Clinical Characteristics of Patients With Cancer Referred for Outpatient Physical Therapy
- M.J. Alappattu, PT, DPT, PhD, College of Dentistry, University of Florida, PO Box 100444, Gainesville, FL 32610-0154 (USA), and Pain Research and Intervention Center of Excellence, University of Florida.
- R.A. Coronado, PT, PhD, CSCS, FAAOMPT, Vanderbilt University, Nashville, Tennessee.
- D. Lee, PT, DPT, University of Florida College of Medicine.
- B. Bour, PT, Department of Physical Therapy, University of Florida.
- S.Z. George, PT, PhD, Doctor of Physical Therapy Program, Department of Physical Therapy, University of Florida.
- Address all correspondence to Dr Alappattu at: meryl{at}ufl.edu.
Abstract
Background Cancer rehabilitation is a developing area, with an increasing number of survivors of cancer in the United States. The increase in survivorship occurs alongside impairments arising directly from cancer or from treatment-related side effects.
Objective This study described clinical characteristics of patients with cancer referred for outpatient physical therapy and explored patterns in frequency of impairments between type of cancer and mode of cancer treatment.
Design This was a retrospective chart review of patients with cancer referred to a tertiary care physical therapy clinic over a 2-year period.
Methods Characteristics such as age, sex, cancer type, mode of treatment, and neuromusculoskeletal impairments were identified. Impairment frequencies were computed based on cancer type and mode of treatment.
Results Data from 418 patients (mean age=57.9 years, SD=14.3; 41.1% female) were examined. Genitourinary cancer (n=169) and breast cancer (n=90) were the most prevalent types of cancer reported in this sample. Impairments in strength (83.6%) and soft tissue (71.3%) were the most common examination findings. Lymphedema was most common in patients with breast cancer, and incontinence was most common in patients with genitourinary cancer.
Limitations The types of cancer identified in this study may be reflective of this tertiary center and may not generalize to other facilities. Impairment identification during the initial physical therapist evaluation was not performed systematically.
Conclusion These data reinforce that physical therapists should screen for lymphedema in patients with breast cancer and incontinence in urogenital cancers. Strength and soft tissue integrity should be evaluated in most patients with cancer. Assessing pain and fatigue levels is recommended for patients who have had radiation therapy.
Cancer rehabilitation is a developing area due, in part, to the increase in cancer survivorship. The increase in number of survivors of cancer may be attributed to advances in medical technology and early detection and treatment. The 5-year survival rate of all cancers diagnosed between 2003 and 2009 is 68%, nearly a 20% increase from 1975 to 1977. The American Cancer Society also estimates that approximately 13.7 million Americans have a history of cancer and more than 1.6 million new cancer cases are expected in 2014.1 Therefore, the overall number of survivors of cancer in the United States may be expected to increase as well.
Despite advances in medical treatments for cancer, including surgical resection, radiation therapy, and chemotherapy, survivors of cancer may experience extensive physical impairments and functional limitations during and after these treatments. These issues include, but are not limited to, cancer-related fatigue (CRF), deconditioning, pain, muscle shortening and contractures, peripheral neuropathy, lymphedema, and genitourinary dysfunction. Evidence exists for conservative management of these cancer-related treatment effects and include strategies directly related to the training and skill of physical therapists. For example, effective lymphedema management strategies may include lymphatic massage, aerobic exercise, and extremity bandaging.2,3 Some studies demonstrate the efficacy of targeted aerobic training and strengthening exercises for prevention and management of CRF and physical deconditioning during and after treatment in various types of cancer in both inpatient and outpatient settings.4–7 Additionally, clinicians may ascertain physical limitations in patients with cancers. For example, urinary and sexual dysfunctions are common in men treated for prostate cancer,8,9 and upper extremity dysfunction10,11 and lymphedema12,13 are common in women with breast cancer. People with head and neck cancers may have difficulty with eating and speaking.14 Still, these physical issues are specific to the location of the cancer in the body and the types of treatments patients receive, but they do not necessarily provide a complete clinical picture of the patient with cancer, such as medication use, the number and types of cancer treatments, and other comorbidities.
