cancer rehabilitation

CANCER
REHABILITATION
Dr. Manik Jamatia
3rd Year Resident, PM&R Dept.
SMS Medical College, Jaipur
(PG Teaching, August 2016)

Introduction
■ Cancer is a pathologic process characterized by dysregulated cell
growth and systemic spread
■ All tissue types have neoplastic potential and can become
cancerous
■ Tissues distinguished by rapid cell turnover (gastrointestinal
mucosa), hormone sensitivity (breast and prostate), and regular
exposure to environmental mutagens (lung and skin) have higher
rates of malignant transformation
■ Any tissue can develop cancer, means that cancer rehabilitation
must address all body parts and systems

■ Despite broad scope, field condenses into a manageable body of
expertise predominantly focused on sequelae of cancer treatment,
maladaptive host responses (e.g., paraneoplastic syndromes),
erosive effects of cancer on bones and neural tissue
■ With ever-increasing cancer survivorship, number of patients
whose disease has been eliminated or successfully temporized
continues to grow
■ Given magnitude of current need, physiatrists can elect to treat
patients who are cured of their cancers or whose cancers have
progressed to being widely metastatic

Disease Considerations
Staging
■ The specifics of cancer staging vary by disease site, but all
conform to a general format geared toward describing spread of
disease from its site of origin
■ According to TNM status, Stage I is early, locally contained
disease, whereas stage IV is advanced disease characterized by
distant metastases
■ Cancer staging dictates the type, duration, and aggressiveness of
anticancer therapy
■ Staging provides critical information for appropriate design of
rehabilitation interventions, and for gauging each patient’s risk of
recurrence or progression

Prognosis and Metastatic Spread
■ Cancer presents patients and clinicians with a staggering array of
prognoses, differential treatment approaches, and patterns of
metastatic spread.
■ In planning a long-term rehabilitation approach, it is important to
anticipate
– where cancer is likely to spread,
– how it will respond to treatment,
– what cumulative toxicities might be associated with ongoing
therapies, and
– how long patients will live,
■ Implications of regional and distant spread at time of diagnosis
vary considerably by cancer type

■ Information informs rehabilitation goal setting, determines level of
emphasis placed on symptom-oriented versus disease-modifying
treatments
■ Lung, breast, colon, and melanoma commonly spread to brain,
regular neurologic screening examinations should therefore be
incorporated into posttreatment, surveillance care
■ Prostate, breast, and lung cancer commonly produce bone
metastases
■ Musculoskeletal pain in cancer populations can be due to primary
or secondary consequences of bony disease and should trigger an
appropriate evaluation
Prognosis and Metastatic Spread cont…

Constitutional Symptoms
■ Many symptoms are common in cancer, particularly among
patients with stage IV disease
■ Failure to adequately address symptoms such as fatigue, nausea,
pain, anxiety, insomnia, and dyspnea can undermine rehabilitative
efforts
■ Pain and fatigue presents most consistent and challenging
obstacles to successful rehabilitation
Fatigue
■ Fatigue is most common symptom experienced by cancer patients
■ Prevalence ranges from 70% to 100%, contingent on type and
stage of cancer

– Diminished energy
– Increasing need for rest
– Limb heaviness
– Diminished ability to
concentrate
– Decreased interest in
engaging in normal
activities
– Sleep disorder
– Inertia
– Emotional lability as a result
of fatigue
– Perceived problems with
short-term memory
– Post exertional malaise
exceeding several hours
Constitutional Symptoms cont…
International Classification of Diseases, Criteria for Cancer-
Related Fatigue

Reversible Sources of Cancer
Fatigue
– Anemia
– Insomnia or lack of
restorative sleep
– Cytokine release (e.g.,
tumor necrosis factor)
– Hypothyroidism
– Hypogonadism
– Depression
– Deconditioning
– Steroid myopathy
– Centrally acting
medications
– Altered oxidative capacity
– Pain
– Adrenal insufficiency
– Cachexia

Interventions for Fatigue
■ Restore energy balance
– Correct anemia,
– Nutritional and vitamin
supplementation,
– Correct endocrine dysfunction
(thyroid)
■ Medications
– Stimulants (methylphenidate,
D-amphetamine)
– Analgesics Antidepressants
(bupropion, SSRIs, TCAs)
– Regulate sleep/wake
– Glucocorticoids
– Investigational—cytokine-
targeted therapy (including
NSAIDs)
■ Exercise
– Aerobic exercise is best-studied
form
– Individualized
– Attention to precautions
– Cachectic patients may not
tolerate
■ Energy conservation
– Education
– Adaptive equipment
■ Psychologic/coping
– Recreational activities
– Relaxation techniques
– Support groups

