INTRODUCTION — Cancer rehabilitation is a specialty of physical medicine and rehabilitation that aims to meet these needs for cancer survivors. Rehabilitation focuses on the evaluation and treatment of functional loss and pain disorders with the goal to restore maximal function, which, depending on the patient's specific needs, may involve a multidisciplinary team, including a physiatrist (ie, physical medicine and rehabilitation clinician), physical therapists, occupational therapists, speech and language therapists, and a lymphedema therapist. The importance of cancer survivorship care inclusive of attention to the medical, functional, and psychosocial consequences of cancer and its treatment were cited as important areas to address in an Institute of Medicine (IOM) consensus study report issued in 2006 . It is important to identify and refer to those health care professionals that are qualified and have the expertise in treating patients' rehabilitation needs .
Cancer rehabilitation is typically a coordinated endeavor that requires an open channel of communication to the primary oncology team (eg, medical oncologist, radiation oncologist, and/or surgical oncologist) and the primary care providers. In addition, supportive services play a critical role in the rehabilitation of cancer survivors, including those by nurses, recreational therapists, nutritionists, social workers, mental health professionals, orthotic and prosthetic specialists, chaplains, vocational counselors, hospice liaisons, home care agencies, support groups, and educational outreach programs .
This topic will discuss cancer rehabilitation, including a specific discussion of the techniques and approaches utilized in the setting of rehabilitation, their indications, and evidence of their benefit. We will discuss in the following sections specific physical impairments that we most commonly see, with evidence of how rehabilitation can be effective (table 1). Other topics in cancer survivorship are covered separately. (See "Overview of cancer survivorship care for primary care and oncology providers".)
MODELS OF REHABILITATION — The majority of rehabilitation programs address specific physical impairments caused by the cancer and its treatments. It is important to note that general physical exercise has been shown in many studies to have tremendous benefits in cancer survivors, including improving fatigue, quality of life, mood, decreased cancer recurrence, and improved survival . This is beyond the scope of this chapter and is discussed extensively elsewhere. (See "The roles of diet, physical activity, and body weight in cancer survivors".)
Cancer rehabilitation plays a role throughout the continuum of cancer survivorship. General cancer rehabilitation is often grouped into categories known as the Dietz Classification . These include the following:
●Preventative rehabilitation – The emphasis in preventative rehabilitation (sometimes referred to as prehabilitation or prospective surveillance ) is on the use of early intervention and exercise to prevent or delay complications related to cancer or its therapies. It includes physical and psychologic assessments done early in the cancer continuum of care to identify physical impairments and to refer as deemed necessary to qualified rehabilitation professionals. The rationale is that earlier detection of impairments makes them easier to treat, which may reduce the incidence and/or severity of future impairments .
●Restorative rehabilitation – For patients in whom a fully functional recovery is expected, restorative rehabilitation envisions full reintegration of the patient back into society, community, school, or work.
●Supportive rehabilitation – For patients in whom cancer treatment has resulted in permanent deficits (including those in whom deficits are very unlikely to resolve), the goal of supportive rehabilitation is to re-establish functional independence as much as possible.
●Palliative rehabilitation – If intensive rehabilitation is not possible or deemed clinically inappropriate, palliative rehabilitation may play a role in supporting the patient, especially if they are facing a terminal diagnosis. The goals are to maximize patient comfort and caregiver support.
These services are not necessarily delivered independently of each other. Instead, they may be offered within a single program, allowing patients to transition to different services as dictated by their needs. This can be done by utilizing both inpatient and various outpatient rehabilitation services:
●Preventative services are generally offered while patients are admitted for acute care. When patients are referred, inpatient physical and occupational therapists assess the patient's current functional status in order to determine if and what types of rehabilitation services might be necessary. This includes assessments of patient safety, their independence in performing tasks (eg, bed mobility, transfers), and ambulation.
●Physical medicine and rehabilitation clinicians provide early education regarding potential impairments that can arise from cancer or its treatments. For example, for patients admitted with newly diagnosed breast cancer, therapists are involved with the early education about postoperative complications of breast surgery, including shoulder range of motion limitation and lymphedema.