Given the increasing rates of cancer survivorship in the United States, physical therapists in outpatient settings should expect to encounter and treat patients who are surviving cancer and have physical problems secondary to cancer treatments. Physical therapists who work in general settings and in tertiary care settings should be cognizant of important aspects of cancer-specific medical history related to patients with cancer. The importance of obtaining a thorough medical history of patients seen by physical therapists is not a new concept. Boissonnault and Koopmeiners15 proposed that the development of a medical history profile of patients seen at outpatient orthopedic physical therapy clinics could help to optimize patient care. Patients with cancer may have complex or detailed medical histories and comorbidities that require special attention by a physical therapist. As the field of oncologic rehabilitation develops and the number of therapists who treat patients with cancer or a history of cancer grows, understanding nuances of the medical history of patients with cancer may improve patient care and contribute to our existing knowledge of medical issues as they relate to movement or functional impairments in patients with cancer.
To our knowledge, no literature exists that describes clinical characteristics of patients with various cancer diagnoses seen for outpatient physical therapy. Given the growing number of survivors of cancer in America and the evidence for the physical and functional issues with which survivors of cancer present, physical therapists in an outpatient setting should have a general knowledge of common cancer diagnoses and the physical sequelae of those cancers in order to provide optimal clinical care. The objective of this study was to describe clinical characteristics of patients with various cancer diagnoses seen over a 2-year period in an outpatient physical therapy clinic that specialized in cancer rehabilitation.
Specifically, we sought to examine the frequency of cancer types, modes of cancer treatment, comorbidities, and impairments in patients with a variety of cancers. We hypothesized that breast and genitourinary cancers would comprise the highest frequencies of cancers, given the amount of evidence for physical therapy interventions in these populations and given their high prevalence in women and men, respectively,16 and the presence of both lymphedema and pelvic health specialist physical therapists in this clinic. We also hypothesized that the majority of patients would have CRF, given that previous research suggests fatigue is a common issue in people with cancer undergoing radiation or chemotherapy.4,17,18 Last, we aimed to identify whether patterns of impairments existed in certain cancer populations. Understanding of the relationships among these factors may assist with proper treatment planning for patients with cancer or a history of cancer.
Method
A retrospective medical record review was used to identify all patients referred for outpatient physical therapy over a 2-year period (from August 2008 to August 2010) at the University of Florida Davis Cancer Center. The patients referred to this clinic are primarily patients with cancer or with a history of cancer who are currently undergoing or previously underwent cancer treatment. A representative 3-month volume for this clinic was 122 new patients with cancer or a history of cancer and 7 patients who did not have cancer. Thus, on average, more than 90% of the new patients evaluated at this clinic fit these characteristics, although occasionally patients who do not have cancer or a history of cancer are evaluated and treated at the clinic.
Patients' records were included in this retrospective analysis if they were referred for outpatient physical therapy for treatment related to a cancer diagnosis. If a patient chart was physically unavailable, the medical and physical therapy treatment records, which were identical to the physical record, were obtained electronically. Patients' records were excluded if their physical therapy referral was unrelated to cancer treatments or if they did not have a cancer diagnosis. The subjective portion of the patient initial evaluation interview, including the time frame of the patients' symptoms relative to their cancer treatments or location of their complaint, was used by the evaluating physical therapist to determine if the physician referral was related to cancer. This study included data that were collected as part of routine clinical care. The medical record review involved acquisition of the following variables: age, sex, medical referral source, cancer diagnostic type, mode of cancer treatments, number of oral medications, comorbidities, number of physical therapy sessions, and musculoskeletal impairments.