Pain
■ Prevalence of cancer-related pain is
– 28% among patients with newly diagnosed cancer,
– 50% to 70% receiving antineoplastic therapy,
– 64% to 80% with advanced disease
■ Adequate pain control is an absolute requisite for successful
rehabilitation
■ Cancer patients generally experience multiple concurrent pain
syndromes
■ Thorough evaluation requires assessment of all relevant pain
etiologies and pathophysiologic processes

■ Pain control require integrated use of anticancer treatments,
agents from multiple analgesic classes, interventional techniques,
topical agents, manual approaches, and modalities
■ Majority of cancer pain is due to tumor effects, for this reason,
disease-modifying, anticancer therapy plays a critical role in pain
management
■ Analgesics with transdermal, parenteral, and transmucosal routes
of administration should be preferentially used when enteral route
cannot be used

Acute Pain
■ Acute pain after surgery or radiation therapy can be successfully
treated
■ Nerves are frequently severed, compressed, or stretched during
tumor resection, making it possible for neuropathic pain to be a
major factor during postoperative period
■ Adjuvant analgesics (e.g., gabapentin) should be initiated when a
neurogenic contribution to pain is suspected
■ In postoperative pain that impedes function, aggressive opioid-
based and anti-inflammatory analgesia should be considered

■ Acute pain control allows movement and limits immobility
Chronic Pain
■ Chronic cancer-related pain can arise from visceral or neural
structures but is most commonly associated with bone metastases
■ Bone metastases occur in 60% to 84% of patients with solid
tumors
■ Prostaglandins have been implicated in pain associated with lytic
bone metastases
■ NSAIDs are considered first-line therapy for bone pain,

Adjuvant for Bone Pain:
■ Opioids: Enhance analgesia afforded by NSAIDs and can reduce
doses required for adequate pain relief
■ Opioid use should be restricted to pure μ-receptor agonists
■ Include morphine, hydromorphone, oxycodone, oxymorphone,
fentanyl, and methadone
■ Opioid analgesic requirements change over time depending on
whether a patient’s cancer progresses or responds to treatment

Invasive and Intraspinal Analgesic Approaches
■ Permanent ablation of central afferent tracts becomes tenable in
context of advanced cancer, and has been used with considerable
success
■ More discrete neural blockade can effectively reduce pain
transmitted by one or several adjacent peripheral nerves
■ Intercostal, paravertebral, genitofemoral, ilioinguinal, and
trigeminal nerve blocks can afford dramatic relief and reduce
analgesic requirements

■ Nociceptive impulses of visceral origin can be blocked by ablation
of sympathetic ganglia
■ Celiac plexus blockade affords excellent relief of visceral cancer
pain
■ Intraspinal opioid administration can reduce dose requirements
and associated side effects
■ Potential benefits, however, must be weighed against added cost,
required maintenance, and risk of infection

Impairments in Cancer
■ Cancer can invade all tissue types and regions of body, producing
a wide array of functional impairments
■ Tumor related deficits generally arise as a result of pain, neural
compromise, loss of osseous or articular integrity, and invasion of
cardiopulmonary structures
■ Cancer-related impairments are often dynamic, characterized by
improvement or progression, depending on treatment
responsiveness

Bone Metastases
■ Bone metastases are important source of cancer related
impairment and a critical consideration in rehabilitation
■ Highly prevalent because bone is most common site of metastatic
spread, and most frequently from cancers lung, breast, and
prostate
■ Of greatest physiatric concern are lesions involving spine and long
bones
■ These structures are critical for weight-bearing and mobility, and
are most prone to fracture
Impairments Caused by Tumor Effects cont…

■ Managed with medications, radiopharmaceuticals, orthoses,
radiation therapy, and/or surgical stabilization
■ Bisphosphonates are primary medications, these agents relieves
pain and mitigates spread and progression of bone metastases
■ Can reduce risk of vertebral fracture, nonvertebral fracture and
hypercalcemia
■ Radiopharmaceuticals such as strontium-99 are used to manage
severe, refractory pain associated with widely disseminated bone
metastases