●At discharge, rehabilitation clinicians provide recommendations about safe disposition of patients and when needed, assist in the transfer of appropriately selected patients to an acute or sub-acute inpatient rehabilitation center or a skilled nursing facility based on the individual's needs and ability to participate in inpatient rehabilitation. Alternatively, individuals who are functioning at a high level independently may be discharged home with referral for outpatient rehabilitation to work on specific functional skills. For other patients who are too sick or immunocompromised to receive rehabilitation on an outpatient basis (but are not candidates or otherwise refuse inpatient rehabilitation services), home therapy can be coordinated and implemented.
●Restorative services are provided on an outpatient basis. Patients are usually referred from their primary care providers, oncologists, surgeons, and radiation oncologists for a wide variety of symptoms and impairments. The work within our program is performed in conjunction with the pain and palliative care service, the anesthesia pain department, and integrative medicine.
Each patient is monitored closely amongst the clinicians and therapists, and any questions regarding his or her safety or care are communicated with his or her respective oncologists, surgeons, and primary care providers. Patients with diffuse metastases are not excluded from rehabilitation, as rehabilitation can help achieve set functional goals. Spinal precautions and weight bearing precautions are carefully executed to prevent injury and harm. Once rehabilitation goals are met and patients have reached maximum benefit, they are usually discharged with home exercises and reassessed by the physiatrists at a later date to see if they would benefit from further rehabilitation.
Role of the physiatrist — The physiatrist is a clinician trained in physical medicine and rehabilitation and typically leads an interdisciplinary team. The role of the physiatrist is to conduct a full initial evaluation, including the following:
●A comprehensive medical assessment – A thorough review of a patient's medical comorbidities that may impact safe and effective rehabilitation. Evaluation of medications is necessary to assess for drug-related side effects that could be contributing to any presenting impairment(s). Additionally, in the event that additional medications are indicated to treat various pain conditions, it is important to identify any potential drug-drug interactions.
●A comprehensive functional assessment – Important aspects of a patient's history include his or her cancer history (eg, initial diagnoses and prior and ongoing treatments, including surgery, radiation therapy, and chemotherapy) and precautions that would be important in the rehabilitation process, such as his or her weight-bearing status and spinal stability.
●Ordering and interpreting specific testing as indicated, including imaging, nerve conduction studies (NCS), electromyogram (EMG), or lab work.
Based on their rehabilitation needs, patients are then referred to specialized services (eg, prosthetics, orthotics, physical therapy, occupational therapy, speech and swallow therapy, and/or lymphedema therapy) with a detailed prescription outlining their rehabilitation course. Interventions may be recommended depending on the precise functional deficit(s) encountered. Some examples include therapeutic exercise, manual therapy (eg, myofascial massage, joint mobilization), electrical modalities (eg, transcutaneous electrical nerve stimulation [TENS]), thermal modalities, lasers, and therapeutic taping. Additionally, many physiatrists also perform various procedures to control pain and subsequently improve the patient's ability to participate in various rehabilitation or exercise protocols. Examples of such procedures include peripheral nerve blocks, joint injections, and spinal injections.
SPECIFIC IMPAIRMENTS — Multiple clinical scenarios may be encountered after treatment for cancer, which depend on the type of malignancy and the therapies administered. The time course for both onset and exacerbation of symptoms is largely dependent on whether there was a preexisting impairment that was mild or had not yet manifested clinically. For example, a patient with a prior history of mild or moderate joint arthritis may be more symptomatic during or after cancer treatment due to a variety of factors, including (but not limited to) overall deconditioning, weakness, and/or the adverse effects of anticancer medications (eg, anastrozole-induced myalgia and arthralgia) and their potential impact on overall tissue healing and homeostasis.
Common impairments are discussed below. Most of these are typically described following treatment for breast cancer, reflecting both that patients treated for breast cancer are a large proportion of cancer survivors  and that much of the literature on cancer rehabilitation has been gained from studies involving these patients. Where data exist, we describe impairments among survivors of other types of cancer.
Upper extremity pain — Cancer survivors, in particular those treated for breast cancer, face a myriad of upper extremity impairments resulting from their treatments, which include surgery, radiation therapy (RT), chemotherapy, and hormonal and biologic therapies. Estimates are that between 10 and 64 percent of patients treated for breast cancer develop upper body symptoms between 6 and 36 months after diagnosis . Persistent arm and shoulder impairments, defined as restricted shoulder mobility, lymphedema, and arm/shoulder pain, occur in 30 to 50 percent of breast cancer survivors .