Medical Referral Source
The medical referral was identified as the department from which the physical therapy consultation was received, including: radiation oncology, urology, surgical oncology or general surgery, pediatric hematology-oncology or general pediatrics, internal medicine, neurosurgery or neurology, adult hematology-oncology, orthopedic oncology, obstetrics-gynecology, otolaryngology, and plastic surgery.
Cancer Diagnostic Type and Mode of Treatment
Cancer diagnostic type was coded based on a specific cancer diagnosis and was designated as one of the following: head or neck, digestive system, central nervous system, respiratory, bones and joints, soft tissue, skin, breast, genitourinary, or blood. In patients with multiple cancer diagnoses, the primary site most relevant to physical therapy referral was coded as their cancer diagnostic type. For example, if a patient had breast cancer and bone cancer and was referred for physical therapy for lymphedema of the arm, the cancer diagnostic type was coded as breast cancer. Modes of treatment referred to any of the following: chemotherapy, hormone therapy, radiation therapy, or surgical resection of the tumor.
Comorbidities
We use a modified version of the Functional Comorbidity Index (FCI) to describe the different comorbidities in our sample. This index is associated with physical function and thus may be more applicable to an outpatient physical therapy setting.19,20 The FCI includes the following comorbidities: arthritis (rheumatoid and osteoarthritis), osteoporosis, asthma, lung disease (including chronic obstructive pulmonary disease, acute respiratory distress syndrome, or emphysema), angina, congestive heart failure (or heart disease), heart attack, neurological disease (eg, multiple sclerosis, Parkinson disease), stroke or transient ischemic attack, peripheral vascular disease, diabetes (types I and II), upper gastrointestinal disease (ulcer, hernia, reflux), depression, anxiety or panic disorders, visual impairment (cataracts, glaucoma, macular degeneration), hearing impairment, degenerative disk disease (back disease, spinal stenosis, or severe chronic back pain), and obesity (body mass index >30 kg/m2).21 We modified the FCI to exclude obesity and include hypertension. We excluded obesity because we were unable to calculate body mass index from the medical records, and we added hypertension because hypertension is a commonly used measure to determine the appropriateness of initiating an exercise program.22,23 The FCI is scored as the total number of positive diagnoses from the index. With our deletion of obesity and addition of hypertension, the score on this modified version of the FCI remained 0 to 18.
Impairments
Impairments were identified by the physical therapist who administered the initial evaluation and were categorized as one or more of the following: decreased strength, decreased range of motion (ROM), decreased joint mobility, postural dysfunction, soft tissue restrictions, lymphedema, gait deviations, soft tissue fibrosis, CRF, skin integrity issues, pain, incontinence (urinary or fecal), and urgency or frequency (urinary or fecal). Decreased strength was determined by manual muscle testing and comparison with the opposite extremity. Decreased ROM represented gross active (or passive) motion and was determined with a goniometer and compared with the opposite extremity. Joint mobility represented joint accessory motion and was a perceptive measure based on the evaluating therapist's observations. Soft tissue restrictions, fibrosis, and skin integrity issues were determined by palpation or visual observation of the evaluating therapist. Lymphedema was determined by girth measurements using a tape measure and compared with the unaffected extremity or side of the body (ie, trunk, face, neck).24,25 A difference of 2 cm or greater indicated the presence of lymphedema.26 Pain and CRF were assessed using an 11-point numerical rating scale, where 0 represented “no pain or fatigue” and 10 represented “worst pain or fatigue imaginable.” Urinary or fecal incontinence, urgency, and frequency were determined by the subjective information provided by the patient to the evaluating therapist.