■ Internal fixation and prosthetic replacements are most effective
ways of relieving pain and restoring function in patients with
pathologic fractures
Brain Tumors (Primary and Metastases)
■ Brain metastases occur in 15% to 40% of cancer patients
■ Lung cancer, most common primary source of metastases, Breast
cancer, second followed by melanoma
■ Presenting symptoms at time of diagnosis with brain metastasis, in
order of decreasing frequency, are as follows

■ Patients can have more than
one:
– headache, 49%;
– mental disturbance, 32%;
– focal weakness, 30%;
– gait ataxia, 21%;
– seizures, 18%;
– speech difficulty, 12%;
– visual disturbance, 6%;
– sensory disturbance, 6%; and
– limb ataxia, 6%
■ Corticosteroids are first-line treatment, with dexamethasone being
drug of choice
■ Treatment generally involves whole brain radiation therapy with
stereotactic radiosurgery or surgical resection via craniotomy

Epidural Spinal Cord Compression
■ Malignant spinal cord compression (SCC) occurs in up to 5% of
patients
■ Pain is by far most common initial (94%) and presenting (97% to
99%) symptom of malignant SCC
■ Radicular pain is present in 58% of patients at time of diagnosis
■ Thoracic spine is most common site of epidural SCC, followed by
lumbosacral and cervical spine

Cancer Involving Cranial and Peripheral Nerves:
■ Cranial nerve palsies are caused by tumors that either originate
near base of skull or metastasize there
■ Clinical presentations vary depending on cranial nerve being
compressed
■ Evaluation should include MRI, which is diagnostic test of choice
■ Acute management should include oral steroids, unless
contraindicated, to preserve neurologic function until definitive
treatment is delivered
■ Treatment generally involves chemotherapy and radiation

■ Spinal Roots: Malignant radiculopathies arise through direct
hematogenous spread to nerve roots or dorsal root ganglia, or
more commonly by invasion from paravertebral space
■ Evaluation of spinal roots for cancerous involvement is best
achieved with MRI
■ Corticosteroids should be considered to minimize peritumoral
edema until disease-modifying therapy can be delivered.
■ Radiation is effective at alleviating symptoms, but its capacity to
spare neurologic function has not been adequately characterized

■ Nerve Plexuses: Brachial and lumbosacral plexus are commonly
compressed or invaded by tumor
■ Pain in shoulder region and proximal arm occurs in 89% of
patients with malignant brachial plexopathy
■ Acute treatment should include steroids for preservation of
neurologic function
■ Radiation can effectively relieve pain but is less helpful in restoring
lost function
■ Chemotherapy is commonly initiated or altered when plexus
involvement heralds cancer progression

■ Paraneoplastic Syndromes: Pertinent to rehabilitation because
they produce refractory neurologic deficits and severe disability
■ Syndromes are produced when antibodies are made against
tumors that express nervous system proteins
■ Discrete or multifocal neural degeneration produces diverse
symptoms and deficits
■ Diagnostic workup can include serum and cerebrospinal fluid
studies, brain MRI, and PET

■ Rehabilitation of patients with PNDs is determined by type,
distribution, and severity of associated neurologic deficits
■ Potential improvement with planned antineoplastic therapy should
be taken into consideration
■ Supportive and preventive measures to protect integrity of skin,
affected joints, and genitourinary symptoms are critical while
awaiting stabilization of neurologic deficits
■ Communication, respiratory, and nutritional issues should be
addressed in patients with bulbar involvement

Skin Metastases
■ Dermal metastases occur in 5.3% of patients and are most
common in breast cancer
■ Malignant wounds should be managed with nonadherent,
bacteriostatic, hyperabsorbent dressings (e.g., SilvaSorb or
Aquacel Ag)
■ Associated pain must be managed aggressively to minimize
adverse functional consequences
■ Proactive range of motion (ROM) activities can prevent formation
of contractures in joints, facilitating hygiene and autonomous self-
care

Cardiopulmonary Metastases
■ Lung, pleural, and pericardial metastases involving heart and
lungs can produce dramatic and abrupt reductions in patients’
stamina and functional status
■ Type and efficacy of anticancer treatment depend on primary
tumor, number and location of metastases, previous antineoplastic
therapies, overall medical condition of patient, and degree of
associated symptomatic distress
■ Malignant pleural effusions should be evacuated when patients
become symptomatic
■ Supplemental oxygen should be initiated as soon as dyspnea
becomes function-limiting

