ Neurological/ musculoskeletal problems
◦ Psychological problems
◦ Respiratory disorders
Specific & relevant information and advice
2013/1/2 14

15. Post-breast surgery
 Progressive shoulder ROM program
◦ All plane of motion
◦ Flexion/ extension/ abduction/ adduction/ rotation
 Posture exercise
◦ Pectoralis stretching
◦ Strengthening of posterior shoulder musculature
 Lymphedema education
 Post surgical education
◦ Avoid splint their arm
◦ Avoid repetitive motions
◦ Avoid heavy lifting the first few weeks
2013/1/2 15

16. Breast reconstruction
 Breast reconstruction
◦ Implants
◦ Transverse rectus abdominus myocutaneous flaps (TRAM)
 Post reconstruction
◦ Round shoulders, pectoralis tightness, weakness of
scapular musculature
◦ Pectoralis spasm
◦ Give gentle exercise: avoid posture changes
◦ Rigorous stretching program is not indicated
◦ Mobility and lifting is limited
Maintain health donor and recipient site
2013/1/2 16

17. Complications after breast
reconstruction
(McNeely ML, 2012)
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18. After breast reconstruction
 Acute care role
◦ Teaching proper body mechanisms within this
limitation prescribed
◦ Transfer and bed mobility techniques
◦ Lymphedema precaution
 After flap healing
◦ Common consequences
 Breast and trunk lymphedema, shoulder adhesive capsulitis,
poor posture, low back pain
◦ PT interventions
 Back stability program, shoulder ROM strengthening,
myofascial techniques, joint mobilization, body mechanics
training
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19. Procedure and Restriction
(Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009)
2013/1/2 19

20. Exercise after surgery
(Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009)
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21. Exercise after surgery
2013/1/2 21

22. Delayed vs. immediate exercise
following surgery – seroma incidence
(Shamley DR, 2005)
2013/1/2 22

23. Delayed vs. immediate exercise
following surgery – drainage volume and
hospital stay
2013/1/2 (Shamley DR, 2005) 23

24. Head and Neck cancer
 Location
◦ Nasal cavity, nasopharynx, oral cavity,
hypopharynx, larynx
 Complication after treatment
◦ Dysfunction in mobility, speech
◦ Dysfunction of the eat and swallow ability
◦ Cause emotional and interpersonal distress
2013/1/2 24

25. Surgery of head & neck cancer
 Surgery
◦ Radical neck dissection
 Used for large metastatic tumors and large
palpable nodes
◦ Modified radical neck dissection
 Remove SCM and lymph nodes
 Preservation of spinal accessory nerves
◦ Selective neck dissection
 Remove the mass and any lymph nodes
2013/1/2 25

26. Common problems
 Poor posture
◦ Forward head, round shoulders, neck rotation
due to pain,
◦ Tracheostomy, fear of damaging the surgical site
Exacerbate any shoulder dysfunction
Decrease the ability to clear secretions
 Alter the venous and lymphatic drainage
system
 Head & neck lymphedema
2013/1/2 26

27. Other common problems
 Severe skin and soft tissue reaction of the
neck, limited ROM of neck
 Decreased jaw ROM
 Formation of copious amounts of sputum
 Dysphagia
 Impaired communication
 Malnutrition
2013/1/2 27

28. Post surgical care
 Acute rehabilitation focus on
◦ Cervical ROM, posture
◦ Shoulder function, scapular kinematics
◦ Cough technique, lymphedema education
 Post-surgery
◦ Caution: allow for proper wound healing
◦ Shoulder flexion≦90°
◦ Conservative cervical ROM (post op day 6)
2013/1/2 28

29. General approach
 Neck and shoulder exercise
◦ Maintain all neck and shoulder movement
◦ As skin healed: more aggressive exercise
 Active jaw exercise
 Postural exercise
◦ Pectoralis stretching
◦ Trapezius & rhomboid strengthening
 Lymphedema education
2013/1/2 29

30. General approach
 Chest PT
◦ Active cycle breathing techniques
◦ Autogenic drainage
◦ Assistive cough
 Progressed functional training
◦ Daily mobilization
◦ Bed exercise
◦ Ambulation, gait correction
◦ Practice steps/ stairs pre-discharge
2013/1/2 30