These impairments were categorized based on a yes/no checklist of impairments (eFigs. 1 and 2), included on the physical therapy plan of care established at the initial evaluation. The initial evaluation forms for certain cancer diagnoses (eg, breast, urogenital, head or neck) included the aforementioned impairments but also impairments specific to the diagnosis, including lymphedema for breast cancer and incontinence for urogenital cancer. The impairments, listed on the plan of care forms developed in the clinic from which these data were collected, were previously identified as common impairments based on the clinical expertise of physical therapists in this clinic; thus, they were included in this study to identify patterns of potentially common impairments based on cancer type and modes of treatment. Therefore, systems and impairment screenings may not have been performed uniformly for all patients. Based on the patient's cancer diagnosis, the clinician who performed the initial evaluation decided which systems and impairments were pertinent to evaluate.
Data Analysis
Descriptive statistics were generated with IBM SPSS Statistics for Windows, version 20 (Armonk, New York) for demographic characteristics (age, sex), medical referral source, cancer diagnostic type, mode of cancer-related treatment, comorbidities, number of medications and physical therapy sessions, and FCI scores. Impairment frequencies and number of physical therapy sessions were examined based on cancer type, modes of cancer treatment, and number of cancer-related treatments. For mode of cancer treatment, we calculated odds ratios and 95% confidence intervals (95% CIs) for specific impairments based on the type of cancer treatment received compared with individuals who did not receive those treatments. Due to multiple comparisons, we used a very conservative P value of .001 to highlight potentially clinically meaningful associations between type of treatment and impairments.
Where statistical analyses were appropriate, one-way analyses of variance (ANOVAs) were used to assess group differences in FCI scores, duration of physical therapy, and number of medications. Shapiro-Wilk tests were used to assess normality of data, and Kruskal-Wallis one-way ANOVAs were used when data were not normally distributed. Significance level was set a priori at .01 for these analyses given the variability in sample size between cancer types and multiple comparisons.
Results
Demographic Data
Table 1 lists demographic and clinical information. A total of 418 participants (41.1% female) with a mean age of 57.9 years (SD=14.3) were included in this analysis. Caucasians comprised 77.9% of the sample, followed by African Americans at 14.1%. All other ethnicities comprised less than 10% of the sample.
Descriptive Characteristics of Sample (N=418)a
Medical Referral Source
Collectively, providers from the radiation oncology and urology departments accounted for more than 75% of referrals for physical therapy, respectively. Plastic surgery and otolaryngology providers had the lowest number of referrals (Tab. 1).
Cancer Diagnostic Type and Mode of Treatment
Genitourinary cancer types (40.4%) were the most frequent in this sample, followed by breast cancer (21.5%) and head or neck cancers (10.3%) (Tab. 1). Approximately 80% of the sample underwent surgical resection of their tumor, 70.6% underwent radiation therapy, 33% underwent chemotherapy, and 6.9% underwent hormone therapy (Tab. 2). Table 2 is a breakdown of mode of treatment based on type of cancer. Some types of cancer show preferential treatment, such as blood cancer (chemotherapy) and skin cancer (radiation therapy), and most others appear to be treated with a mix of treatment modes.
Percentage of Individuals by Cancer Types Who Received or Were Receiving Cancer Treatments at Time of Initial Physical Therapy Evaluationa
Two records were missing data for treatment mode. Of the remaining 416 records, approximately 36.7% of the sample had only one cancer-related treatment. Of those receiving multiple cancer-related treatments, 23.7% underwent both resection and chemotherapy, and 28.5% underwent resection and radiation therapy. Only 5% of the participants underwent resection and hormone therapy. Nearly 29% of the participants underwent chemotherapy and radiation therapy, and 22.4% underwent resection, chemotherapy, and radiation therapy.
Comorbidities and Medication Use
Hypertension (44.3%) was the most frequently reported comorbidity in our sample, with diabetes, arthritis, heart disease, and upper gastrointestinal disease also frequently noted (Tab. 1). The scores on the FCI ranged from 0.42 to 2 for all diagnostic groups, but there were no significant differences between groups (H9=10.25, P=.33). The mean number of medications for the sample was 4.83 (SD=4.01, range=0–29), but the number of medications did not differ among the different diagnostic groups (H9=8.53, P=.48).