Impairments Caused by Cancer Treatment
■ Combined Modality Therapy: Push toward organ preservation in
primary cancer care has led to widespread use of combined
modality therapy
■ It is relevant to rehabilitation because most cancer patients receive
some combination of chemotherapy, radiation therapy, and surgery
contingent on type and stage of cancer
■ This makes patients vulnerable to cumulative normal tissue
toxicities associated with each modality
■ Surgery-Related Impairments: Normal tissue is inevitably affected
by surgical efforts to achieve local control of cancer

■ Cancer surgery has greatest physiatric relevance when certain
tissue types are affected, includes bone, nerve, muscle, lung
parenchyma, and lymphatics
■ Normal postoperative healing is often compromised by previous
administration or co-administration of additional anticancer
treatment (e.g., radiation and chemotherapy)
■ Operations that warrant attention of a physical medicine specialist
include
– neck dissection for oropharyngeal carcinomas (spinal
accessory nerve palsy),
– limb salvage or amputation for osteosarcoma (impairments
vary by site),
Impairments Caused by Cancer Treatment cont…

– resection of truncal or limb myosarcoma (weakness, gait
dysfunction, biomechanical imbalance), and
– pneumonectomy or lobectomy for lung neoplasms (aerobic
insufficiency)
■ Neurosurgical resection of central and peripheral nervous system
malignancies mandates physiatric evaluation, irrespective of
presence of gross deficits, given the potentially devastating effects
of subtle impairments and high likelihood of future recurrence and
progression
■ Donor Site Morbidity: Muscle, skin, bone, and fat are used to
achieve adequate coverage of surgical defects and to optimize
cosmesis

■ Radiation Therapy Related Impairments: RT has become an
integral part of combined modality and organ preservation therapy
for many cancers
■ Radiation injury is multiphasic
■ Acute injury is predominantly caused by inflammation and death of
rapidly proliferating cell types
■ Cell death occurs through induction of apoptosis and free radical-
mediated DNA damage

■ Late radiation effects most relevant to rehabilitation medicine
include those involving connective tissue, muscles, and nerves
■ Fibrosis occurs to some degree in all muscles and connective
tissue within a radiation portal
■ In absence of ongoing ROM, patients can develop contractures
■ Most devastating effects include myelopathy, plexopathy, and
encephalopathy
■ Medical treatment of radiation therapy-associated neural
compromise include short-term steroids, anticoagulation, and/or
hyperbaric oxygen therapy

Chemotherapy : Mainstay of anticancer therapy with varying efficacy
■ Induction chemotherapy is administered to patients with advanced
disease for which no other treatment exists
■ Adjuvant therapy is administered after local control is achieved
through surgery or radiation, when no obvious tumor is present to
eliminate undetectable micro metastases and reduce the risk of
recurrence
■ Neoadjuvant therapy can be used before surgery to reduce tumor
size and thereby minimize degree of anatomic disruption

Rehabilitation Approaches
Rehabilitation of Bone Metastases :
■ Integrated cross-disciplinary, long-term management plan offers
patients best chance of preserved comfort and function
■ Physiatric approaches can be grouped into use of orthoses,
assistive devices, therapeutic exercise, and environmental
modification
■ All essentially de-weight or immobilize compromised bones
■ Use of thoracolumbosacral or spinal extension orthoses, such as
cruciform anterior spinal hyperextension or Jewett braces

Rehabilitation of Bone Metastases cont…
■ Orthoses limit spinal flexion, thereby reducing loads on anterior
vertebrae to protect against compression fractures
■ Orthoses can also be used to protect and de-weight sites of
fracture or impending fracture
■ Extreme caution must be used in patients with diffuse bone
metastases while redistributing weight and loading patterns
■ Assistive devices and instruction in compensatory strategies might
similarly unload compromised bones

■ Canes, crutches, and walkers are frequently used to minimize
fracture risk
■ Patients should be instructed to minimize forces by performing
activities close to body, which limits torque on long bones
■ Although theoretically appealing, evidence is lacking for
usefulness of therapeutic exercise in prevention of pathologic
fractures
■ Regardless, patients at risk for vertebral fractures routinely tolerate
exercise programs designed to strengthen abdominal and spinal
extensor muscles and to enhance their awareness of body
positioning

■ A comprehensive exercise program should include postural and
balance training, as well as truncal strengthening
■ Simple environmental modifications can significantly reduce
patients’ fracture risk
■ Throw rugs and other hazards that increase fall risk should be
removed
■ Railings can be added to stairwells and bathrooms as appropriate
■ Patients’ prognoses should obviously be considered in the zeal
and expense with which such modifications are implemented

