Stronger Together – The Synergy Between Physical Therapy and Exercise Physiology in Oncology Settings

The following blog post is a quick summary of a recent publication by our research team on the synergy between physical therapy and exercise physiology professionals. When we all work together – the patient wins!

Over the last several decades, there have been some major advances in the fight against cancer. Early detection and awareness are on the rise. Genetic sequencing and targeted therapies have yielded impressive results. Mortality rates from cancer are at an all time low.

Now, more than ever, cancer survivors have a reason to be optimistic about what the future holds.

Along with these advances comes one potential downside – cancer survivors are living with the long term and late effects of cancer longer than ever before. These include fatigue, muscle cachexia and weakness, pain, sleep disturbances, nausea, reduction in bone density, depression and anxiety, body image issues, weight gain, decreased range of motion, cognitive impairment, chemotherapy-induced neuropathy, and reduction in physical activity

Even survivors who are relatively fit and free of co-morbidities at the time of diagnosis are likely to experience negative effects of treatment, to some degree.

There is strong evidence to support the management of physical impairments through a comprehensive oncology rehabilitation program, involving a collaborative team of physical therapists and exercise physiologists.

Physical Therapists are trained to gage deficiencies in strength, endurance, mobility, balance, and motor control. Based on this assessment, they develop and implement a targeted treatment plan designed to restore optimal function while navigating co-morbidities, patient values and beliefs, schedule limitations, and other physical demands present in the patient’s life. In their sessions, physical therapists instill education to patients regarding their condition, empowering them for long term success and prevention of prolonged or future issues.

An Exercise Physiologist is trained to analyze an individual’s level of fitness in order to improve or maintain health, mitigate side effects, and improve quality of life. In an exercise program, the five components of fitness are addressed – body composition, cardiorespiratory fitness, muscular strength, muscular endurance, and flexibility. Based on the patient’s baseline assessment, the exercise physiologist develops an individualized exercise program to target patient strengths, weaknesses, and goals. Sessions are then carried out once each week for 45-60 minutes through a supervised, whole body workout.

Together, oncology-trained physical therapists and exercise physiologists can provide the best possible care for cancer survivors, meeting the comprehensive goals set by NCCN guidelines and using a whole person approach to cancer care.

Nationally, less than 5% of patients participate in an exercise program. Most studies report that barriers to participation include treatment-related side effects, emotional status, feelings of lack of control over health and cost. Further, insufficient patient education is believed to contribute to the belief that participation in a physical therapy or exercise program is not helpful. Therefore, we assert that identifying and addressing these barriers can lead to improved support and education from health professionals, thereby increasing patient involvement.

In light of this, we propose that at the time of diagnosis, each patient be referred to physical therapy for initial screening. The physical therapist will take baseline measurements and screen the patient for impairments. Based on this assessment, the patient will then be placed in one of two categories:

1. Appropriate for physical therapy
2. Not appropriate for physical therapy, but will benefit from individualized exercise therapy.

In this manner, the early and late effects of cancer will be monitored by the most appropriate oncology-trained exercise professional. This will maximize patient safety, reduce side effects, improve patient compliance to treatment, and improve patient quality of life.

Together, exercise physiology and physical therapy professionals can work together to create a unique patient experience, addressing their functional needs through a holistic approach to cancer care.

Table 1. Specific benefits of exercise on cancer-related toxicities.

Adverse Effect of Cancer Treatment	Description	Physiological Effect of Exercise
Muscular Degeneration	Cancer treatments can damage the integrity of muscle tissue by decreasing protein synthesis. The release of hormones that cause muscle cell growth and development are blunted [29, 30].	Exercise increases the integrity of muscle tissue and protein synthesis, stimulates the release of numerous hormones that increase muscle cell growth and development, and improves metabolism [30, 31].
Cardiotoxicity	Cancer treatments can lead to left ventricular dysfunction, reduced ejection fraction, diminished contractility, reduced cardiac output, decreased nutrient and oxygen delivery to tissues [29, 30].	Exercise can improve  cardiovascular efficiency by: o   Strengthening the myocardium o   Increasing cardiac output and stroke volume o   Decreasing resting heart rate and lowering exercise heart rate [30, 31].
Pulmonary toxicity	Cancer treatments can cause a disruption in the structural integrity of the airways [31, 32].	Exercise can improve ventilation and transport of oxygen from the environment to the cellular level [32, 33].
Fatigue	Cancer treatments cause persistent, whole-body exhaustion that interferes with daily functioning [34].	Exercise has been shown to decrease fatigue and anxiety, and improve quality of life [35].
Pain	Pain can be caused by damage to tissue and nerves from the original tumor by the cancer itself or its related treatment.	Pain thresholds and pain tolerance levels have been reported to increase both during and following exercise.  In addition, intensity ratings of pain appear to decrease following exercise [36-41].
Neuropathy	Damage to the peripheral nervous system caused by chemotherapy is referred to as chemotherapy-induced peripheral neuropathy, and produce pain symptoms that are often described as burning, paroxysmal, stabbing, or electric shock-like sensations [42] and are often accompanied by pins-and-needles sensations and itching [43].	Several studies report improvements in muscular strength following moderate resistance exercise programs in patients with hereditary motor and sensory neuropathies [44-47].
Immune Dysfunction	White blood cells have the ability to destroy foreign cells, including cancer cells in the body. Certain cancer treatments may cause a decrease in the body’s white blood cell count, making it harder to fight off infection [47].	Chronic exercise training at a moderate intensity is associated with improved immune function through increases the amount of white blood cells and therefore strengthens the immune system.
Endocrine changes	The majority of endocrine changes are tumor-specific and treatment-specific. Reproductive function, thyroid health, and bone health are often adversely affected.	During exercise, extracellular substrates are mobilized that augment the effects of the endocrine system.
Gastrointestinal dysfunction	Cancer treatments can often result in disruption to the gastrointestinal system, causing constipation, malabsorption, diarrhea [47].	Exercise can improve gastric emptying and lower the relative risk of colon cancer. Overtime, regular physical activity can strengthen the digestive tract, making muscles more efficient.
Weight loss	Some patients may experience weight loss both before diagnosis and as an effect of chemotherapy and radiation treatments. Factors that contribute to weight loss during treatment include loss of appetite, early satiety (feeling full), altered sense of taste and smell, difficulty chewing and swallowing, nausea, vomiting, diarrhea, and compromised nutrient intake	Exercise training has been suggested as a promising measure to prevent cachexia and restore muscular strength and endurance.

 

 

 

Table 2. General exercise program guidelines.

 

	Aerobic Training	Strength Training	Flexibility Training
Frequency	3-5 days/wk	2-3 days/wk	2-7 days/wk
Intensity	40-60% HRR*	40-60% HRR*	Stretch to the point of mild discomfort
Duration	20-60 min/session	1-3 sets, 8-12 reps per exercise	10-30 seconds per stretch
Mode	Walking, cycling, cross trainers, swimming	Free weights, machines, resistance bands, resistance balls	Static stretching

 

Figure 1. Screening Chart.

Basic Questions	Yes	No
1.    Do you have trouble completing your daily home and self care tasks due to weakness or physical limitations?
2.    Can you walk more than one block without difficulty?
3.    Can you climb more than one flight of stairs without difficulty?
4.    Are you able to complete your job responsibilities?
5.    Do you have pain that limits function or makes it difficult to sleep?
* If Physical Therapist answers yes to any of the above questions, patient is referred to physical therapy first. If answers to all questions are no, patient is referred to exercise oncology.

 

 

Figure 2. Synergy Between Physical Therapy and Exercise Physiology.

 

 

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