Duration of Physical Therapy
The number of physical therapy sessions ranged from 2 to 122 (X̅=8.5, SD=11.0) for the sample (Tab. 1). Participants with breast cancer (mean visits=14.1) and blood cancer (mean visits=13.4) had the highest average number of sessions, and those with cancer of the bones or joints (mean visits=4.0) had the lowest average number of sessions (Tab. 3). Individuals receiving chemotherapy had the highest average number of physical therapy sessions (mean visits=11.0) (Tab. 4). There was a pattern of increasing physical therapy sessions with the number of treatment mode increases (Tab. 5). Significant differences existed in the number of physical therapy sessions among the diagnostic groups (H9=37.63, P<.001). Specifically, participants with head or neck cancers had a significantly higher number of physical therapy sessions compared with those with cancers of the bones and joints (P=.003). Participants with breast cancer also had a significantly higher number of physical therapy sessions compared with those with genitourinary cancers (P=.003), cancers of the bones and joints (P<.001), and cancers of the respiratory system (P=.003).
Percentage of Neuromusculoskeletal Impairment Frequencies and Number of Physical Therapy Sessions Based on Cancer Typea
Association Between Mode of Treatment and Neuromusculoskeletal Impairmentsa
Percentage of Neuromusculoskeletal Impairments and Mean Number of Physical Therapy Sessions Based on Number of Cancer-Related Treatmentsa
Impairments
Seventy-seven records were lacking impairment data. Age was the only significant difference between the group whose impairment data were present versus the group whose data were missing. The group lacking impairment data was significantly younger (mean age=52.8 years versus 59.1 years [P<.001]). Of the remaining 341 records (81.5%), the most common physical therapist–identified impairments were noted in strength (83.6%) and soft tissue (71.3%), and less common impairments were identified in gait (14.4%) and skin integrity (14.4%) (Tab. 3). There were a few patterns observed based on cancer type and mode of treatment. Digestive and genitourinary cancers were uniquely associated with incontinence and urgency complaints with all other cancer types not having these complications (Tab. 3). Similarly, the presence of lymphedema was noted in 66% of patients with breast cancer. Given the risk of lymphedema in patients with breast cancer, this likely was a targeted assessment by the evaluating clinician rather than one that was performed on all patients. There were common impairments across all cancer types, including posture, ROM, soft tissue, strength, and pain (Tab. 3). Several associations existed between specific impairments and mode of treatment (Tab. 4). The odds of having posture and ROM impairments, in addition to the presence of lymphedema, were significantly higher in patients who received radiation or chemotherapy. Interestingly, the odds of having urinary incontinence and urinary urgency were significantly lower in patients who received these treatments.
Discussion
The objective of this study was to describe clinical characteristics of patients with various cancer diagnoses who were seen for cancer rehabilitation outpatient physical therapy over a 2-year period. Given the increase in cancer survivorship in the United States, physical therapists who work in oncology rehabilitation or in general outpatient settings with patients who have a history of cancer should be familiar with common side effects and impairments related to cancer treatments and particular types of cancer. As we hypothesized, patients with breast and genitourinary cancers comprised more than 60% of our sample. As expected and consistent with previous reports, patients with breast and urogenital cancers also demonstrated the highest frequency of lymphedema and incontinence, respectively. The presence of these impairments was not unexpected given the prevalence of patients with these cancers in our sample. These findings should be interpreted with some caution, however, as these frequencies may be inflated due to several of the physical therapists in this outpatient clinic specializing in lymphedema or pelvic rehabilitation.