Although the etiology is usually multifactorial, it is important for the treating clinician to properly examine the patient to find the source that can guide the course of rehabilitation and optimize the treatment strategy. Two common conditions include issues related to shoulder dysfunction and the axillary web syndrome.
Shoulder dysfunction — Surgery and RT fields that involve the upper extremity (typically indicated for treatment of breast cancer, lymphoma, and sarcomas) may induce painful scar tissue formation and nerve damage. This in turn can lead to abnormal protective posturing by the patient, which can result in the shortening of soft tissues in the anterior chest wall, including the pectoralis major and minor muscles, causing a protracted or forward depression of the shoulder girdle . The misalignment can lead to subsequent impingement of the rotator cuff, leading to pain and immobility, and eventually, to adhesive capsulitis. Shortening of the pectoral muscles can also lead to overuse and strained scapular retractors, leading to subsequent myofascial dysfunction in the back and neck muscles . (See "Rotator cuff tendinopathy" and "Frozen shoulder (adhesive capsulitis)".)
For patients experiencing shoulder symptoms, data are available to suggest there are benefits to an exercise prescription [12-14]. As examples:
●In one randomized controlled trial involving 160 patients who underwent breast cancer surgery, the patients were randomly assigned to either an eight-week exercise program or to periodic assessments without an exercise prescription (controls) . The exercise program consisted of weekly sessions and a home program of passive stretching and progressive resistance training for shoulder muscles that started four to six weeks postoperatively. Compared with controls, patients in the exercise group gained slightly greater range of motion in both forward flexion and abduction and strength in abduction plane. Of note, resistance training in the postoperative period was not associated with an increased risk of lymphedema.
●In another trial, 30 patients who had undergone breast cancer surgery and axillary lymph node dissection were randomly assigned to receive standardized physiotherapy treatment for the arm and shoulder (beginning two weeks post-surgery and then for three months afterwards) or to a control group that received a leaflet containing advice and exercise suggestions . After three and six months, the treatment group showed a significant improvement in shoulder mobility and had significantly less pain than the control group. Quality of life improved significantly, and arm volume did not change significantly.
Beyond exercise for shoulder symptoms, it is also important to evaluate patients for co-existing edema involving the arm and/or chest wall, which are also etiologies of impaired range of motion . The approach to lymphedema is discussed separately. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema".)
Exercise prescriptions must be accompanied by adequate pain control, which can be achieved with antiinflammatory agents (eg, nonsteroidal antiinflammatory drugs). Patients may be offered subacromial and glenohumeral corticosteroid injections with minimal complications. However, the role of corticosteroid injections for shoulder dysfunction in this population needs to be further evaluated.
In addition to treating existing shoulder dysfunction, early exercise interventions can also prevent shoulder dysfunction arising from breast cancer treatments, based on data from prospective clinical trials [15-18].
Axillary web syndrome — Axillary web syndrome or "cording" is characterized by palpable cord-like subcutaneous tissue extending from the axilla into the medial arm and sometimes to the palm, usually manifest when the shoulder is abducted. It may be due to damage and sclerosis of the lymphatic and/or venous system , although the exact etiology is not clear. Although not always painful, the cords can limit the range of motion of the shoulder.
Therapy is usually directed at maintaining shoulder range of motion and reducing edema through manual lymphatic drainage. Depending on the degree of range of motion deficit, therapy can begin with gentle, gravity-assisted pendulum exercises (eg, Codman technique) and can gradually progress to wall walking and active assisted range of motion. Manual mobilization techniques can sometimes release or "break" the cords.
While treatment can be successful, patients may experience recurrence of axillary webs. Further research is needed in the etiology and best management strategy for patients who present with this syndrome.