31. Effect of deep breathing exercise on
POD 1
(Genc A, 2008)
2013/1/2 31

32. A patient with oropharyngeal cancer
s/p surgery and tracheostomy
2013/1/2 32

33. Oropharyngeal cancer s/p wide excision,
bilateral modified radical neck dissection and
tracheostomy
2013/1/2 33

34. A patient with left lower gingiva cancer s/p
wide excision and modified redical neck
dissection
2013/1/2 34

35. Remove spinal accessory nerve
 Abnormal scapulohumeral rhythm
 Musculoskeletal abnormalities
◦ Trapezius atrophy
◦ Shoulder flexion and abduction< 90°
◦ Pain with shoulder flexion and abduction
◦ Scapular wining and downward rotation
◦ Scapular protraction and depression
◦ Subluxation of the humeral head
Levartor scapular, rhomboid strained
Capsular tightness and chronic pain
2013/1/2 35

36. Remove spinal accessory nerve
(Malone DJ, editors.
Physical therapy in acute
care. 2006)
2013/1/2 36

37. Remove spinal accessory nerve
 Specific approach after SAN remove
◦ Education: supporting the arm during
sitting and standing activities
◦ Positioning
◦ Training rhomboids to assist stability of
scapular
2013/1/2 37

38. Head and Neck reconstruction
 Osteocutaneous/ mycutaneous
reconstruction
◦ Pectoralis flap
 With SAN damage: loss both post. and ant. stabilization
of shoulders
◦ Fibular flap
 Reconstruct the mandible
◦ Radical forearm flap
 Replace skin on the face
 Reconstruction of the oral pharynx
2013/1/2 38

39. Intervention after reconstruction
Pectoralis flap Fibular flap Radial forearm flap
Acute Postural training •non-weightbearing •Avoid weight
Cervical ROM 4~7 days bearing through the
•Transfer technique donor site during
•Bed mobility transfers and ADLs
•Pulmonary hygiene •Shoulder ROM <90°
until drains removed
Long- Wound healing Weight bearing
term achieved: advanced:
Scapular retraction •Household/
and latissimus community
strengthening for ambulation
posterior stability •Verbal feedback to
avoid compensatory
gait deviation
2013/1/2 39

40. Progressive resistance training
improve shoulder dysfunction
2013/1/2 (Carvalho APV, 2012) 40

41. Lung cancer
 Two groups of lung cancer
◦ Non-small-cell lung cancer (NSCLC)
 Squamous cell carcinoma, adenocarcinoma, large cell
carcinoma
◦ Small-cell-lung cancer (SCLC)
 High growth rate, worse prognosis
 Symptoms of lung cancer
◦ Cough, hemoptysis, dyspnea, wheezing
◦ Invasion of the brachial plexus: shoulder pain and
weakness
2013/1/2 41

42. General intervention in lung cancer
 Physical therapy intervention
◦ Posture correction
◦ Breathing facilitation technique
◦ Conditioning of the musculature system
◦ If metastatic disease
 Gait training, pain control, cognitive rehabilitation
 Acute care
◦ Symmetrical movement of the thoracic cage
◦ Splinted coughing
◦ Shoulder ROM
◦ Pacing & energy conservation techniques education
2013/1/2 42

43. Surgery of lung cancer
 Types of surgery (early stage: I~IIIA)
◦ Wedge resection
◦ Segmentectomy
◦ Lobectomy
◦ Bilobectomy
◦ Pneumonectomy
2013/1/2 43

44. Prior to surgical resection
 Selection of the patient
◦ General and pulmonary-specific evaluation
◦ Symptom limited cardiopulmonary exercise test
 Independent predictor of surgical complication rate
(Courneya KS, editors. Physical activity and cancer. 2011)
 Pre-surgery exercise training
◦ VO2peak improve
◦ Lower perisurgical complication
◦ Improve postsurgical recovery
2013/1/2 44

45. Pre-surgical exercise training
(Courneya KS, editors. Physical activity and cancer. 2011)
2013/1/2 45

46. Pre-surgical exercise training
(Jones at al, 2007)
2013/1/2 46

47. Post-surgical complication
 Postoperative morbidity is considerable
◦ Reduction in VO2peak 30% up to 3 years
(Bolliger et al, 1996; Nagamatsu et al, 2007)
◦ Reduce ventilatory capacity and reserve
◦ Deconditioned
◦ Present concomitant cardiovascular disease
2013/1/2 47