Physical therapists who treat patients with breast or urogenital cancers or who have a history of these cancers should screen for impairments specific to these cancers that may persist long after the completion of treatment. More than 80% of the patients in the urogenital cancer group in this study had a diagnosis of prostate cancer. Urinary incontinence is one of the most common side effects of prostate cancer treatment. Wolin et al27 estimated the prevalence of incontinence (defined as any leakage pad use) at 6 and 58 weeks postprostatectomy at 59% and 22%, respectively. A conservative approach of pelvic-floor rehabilitation and behavioral modifications has demonstrated some value in improving the speed of continence recovery postprostatectomy.28–30 Parekh and colleagues31 evaluated continence outcomes in patients who received preprostatectomy pelvic-floor muscle (PFM) training. The treatment group underwent 3 preoperative and 3 postoperative physical therapy sessions consisting of rectal probe electromyographic biofeedback, verbal cueing, visualization of the PFM, and functional PFM training. Compared with the control group, which did not receive formal PFM training, the treatment group achieved a significantly faster return to continence at 12 weeks. The results from these studies suggest that incontinence may persist long after prostatectomy and that physical rehabilitation may help hasten continence recovery. Thus, physical therapists who treat patients with a history of prostate cancer should routinely screen for the presence of urinary incontinence and treat or refer appropriately.
The results from our analysis and previous research provide evidence for common impairments or side effects of breast cancer, including lymphedema, glenohumeral joint dysfunction, pain, and fatigue.10,11,32–34 Scaffidi et al35 evaluated rehabilitative outcomes in women following breast cancer surgery who received early (postoperative day 1) physical therapy compared with usual care. They reported that early physical therapy group demonstrated improved shoulder mobility and function and lower rates of lymphedema and referral for outpatient physical therapy at 6 months postsurgery. Stout and colleagues36 recommend that optimal care for patients with breast cancer include a prospective model of care that has 3 stages: preoperative evaluation and education, early postoperative rehabilitation, and multidisciplinary ongoing surveillance. The physical therapist's role in this model of care includes patient education and identification and management of upper extremity ROM, strength, limb volume, activity limitations, pain, fatigue, and weight. Additionally, they recommend that each stage include promotion of healthy behaviors such as weight management, strategies for exercise prescription, and assessment of physical function. The ongoing surveillance period is specific to the individual patient and may include months or years after cancer treatments. Physical therapists in an outpatient setting who treat patients with a history of breast cancer should be aware of and screen for common side effects of treatment, including fatigue, pain, lymphedema, and shoulder dysfunction. Additionally, they should recognize that these issues might develop or extend after the immediate treatment period (eg, months or years).
The high frequency of hypertension across all cancer diagnostic groups is consistent with estimates of hypertension across the general population,37 and this frequency is likely not specific to the presence of cancer. Like other patients with whom an exercise program may be initiated, screening for and controlling moderate to severe hypertension also is warranted prior to initiating an exercise program in patients with cancer. Over the last decade, research has demonstrated positive benefits of physical activity in patients with cancer during and after cancer treatments, including the prevention and management of consequences of treatment, including CRF.38–42 Given the associations between sedentary behavior and increased cancer risk and mortality,43,44 physical activity is recommended for patients undergoing active treatment45 and during survivorship.46 Stewart22 recommended additional precautions prior to starting an exercise program for patients with hypertension, including stress tests to rule out ischemia and complex arrhythmias and controlling moderate to severe hypertension.
The neuromusculoskeletal early and late effects of radiation and chemotherapies are extensive. Radiation therapy is associated with neuropathic pain believed to be caused by damage to nerve roots, plexus, and peripheral nerves.47–49 Additional late musculoskeletal side effects of radiation therapy may include muscle atrophy and fibrosis,50,51 muscle spasms and pain,47,52 and decreased bone density.53 Common side effects of chemotherapy exist, including, but not limited to, neurotoxicity (eg, peripheral neuropathy, myelopathy, cognitive changes), hair loss, gastrointestinal dysfunction, nausea, fatigue, and weight loss. Although we did not stratify patients based on the type of chemotherapy they received, recognizing common physical effects of different chemotherapeutic agents is important for therapists treating patients with a history of cancer. For example, platinum-based drugs (cisplatin, carboplatin, oxaliplatin), vinca alkoids (vincristine, vinblastine), and taxanes (docetaxel, paclitaxel) are associated with painful neuropathies that can last for months to years after treatment.54 Anthracyclines (daunomycin, doxorubicin) are associated with cardiotoxicity,55,56 which can present anywhere from during treatment to years after treatment.57 The patients in the current study exhibited a wide range of impairments, including deficits in strength, ROM, soft tissue, postural dysfunction, and pain, and some of these impairments were nearly universal across all cancer diagnostic groups.