Postmastectomy pain syndrome — Postmastectomy pain syndrome (PMPS) is characterized as any pain persisting beyond the period of healing post-mastectomy, although it is also seen post-lumpectomy. Among females with breast cancer treated with a mastectomy, the risk factors for this syndrome include the following :
●History of severe and acute pain postoperatively
●Younger age at diagnosis
●RT to the axilla
●Extensive axillary surgery
The pain is typically characterized as burning, stabbing, neuropathic (eg, numbness, hyperesthesia, or paraesthesia), or as an "electric shock" at the operative site or ipsilateral arm. It is thought to be caused by direct nerve injury during breast cancer operations or from the development of a traumatic neuroma or scar tissue involving the neural tissue in the axilla and/or chest wall (eg, brachial plexus, intercostobrachial, lateral cutaneous branch of the second intercostal, long thoracic and medial and lateral pectoral nerves). The clinical manifestations and diagnosis of PMPS are discussed more extensively elsewhere. (See "Clinical manifestations and diagnosis of postmastectomy pain syndrome".)
Although there are no prospective data on the impact of rehabilitation services on PMPS, physical therapy (PT) is often prescribed to help relieve the symptoms of PMPS. This includes modalities such as desensitization techniques, transcutaneous electrical nerve stimulation (TENS), and the application of cold packs topically. The approach also involves pain management, including neural stabilizers (pregabalin or gabapentin), serotonin-norepinephrine reuptake inhibitors ([SNRIs]; eg, duloxetine), or topical agents (eg, lidocaine or nonsteroidal antiinflammatory drugs).
Interventional techniques such as intercostal or paravertebral nerve blocks and/or ablation can be used in the usual manner to treat regional pain syndromes. (See "Complex regional pain syndrome in adults: Treatment, prognosis, and prevention", section on 'Interventional options for refractory pain'.)
Botulinum neurotoxin type A (BoNTA) injections into hyperirritable muscles such as the pectoralis major and serratus have been safely used in our practice with good efficacy to treat refractory PMPS. Its use is extrapolated from other data showing that BoNTA may prevent postoperative pain after mastectomy and subsequent breast reconstruction [21,22]. However, no clinical trials exist on its use in PMPS. (See "Postmastectomy pain syndrome: Risk reduction and management".)
Aromatase inhibitor-associated musculoskeletal syndrome — Aromatase inhibitors (AIs) are important agents utilized in the treatment of hormone receptor-positive breast cancer in the adjuvant and metastatic disease settings. However, AIs can cause a constellation of symptoms known as the Aromatase Inhibitor-associated Musculo-Skeletal Syndrome (AIMSS). Associated symptoms include arthralgia, joint stiffness, and bone pain, which can be severe in up to 30 percent of patients. The pain and stiffness typically involves the hands, arms, knees, feet, pelvic and hip bones, or back. It is usually symmetrical and may be associated with mild soft-tissue thickening . Trigger finger and carpal tunnel syndrome are often the most frequently reported signs .
Initial management of AIMSS includes nonsteroidal antiinflammatory drugs and exercise, as these interventions may allow patients to minimize or avoid the use of narcotic medications. As an example, one trial (Hormones and Physical Exercise [HOPE]) demonstrated that patients with AIMSS derive benefit from exercise, including reduction in pain, weight loss, and improved exercise capacity. Further details on this trial, as well as the optimal medication-based management of AIMSS, are discussed separately. (See "Adjuvant endocrine therapy for postmenopausal women with hormone receptor-positive breast cancer", section on 'Musculoskeletal pains and stiffness'.)
The approach to these patients is also similar to those with signs and symptoms of fibromyalgia. Physical and occupational therapy is aimed at increasing range of motion, while strengthening exercises aim to increase flexibility and relieve tension. Any exercise prescription should also include weight-bearing exercises to prevent osteoporosis. (See "Treatment of fibromyalgia in adults not responsive to initial therapies", section on 'Exercise and physical therapy'.)
Beyond medical therapy and exercise, complementary modalities such as acupuncture may be helpful . If carpal tunnel syndrome or trigger finger is present, an injection with corticosteroids and/or splinting may relieve symptoms. In our experience, injections to alleviate the symptoms associated with carpal tunnel syndrome do not worsen lymphedema in patients with mild to moderate lymphedema; therefore, the presence of lymphedema should not be taken as an absolute contraindication to this therapy. Of note, isolated knee pain can also be treated with intra-articular corticosteroid injections.