Aerobic Conditioning and Resistive Exercise:
■ Exercise studies performed in cancer population have consistently
substantiated gains in cardiopulmonary fitness, fatigue, quality of
life, depression, and anxiety
■ Benefits of exercise may extends on immune function, such as
improved natural killer cell activity, monocyte function, proportion
of circulating granulocytes, and duration of neutropenia
■ Physical activity appears to exert a protective effect against
development of some types of cancers, most notably colon and
breast cancers

■ Cancer prevention recommendations developed by American
Cancer Society include
– at least 30 minutes of moderately vigorous physical activity on
5 or more days of the week for adults, and
– at least 60 minutes for children and adolescents.
■ Among exercise forms, cycle ergometry is often favored, with its
advantages of positioning options, and relative ease of use by
individuals with balance or coordination deficits

■ Aerobic conditioning reduces symptom burden and mitigates
physiologic impact of high-dose chemotherapy delivered in context
of bone marrow transplantation
■ Definitive improvement was reported with resistance training
among prostate cancer patients receiving androgen deprivation
therapy, as well as in breast and head and neck cancer survivors
Rehabilitation of Cardiopulmonary Dysfunction:
■ Exertional intolerance resulting from cardiopulmonary factors
occurs commonly among cancer patients

■ Incremental aerobic conditioning with supplemental oxygen as
needed usually produces a reduction in exertional intolerance
■ Improvements in stamina and perceived exertion are due to
muscle-training effects
Flexibility Exercises:
■ Activities to enhance ROM are critical for rehabilitation of
postsurgical and post radiation soft tissue contractures
■ Patients is provided with a series of active-assisted ROM activities
that target all affected muscle groups, with emphasis placed on
restricted planes of motion and instructions to hold each stretch for
three to five deep breaths

Lymphedema Management
■ Lymphedema is a chronic and currently incurable condition that
frequently complicates cancer therapy
■ After resection or irradiation of lymph nodes and vessels,
lymphatic congestion can develop in any region of body drained by
affected structures
■ If congestion becomes sufficiently severe, swelling can result from
accumulation of protein-rich fluid
■ Complete (or complex) decongestive therapy (CDT) represents
current international standard of care for lymphedema
management

■ CDT is intensive integration of manual approaches and is able to
achieve and maintain substantial volume reduction for majority of
lymphedema patients
■ Initial phase I, Reductive, has its primary goal in decreasing
lymphedema volume
■ Patients receive approximately 45 minutes of manual lymphatic
drainage (MLD), followed by application of compression bandages
and performance of remedial exercises
■ In phase II, compressive garments are used during day, with
application of compressive bandages overnight

■ Compression garments achieve the following:
– Improve lymphatic flow and reduce accumulated protein
– Improve venous return
– Properly shape and reduce size of limb
– Maintain skin integrity
– Protect limb from potential trauma
■ MLD stimulates intrinsic contractility of lymph vessels, leading to
increased sequestration and transformation of macromolecules in
interstitium

■ MLD permits shifting of congested lymph to lymphotomes
■ Remedial lymphedema exercises refer to repetitive movements
designed to encourage rhythmic, serial muscle contractions in
lymphedematous territories
■ Remedial exercises are always performed with external
compression, most commonly compressive garments or bandages
■ It repeatedly compress lymph vessels through sequential muscle
contraction and relaxation, thereby triggering smooth muscle
contraction in lymph vessel walls
■ Skin care is stressed in manual approaches to lymphedema

■ Goals of skin care include controlling skin colonization with
bacteria and fungi, eliminating overgrowth in skin crevices, and
hydrating the skin to eliminate microfissuring
■ Daily cleansing with mineral oil-based soap will remove debris and
bacteria while moisturizing the skin
Augmentative and Compensatory Strategies
■ Adaptation of conventional rehabilitation programs to alternative
and compensatory strategies allows patients to remain functionally
independent

■ Use of assistive devices for mobility and ADL performance might
be necessary
■ Environmental modification and augmentative communication
devices should be explored in appropriate cases
■ Pacing strategies become essential for fatigued patients receiving
intensive anticancer therapy, or for those with advanced disease

Rehabilitation of Specific Cancer Populations
Breast Cancer
■ Functional impairments unique to breast cancer patients are
developed after surgical procedures for tumor removal and breast
reconstruction
■ Persistent deficits in shoulder ROM occur in as many as 35% of
patients after ALND
■ Axillary web syndrome refers to presence of taut, palpable cords
originating in axilla and extending distally along anterior surface of
arm, often below elbow
■ Clinical relevance of axillary web syndrome arises from its
potential for painful restrictions in shoulder ROM