The odds of having impairments in posture, ROM, lymphedema, and fatigue were significantly greater in patients who underwent chemotherapy or radiation therapy compared with those who did not undergo these interventions. The odds of reporting pain was 4.7 times more likely in patients who underwent radiation therapy than those who did not undergo radiation therapy. These data suggest that screening for postural deficits, ROM deficits, fatigue, and lymphedema may be appropriate for patients who have undergone radiation therapy or chemotherapy. Pain assessment should be included for patients who have undergone radiation therapy. Last, soft tissue impairments should be evaluated in patients who have undergone surgical resection.
Collectively, our data indicate that certain types of cancer and modes of treatment may be associated with particular impairments. In addition to assessment of strength among all patients with cancer, we also suggest targeted screening for impairments by cancer type and mode of treatment (Tab. 6). We encourage interpretation of this table with some caution because the number of patients with some types of cancer was lower than others (eg, bone, respiratory, skin, blood, and digestive cancers). However, we recommend the screenings based on the percentage of individuals (eg, greater than 50%) who had those listed impairments. Strength, soft tissue integrity, and ROM should be evaluated in most, if not all, patients with cancer. Screening for lymphedema and deficits in ROM or postural dysfunction may be warranted in patients who have had chemotherapy or radiation therapy, as assessing pain and fatigue levels may be appropriate in patients who have had radiation therapy. Last, evaluating for the presence of incontinence and urgency in patients with urogenital cancers who have undergone radiation therapy also is recommended.
Physical Therapy Screening Recommendations Based on Cancer Type and Mode of Treatmenta
This analysis provides novel clinical information about patients with cancer referred for outpatient physical therapy and the impairments that they presented. Additionally, these data add to existing literature linking cancer treatments to functional limitations and physical signs and symptoms in patients with cancer. Cheville et al58 reported that 65% of patients undergoing outpatient cancer treatment who identified issues related to cancer treatment described having functional problems related to activities of daily living. They also reported that the rate of oncology physician and nurse practitioner documentation of physical symptoms, including pain and nausea, were more likely to be documented than functional issues such as ambulation and balance. These data indicate a discrepancy between patients' perceptions of their needs regarding functional activities and clinicians' screening and documenting these issues. Although the current study focused on the presence of physical impairments, Cheville et al58 and other authors59–61 indicated that functional limitations are present in patients with cancer and should be considered through active surveillance during the cancer continuum. The novelty of our study includes the inclusion of patients with a variety of different cancer diagnoses who were referred to an outpatient physical therapy center, the types of cancer treatments they underwent, and the physical impairments identified at the initial physical therapy evaluation.
Additionally, our data suggest that patients with breast and urogenital cancers are frequently referred for outpatient physical therapy in a tertiary care setting. Physical therapists who treat patients with a history of these cancers should be aware of and screen for specific impairments, including lymphedema and incontinence, even if the time in which the initial physical therapy evaluation occurs extends beyond when the cancer treatments were received. Future studies should consider the efficacy of physical therapist treatment on specific impairments identified in this study, including urinary incontinence, lymphedema, strength deficits, fatigue, and pain. Another direction for future research should include examining the frequency of survivors of cancer seen in stand-alone physical therapy centers (ie, not in a radiation oncology clinic at an academic tertiary care center) to determine the prevalence of patients with cancer in general outpatient rehabilitation settings.