48. Post-surgical care
 Identify any risk factors
◦ Smoking, obesity, age
 Review complete blood counts (CBC)
◦ Raised WBC → infection
◦ Reduced RBC → breathlessness
◦ Low platelet count → precaution while
prescribing exercise
2013/1/2 48

49. Post-surgical intervention
 Chest PT
◦ Positioning
◦ Breathing exercise
◦ Chest clearance techniques
◦ Supported cough
 Aerobic exercise training and early ambulation
 Functional training
 Shoulder ROM exercise
 Pain control
 Breathlessness and relaxation technique
2013/1/2 49

50. Post-surgical exercise training
2013/1/2 50
(Courneya KS, editors. Physical activity and cancer. 2011)

51. Post-surgical exercise training
(Jones et al, 2008)
2013/1/2 51

52. Gastrointestinal tumors
 Types of gastrointestinal tumors
◦ Upper GI cancer
 Esophagus/ Gastric/ liver/ pancreas
 Cancer incidence of upper GI
◦ Lower GI cancer
 Small intestine/ colon/ rectum
2013/1/2 52

53. Common problem of GI cancer
 Significant physical impact on the patient
◦ Malnutrition: up to 85% patients
◦ Weight loss, deconditioning and fatigue
◦ Anxiety, reduce independence
◦ Loss of role in family
◦ Change with body image, tube feeding, stoma
bags
2013/1/2 53

54. Clinical presentation of GI cancers
 Upper GI cancers
 Lower GI cancers
(Rankin J, editors. Rehabilitation in cancer care 2008.) 2013/1/2 54

55. Types of surgery
 Upper GI cancers
◦ Oesophagectomy
◦ Radical gastric resection
 Lower GI cancers (80%)
◦ Local excision
◦ Resection followed by anastomosis
◦ ileostomy
◦ Colotsomy
◦ With stoma formation
Ileostomy,
2013/1/2 55

56. Post-surgical complication
 Increase pulmonary complication
◦ 50% patients (McCulloch et al, 2003)
◦ Pre-OP: FEV1 reduced 20% predicted value
◦ Upper abdominal/ thoracic surgery
 Large decrease in lung volume
◦ Functional residual capacity ↓ 30%
◦ Remain for several days
 Impaired mucociliary action →
◦ Small airway closure
◦ Ventilation/perfusion mismatch
◦ Impaired gas exchange
2013/1/2 56

57. Pre-surgical intervention
 ↓sputum retention, maximising lung volume
◦ Prophylactic deep-breathing exercise
◦ Supported expectoration techniques
◦ Early mobilization
◦ Adequate functional pain control
◦ Incentive spirometry
2013/1/2 57

58. Post-surgical intervention
 Upper GI cancers
Prevent complication & progressive exercise
◦ Deep-breathing exercise
◦ Supported coughing
◦ Incentive spirometry
◦ Early mobilization
◦ Shoulder exercise
 Lower GI cancers
Lower incidence of pulmonary complications
◦ Independent exercises
◦ Encourage gradual return to normal function
2013/1/2 58

59. Following an oseophagectomy
(Rankin J, editors.
Rehabilitation in cancer care
2008.)
2013/1/2 59

60. Exercise Caution
 High anastomosis associated with an
oesophagectomy
◦ Head-down postural drainage
◦ Suction via oropharyngeal/ nasopharyngeal airway
◦ Positive pressure technique
(Aston T et al, multi-professional management of gastrointestinal tumors)
2013/1/2 60

61. Post-surgical long term exercise
(Courneya KS, editors. Physical activity and cancer. 2011)
2013/1/2 61

62. Neurological tumors
 Brain tumor
◦ Primary: <2 % of all cancers
 Gliomas
 Meningiomas
◦ Secondary: up to 50 % of all intercranial tumors
 Primary spinal tumors
◦ Extramedulary tumor
 Schwannomas, meningiomas, gliomas
◦ Intramedullary tumor
2013/1/2 62