Musculoskeletal complications associated with other cancer-related therapies, such as checkpoint inhibitor immunotherapy, are discussed separately. (See "Rheumatologic complications of checkpoint inhibitor immunotherapy".)
Lymphedema — Lymphedema is the collection of protein-rich fluid into the interstitial spaces due to disruption of lymphatic flow. Cancer and/or its treatment are the most common causes of lymphedema in the developed world and can be a significant cause of both physical and functional distress. The most common cancer associated with lymphedema is breast cancer, although it is not uncommon among patients treated for other cancers, including soft-tissue sarcoma, lower extremity melanoma, gynecologic or genitourinary cancers, and cancers of the head and neck. (See "Breast cancer-associated lymphedema".)
The clinical manifestations, diagnosis, and treatment of lymphedema are discussed separately. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema" and "Surgical treatment of primary and secondary lymphedema".)
The hallmark of treatment for lymphedema is complete decongestive therapy, which is discussed separately. In addition, for patients referred to rehabilitation, the application of Kinesio tape may be an additional modality for treatment [26,27]. Kinesio taping is a specific type of modality that involves the use of an elastic adhesive tape applied to a patient's skin to facilitate proper fascial plane alignment. It is theorized that re-aligning such fascial planes will enhance tissue healing and serve to alleviate pain. Kinesio taping has rapidly become popular in the fields of sports medicine and rehabilitation, but clinical trials demonstrating its efficacy are limited.
Neuropathy — Chemotherapy-induced neuropathy (CINP) may result from direct toxic effects on the nervous system or indirectly from drug-induced metabolic derangements or cerebrovascular disorders. The platinum compounds (cisplatin, oxaliplatin), taxanes (paclitaxel), and microtubule binding agents (vincristine, ixabepilone) are among the more common agents implicated . Clinically, patients experience burning paresthesias, pain, sensory ataxia, and sometimes loss of motor function. (See "Overview of neurologic complications of platinum-based chemotherapy" and "Overview of neurologic complications of conventional non-platinum cancer chemotherapy" and "Prevention and treatment of chemotherapy-induced peripheral neuropathy".)
It is important to rule out other causes of neuropathy, and the following important conditions should be excluded when a patient presents with neuropathic complaints:
●Diabetes mellitus – Diabetic neuropathy presents as a symmetrical sensory neuropathy involving both the large myelinated and small myelinated and demyelinated nerve fibers, often involving the feet initially with ascending, progressive involvement. In addition, loss of temperature sensation is often present. In contrast, CINP frequently involves the hands at the time of presentation, and temperature sensation remains intact. (See "Screening for diabetic polyneuropathy", section on 'Neuropathic signs and symptoms'.)
●Vitamin B12 deficiency – Vitamin B12 deficiency also typically presents with symmetric lower extremity paresthesias and ataxia. Central nervous system (CNS) changes are also seen, including cerebellar ataxia, memory loss, and dementia. The presence of CNS symptoms and predominant lower extremity involvement differentiate this from CINP. (See "Clinical manifestations and diagnosis of vitamin B12 and folate deficiency", section on 'Neuropsychiatric changes'.)
●Alcoholism – Chronic alcohol use can result in an alcoholic polyneuropathy of sensory, motor, and autonomic nerves, which distinguishes it from CINP. The symptoms are usually symmetric and predominantly involve the distal extremities. (See "Overview of the chronic neurologic complications of alcohol", section on 'Peripheral neuropathy'.)
●Lyme disease – Peripheral neuropathy can be a manifestation of nervous system Lyme disease and often involves the cranial nerves rather than the extremities. (See "Nervous system Lyme disease", section on 'Peripheral neuropathy'.)
●Immune-mediated neuropathies – Immune-mediated neuropathies can be distinguished from CINP by predominant motor involvement. These include Guillain-Barre Syndrome, Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Monoclonal gammopathy of undetermined significance (MGUS), and neuropathy associated with IgM gammopathy, among others. (See "Immune-mediated neuropathies".)
●Charcot-Marie-Tooth disease – Charcot-Marie-Tooth disease is a hereditary motor sensory neuropathy characterized by distal leg weakness and sensory deficits. Unlike CINP, it is often associated with foot deformities as well (eg, hammer toes, pes cavus). (See "Charcot-Marie-Tooth disease: Genetics, clinical features, and diagnosis".)