■ In severe cases, cords tether the humerus, preventing full shoulder
flexion or abduction
■ Pain generally responds to NSAIDs, but opioid analgesics might
be necessary during passive and active assisted ROM if pain is
severe
■ Therapy involves incremental ROM activities, topical heat,
manipulation to soften
■ Surgical community has increasingly recognized need for
rehabilitation after TRAM flap breast reconstruction
Rehabilitation of Breast Cancer Populations

■ It denervate and disrupts integrity of abdominal wall, producing
significant deficits in truncal stability, particularly during functional
transfers
■ Goals of post-TRAM rehabilitation are to
– prevent subdermal fibrosis and adhesions,
– restore truncal alignment,
– minimize stress on the lumbar spine,
– optimize proprioceptive acuity in residual abdominal muscles,
and
– encourage normal muscle recruitment patterns
Rehabilitation of Breast Cancer Populations

■ Combined modality therapy for head and neck cancer has afforded
improved cure rates and reduced normal tissue compromise
■ Treatment of head and neck cancer continues to produce some of
most challenging impairments within scope of cancer rehabilitation
■ Many of impairments directly undermine patients’ ability
– to socialize because of facial dysmorphism,
– loss of spontaneous or intelligible speech, and
– inability to eat normally
Rehabilitation of Head and Neck Cancer

■ Common rehabilitation problems include
– spinal accessory nerve palsy,
– radiation-induced xerostomia, soft tissue contracture of neck
and anterior chest wall soft tissues,
– dysphagia,
– dysphonia, and
– myofascial dysfunction
Spinal Accessory Nerve Palsy:
■ Integrity of spinal accessory nerve can be easily assessed by side-
to-side comparison of resisted end-range forward flexion of
shoulder

■ Some degree of weakness can be elicited in most patients on the
side of the neck dissection
■ Important elements of spinal accessory nerve rehabilitation
include:
– Prevention of frozen shoulder through active ROM and active-
assisted ROM
– Prevention of anterior chest wall flexibility deficits
– Strengthening of alternate scapular elevators and retractors
■ Instruction in compensatory techniques for activities requiring
sustained shoulder abduction and forward flexion

■ Neuromuscular retraining
■ Preservation of trapezius muscle tone through electrical
stimulation if reinnervation is anticipated
■ Postural modification
■ Instruction in shoulder support to allow recovery of the levator
scapulae
Cervical Contracture:
■ Progressive fibrosis of anterior and lateral cervical soft tissue can
be highly problematic for head and neck cancer patients

■ Proactive ROM in all planes of neck motion should be initiated as
soon as safely possible
■ Cervical ROM can continue throughout radiation therapy in the
absence of significant skin breakdown
■ Ranging activities should ideally begin immediately after surgery
and before radiation
■ Stretches should be held for five deep breaths and repeated
between 5 and 10 times per session

■ Isometric strengthening of cervical extensors and postural
modification with visual cuing are beneficial
Aphonia and Dysphonia
■ Impaired vocal communication occurs in majority of head and neck
cancer patients at some point during treatment
■ Many conditions other than total laryngectomy can compromise
phonation
– radiation-induced laryngeal or pharyngeal swelling and
fibrosis,
– tracheostomy,

– partial or total glossectomy,
– reduced oral excursion secondary to trismus,
– copious secretions, and
– neurogenic pharyngeal or laryngeal paralysis
■ Various approaches to restore communication can be used
depending on anticipated duration, severity, and nature of deficit
■ Most common compensatory strategies used by acutely voiceless
adults include mouthing words, gestures, writing, and head nods

Conclusion
■ Cancer rehabilitation is a varied and challenging field of increasing
public health importance
■ An accruing evidence base suggests that conventional
rehabilitative interventions
succeed in preserving and restoring functional status of cancer
patients
■ A marked lack of hypothesis-driven research continues to limit
field, as does a lack of experienced and interested clinicians
■ It is hoped that these deficits will be remedied given the
projections for steadily
increasing cancer survivorship

Reference
■ Physical Medicine and Rehabilitation Braddom, 4th Edition
- RANDALL L. BRADDOM MD, MS
■ DeLisa's Physical Medicine and Rehabilitation Principles and
Practice, 5th Edition
- Walter R. Frontera, MD, PhD, FAAPM&R, FACSM

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