63. Characteristics of brain tumor
2013/1/2 63

64. Signs & symptoms
 Complex physical, cognitive, psychosocial
tymptoms
◦ ↑ intercranial pressure
◦ Local tumor invasion
◦ Hydrocephalus
◦ Cerebral ischemia
◦ Non-specific headache
◦ Specific depends on the site and size of lesion
2013/1/2 64

65. Common problem of brain tumors
(Rankin J, editors. Rehabilitation in cancer care 2008.)
2013/1/2 65

66. Intracranial neurosurgical
procedure
 Low-grade tumor
◦ May surgical intervention until symptoms appear
◦ May elective surgery to ↓ “ticking time bomb”
 High-grade tumor
◦ Rapidly deteriorating symptoms→ emergency
surgery
 Types of surgery
◦ Craniostomy
◦ Craniectomy (decompression)
◦ Cranioplasty (3~6 months after craniectomy)
2013/1/2 66

67. Intervention post brain surgery
 Primary aims
◦ Maintain or improve mobility/ function
◦ Improve strength and ROM
◦ Prevent contracture and deformities
◦ Optimise safety
 Treatment technique
◦ Progressive exercise program
◦ Balance training
◦ Gait re-education
◦ Transfer practice and assistive device education
2013/1/2 67

68. Early rehabilitation post surgery
(Bartolo M, 2012)
2013/1/2 68

69. Primary spinal tumor
 Low grade tumors
◦ Intervention mimics the patients of spinal injury
 High grade tumor
◦ Deteriorate rapidly
◦ Need immediate intervention
Malignant spinal cord compression
◦ Compression of spinal cord or cauda equina
◦ Need urgent investigation and immediate
intervention
2013/1/2 69

70. Relative risk for MSCC
(Rankin J editors. Rehabilitation in cancer care. 2008)
 Metastatic compression lesion
◦ 70% thoracic spine
◦ 20% lumbar spine
◦ 10% cervical region
2013/1/2 70

71. Spinal neurosurgical procedure
 Aim of surgery
◦ Decompression of the spinal cord
◦ Excision of tumor bulk
 Types of surgery
◦ Disectomy
◦ Laminectomy
◦ Microdisectomy
◦ Foraminotomy
2013/1/2 71

72. Passive intervention after surgery
 Immobilize phase
◦ Appropriate handling and positioning
◦ Prevent prolonged bed rest complication
 Improve respiratory function
 Prevent circulatory complication
 Stokings, passive movements, calf massage
 Pumping exercise
2013/1/2 72

73. Active intervention after surgery
 When spinal condition is stable
◦ Clinical signs & symptoms relieved
◦ Head up to 45°without increase in symptoms
◦ Transfer and mobility with equipment
◦ Problem solving approach
 Washing, dressing, bathing
 Coping with compensation strategy
 Assistive device prescription
2013/1/2 73

74. Physical intervention for MSCC patient
2013/1/2 74
(Rankin J editors. Rehabilitation in cancer care. 2008)

75. Musculoskeletal tumor
 Types of musculoskeletal tumors
◦ Primary bone tumor
 Osteosarcoma
 Chondrosarcoma
◦ Bone metastasis
 Types of surgery
◦ Amputation
◦ Limb salvage surgery
 Resection of tumor without replacement
 Endoprosthetic replacement (75% of the patients)
 Rotationplasty
 Autografts or allografts
2013/1/2 75

76. Pre- and post-surgical management
 Pre-surgical
◦ Mobilize with PWB or NWB depending on extent
bone destruction
◦ Maintenance of ROM and strength
 Post-surgical
◦ Restore muscle strength, ROM
◦ Balance exercise, gait re-education
◦ Full weight-bearing (tolerate weight bearing) with
prosthesis keep knee extension
2013/1/2 76

77. General protocols of osteosarcoma
Presurgical phase Acute Subacute Chronic
postsurgical phase postsurgical phase subsurgical phase
0~2 weeks 2~6 weeks >6 weeks
• Correct • Minimal • Begin to wean off • Restoration of
limitations or assistance to assistive device joint stability and
improve current modified • Restore full range functions
functions independence in of motion • Advancing
• Identify needs functional • Progressive strength and
from other transfer resistance training endurance
members • Maximum • Progressive gait training
• Identify realistic protection of training • Incoporating
postsurgical/ affected joint/ sports-related
treatment goals limb functional training
(Punzalan M, 2009)
2013/1/2 77