Others on the differential should include primary CNS lesions (eg, epidural tumor, leptomeningeal metastases, and intramedullary metastasis), other etiologies causing peripheral nervous system dysfunction (eg, carpal tunnel syndrome and ulnar nerve neuropathy), and degenerative disorders (herniated disks and spinal stenosis).
Successful treatment is based on accurate diagnosis, which can guide the proper care and treatment. In addition, rehabilitation, which includes physical and/or occupational therapy, may be useful to work on deficits such as decreased balance, gait abnormalities, muscle weakness, and difficulties with performing activities of daily living. Pain or discomfort should be properly managed for full participation in therapy. (See "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)" and "Cancer pain management: Use of acetaminophen and nonsteroidal anti-inflammatory drugs".)
Nerve conduction studies (NCS) and needle electromyography (EMG) studies are often used to characterize the location and severity of nerve damage and help to rule out other causes of neuropathy, including carpal tunnel syndrome or radiculopathy. They may strengthen the working diagnosis based on the history and physical examination. NCS/EMG may be useful for deciphering the location of a nerve lesion such as root, plexus, or peripheral nerve itself. This, in turn, may prompt additional work-up, including blood work, as in the case of peripheral neuropathy, to determine potential reversible causes. Additionally, NCS/EMG results indicating nerve root origin for pathology may warrant follow-up imaging such as magnetic resonance imaging (MRI) to further examine for causes of extrinsic insult to a nerve root from a herniated disc or mass. NCS/EMG can be helpful in the management of carpal tunnel syndrome, as individuals who have electrodiagnostic evidence for axonal loss may need more aggressive treatment such as surgery, while those with pure conduction block may respond better to corticosteroid injection. (See "Carpal tunnel syndrome: Treatment and prognosis".)
The treatment approach to CINP is discussed in detail separately. (See "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Treatment'.)
Spinal accessory nerve palsy — For patients with tumors involving the head, neck, or spine, the spinal accessory nerve can be damaged directly or indirectly from surgery and/or RT and can result in pain and decreased muscle function . For patients treated for head and neck cancer, symptoms typically consist of trapezius atrophy, shoulder girdle depression, limited active shoulder abduction to less than 90 degrees, shoulder pain, and shoulder weakness. RT and surgery can also lead to hyperirritable muscles and nerves, resulting in spasm, pain, and muscle tightness. (See "Overview of upper extremity peripheral nerve syndromes", section on 'Spinal accessory neuropathy'.)
Rehabilitation includes preserving range of motion of the shoulder, strengthening of alternate scapular elevators and retractors, neuromuscular retraining of shoulder girdle muscles, postural modification, and using electrical stimulation . Patients with complete spinal accessory nerve palsy can be fitted with an orthosis to reduce pain . For patients experiencing spasm or tightness of a specific muscle group, we have found a combination of PT as well as botulinum toxin injections into the sternocleidomastoid muscle to decrease painful spasms [32,33]. Integrative techniques, such as acupuncture, may also be helpful .
Dropped head syndrome — Patients with a history of radiation to the head and neck can develop neck extensor weakness secondary to myopathy and atrophy, leading to dropped head syndrome or an inability to keep the head up for a prolonged period of time. RT leads to progressive fibrosis that can involve tissues encompassed by the radiation field, such as the spinal cord, cervical nerve roots, cervical and brachial plexus, and peripheral nerves and muscles. This neuromuscular damage, known as "myelo-radiculo-plexo-neuro-myopathy," results in functional compromise of the cervical and thoracic paraspinals and subsequent difficulty keeping the head upright . Dropped head syndrome is seen most commonly in survivors of Hodgkin lymphoma who have received mantle field RT. (See "Approach to the adult survivor of classic Hodgkin lymphoma", section on 'Neuromuscular complications'.)
PT can improve patients' quality of life by improving core muscles as well as neck strength, posture, body mechanics, proprioception, and endurance with emphasis on a lifelong home exercise program, as over time patients can develop neck flexor contractures . Manual myofascial release techniques are beneficial over fibrotic tissue. A cervical collar such as the Headmaster (picture 1) or a similar device can be used for functional assistance in elevating the neck, energy conservation, and improving quality of life.