Limitations
This study had several limitations. A significant limitation is that this analysis did not include information about the duration of the patients' impairments or duration from cancer treatments relative to their initial physical therapy evaluation. Therefore, we were unable to determine if the impairments with which they presented resulted from recent cancer treatments or if these were long-standing issues related to previous cancer treatments. Another limitation was the categorization of patients based on their primary cancer diagnosis, as it is possible that some patients may have had more than one diagnosis. The outpatient physical therapy clinic from which these records were collected was housed within a radiation oncology clinic. The high number of medical referrals for physical therapy from radiation oncology may have been skewed due to the physical location of the physical therapy clinic. The impairments identified in the medical chart review were clinician determined and, to our knowledge, were not necessarily based on standardized, objective measures. Also, one of the physical therapists in this clinic specialized in pelvic-floor rehabilitation, including incontinence and pain, and another specialized in lymphedema management. The high number of patients with breast and urogenital cancers may have been related to the presence of these specialized providers.
Another limitation was the exclusion of body mass index as one of the comorbidities in the FCI, given the lack of this information from the collected records. Therefore, the reliability and validity of this measure may have changed due to our modification. Last, the clinicians who performed the initial physical therapy evaluation were not blinded to the cancer diagnosis of the patient and did not perform a standard examination but rather an examination tailored toward a specific cancer diagnosis. Thus, if a patient had a particular diagnosis, the physical therapist was likely biased toward specific assessments of impairments, such as lymphedema in patients with breast cancer or urinary incontinence in patients with genitourinary cancers. Although this relationship between a patient with a specific cancer diagnosis and symptoms specific to that diagnosis may enhance the clinical application of these findings, it means that the frequency of impairments reported should not be interpreted as accurate prevalence estimates.
Future studies in cancer rehabilitation should consider stratifying patients by their location on the cancer treatment continuum (eg, prediagnosis, diagnosis, active treatment, recovery, and long-term survival) to determine the presence of impairments based on duration from cancer treatments, particularly given that radiation therapy and different chemotherapies have both short- and long-term adverse effects. Additionally, longitudinal studies that follow patients throughout this treatment continuum may help to identify the likelihood of developing particular impairments or functional limitations as a result of treatment.
In conclusion, physical therapists who treat patients with breast or urogenital cancers or who have a history of these cancers should screen for common treatment side effects specific to these cancers that may persist long after the completion of treatment. Last, side effects of surgery, chemotherapy, and radiation therapy—including neuropathies, soft tissue fibrosis and contracture, pain, and fatigue—may persist long after cessation of these therapies. Physical therapists who treat patients who have undergone these types of cancer treatments should screen for these side effects and their potential impact on function and quality of life. Given the limitations described above, the findings of this study may be specific to settings similar to this study and may not be generalizable to other outpatient cancer rehabilitation settings.
Footnotes
Dr Alappattu, Dr Lee, Ms Bour, and Dr George provided concept/idea/research design. Dr Alappattu, Dr Coronado, Ms Bour, and Dr George provided writing. Dr Alappattu, Dr Lee, and Ms Bour provided data collection and project management. Dr Alappattu, Dr Coronado, and Dr Lee provided data analysis. Dr Alappattu and Ms Bour provided participants and facilities/equipment. Dr Coronado provided administrative support. Ms Bour and Dr George provided consultation (including review of manuscript before submission).
This study was approved by the University of Florida Institutional Review Board.
The data were presented at the Combined Sections Meeting of the American Physical Therapy Association; February 8–11, 2012; Chicago, Illinois.
This work was supported, in part, by the Foundation for Physical Therapy (M.J.A.), the National Center for Medical Rehabilitation Research (T32 HD043730, M.J.A. and R.A.C.), and the National Institute for Neurological Disorders and Stroke (T32 NS045551, M.J.A.).
- Received March 10, 2014.
- Accepted November 25, 2014.
- © 2015 American Physical Therapy Association