78. Physical therapy after LE surgery
(Punzalan M, 2009)
2013/1/2 78

79. POD 1~3 Days to 1 month
Distal Femur Proximal Tibia
Falling risk
Bed exercise
Ambulation with tolerated weight bearing
knee locked at 0° with brace
ROM exercise begin after Knee locked at 0° with
Post-op 1 week, brace for 1 month
progress to 90° slowly. No ROM exercise!!
2013/1/2 79

80. Post-OP to 6 months
Distal Femur Proximal Tibia
Brace Using for Using for 6 months with
1 year with 90° restriction, then,
no restriction of 6-12 months with no
knee motion restriction
Assisted 6 months, depends on strength
devise
ROM Post-op Post-op 6 month: 90°
Exercise 3 month: 140° then, progress slowly
to 120° in 3months.
Strength 1.SLR exercise with knee locked at 0°
Training 2. Functional Electric Stimulation for
Quadriceps 2013/1/2 80

81. Post-OP quadriceps setting
2013/1/2 81

82. Post-OP hip abduction/adduction
2013/1/2 82

83. Post-OP / OPD follow-up
4-phase straight-leg-raising
平躺抬腿 側躺抬腿
趴姿抬腿
側躺夾腿
2013/1/2 83

84. OPD follow-up
Active knee flexion
Passive knee extension
2013/1/2 84

85. OPD follow-up
承重訓練 穩定訓練
2013/1/2 85

86. Summary
 Physical therapy in pre-/ post- surgical
cancer patients
◦ Early intervention and monitoring can ameliorate
the negative effects
◦ Prevention and restoration of impairments and
functional limitation
◦ Familiar with treatment strategies and side
effects to provide quality, appropriate
interventions
2013/1/2 86

87. Reference
 Packel L. Oncological diseases and disorders. In Malone DJ,
Lindsay KLB. Physical therapy in acute care: A clinician’s guide.
Thorofare, NJ: Slack; 2006, 503-544.
 Rankin J, Robb K, Murtagh N, Cooper J and Lewis S, editors.
Rehabilitation in cancer care. Chichester UK: Wiley-Blackwell, 2008.
 Courneya KS, Friedenreich CM, editors. Physical activity and cancer.
Heidelberg: Springer, 2011.
 Stubblefield MD, O’Dell MW, editors. Cancer rehabilitation:
Principles and practice. New York: Demos Medical. 2009
 Frownfelter D, Dean E. Cardiovascular and pulmonary physical
therapy: evidence and practice. St. Louis, Mo.: Mosby/Elsevier. 2006.
 Raven RW, editors. A practical guide to rehabilitation oncology.
Carnforth, Lancs, UK; Park Ridge, N.J., USA: Parthenon Pub. Group.
1992
2013/1/2 87

88. Reference
 McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW. A
Prospective Model of Care for Breast Cancer Rehabilitation: Postoperative
and Postreconstructive Issues. Cancer 2012;118:2226-36.
 Shamley DR, Barker K, Simonite V, Beardshaw A. Delayed versus immediate
exercises following surgery for breast cancer: A systematic review. Breast
Cancer Res Treat 2005;90:263-71.
 Genc A, Ikiz AO, Guneri EA, Gumerli A. Effect of deep breathing exercises on
oxygenation after major head and neck surgery. Otolaryngol Head Neck Surg.
2008;139:281-5.
 Garvalho APV, Vital FMR, Soares BGO. Exercise interventions for shoulder
dysfunction in patients treated for head and neck cancers. Cochrane
Database Syst Rev 2012;18:CD008693.
 Bartolo M, Zucchella C, Pace A, Lanzatta G, Vecchione C, BartoloM, et al.
Early rehabilitation after surgery improves functional outcome in inpatients
with brain tumours. J Neurooncol 2012;107:537-44.
 Punzalan M, Hyden G. The role of physical therapy and occupational therapy
in the rehabilitation of pediatric and adolescent patietns with osteosarcoma.
Cancer Treat Res 2009;152:367-84.
2013/1/2 88

89. Thanks for your listening!!