Trismus — Trismus is a common complication of head and neck cancer and is usually due to a combination of factors, including direct tumor invasion, surgery, and/or RT. (See "Management of late complications of head and neck cancer and its treatment", section on 'Trismus'.)
Treatment should be aggressive and started early, as mature scar tissue becomes more resistant to exercise therapy . Multiple modalities have been implemented and can be used alone or in combination. Aside from an evaluation from a speech and swallow specialist, dentist, and nutritionist, PT should be initiated for myofascial release techniques as well as initiation of oromotor tongue and jaw exercises to preserve range of motion [37,38]. The most commonly prescribed devices used to treat trismus in this population are the TheraBite System  and The Dynasplint Trismus System [40,41]. In the past, stacked tongue depressors and/or corkscrew-like devices were used but have now fallen out of favor due to the oral and dental trauma associated with their use. Other modalities, such as low-level laser therapy and low-intensity ultrasound, have also shown some improvement .
Botulinum toxin injections to the masseter or pterygoid by themselves do not improve mouth opening, but they can help with muscle pain and decrease dynamic muscle spasm . Pain medications, including muscle relaxants, analgesics, and nerve stabilizers can be used to diminish the pain and spasm, which can make jaw opening devices and therapy more effective.
Speech and swallowing dysfunction — This should be evaluated in every head and neck cancer patient and should be treated appropriately. An extensive discussion on the approach to these issues is covered separately. (See "Speech and swallowing rehabilitation of the patient with head and neck cancer".)
Cognitive dysfunction — Cognitive dysfunction is associated not only with intracerebral malignancies, but is also secondary to cancer treatments such as chemotherapy, RT, corticosteroids, and immunotherapy, as well as other medications such as antiepileptics, opioids, and antiemetics. Although "chemo brain" is commonly used, cognitive dysfunction is usually multifactorial in nature, and the treating clinician should rule out other concomitant factors such as anxiety, depression, fatigue, and sleep disturbances. Cognitive dysfunction can include memory impairment, mental fogginess, difficulty concentrating, slower processing speed, and difficulty with executive functioning. These symptoms can persist even after treatment cessation. Neuropsychologic evaluation and testing are important to determine the nature and extent of the patient's impairment, which then would guide appropriate treatment interventions. (See "Cognitive function after cancer and cancer treatment" and "Clinical features and diagnosis of cognitive impairment and delirium in patients with cancer", section on 'Cognitive impairment'.)
Cognitive rehabilitation for cancer patients is not yet based on solid evidence-based research and oftentimes uses the guidelines approached for traumatic brain injury and stroke patients . Goals usually involve maximizing functioning, coping, and quality of life through the use of compensatory strategies and reliance on residual abilities . Compensatory strategies include making changes in the patient's home or hospital environment to increase structure, decrease demands for planning and decision making, and enhance orientation. External memory aides such as checklists, planners or memory books, wall calendars, and alarms can be used. It is important to treat other etiologies such as fatigue, sleep disturbances, stress, and depression as well.
Pharmacologic interventions (eg, cytokine antagonists, antiinflammatory agents, stimulants, and anticholinergics) have also been used in conjunction with formal rehabilitation. Exercise has not yet been studied for cognitive dysfunction in cancer patients, but it has shown improvement in cognitive recovery among patients with acquired brain injury . Exercise is generally advocated for its overall benefits, including decreasing fatigue, depression, anxiety, improving quality of life, and decreasing bone loss and fracture. (See "The roles of diet, physical activity, and body weight in cancer survivors".)
Cardiotoxicity — Cancer survivors are at increased risk for cardiovascular disease related to direct effects from cancer treatment, development of cardiovascular risk factors, and lack of cardiorespiratory fitness during or after treatment [47,48]. A subset of patients may benefit from cardio-oncology rehabilitation (CORE) to prevent or mitigate cardiovascular events.
The American Heart Association (AHA) used guidelines from the American Society of Clinical Oncology (ASCO) to identify cancer survivors at high risk of cardiovascular disease who may benefit from cardiac rehabilitation . They then proposed a multimodality approach based on principles of cardiovascular rehabilitation, including exercise, nutritional counseling with dieticians who specialize in cancer, and modification of cardiovascular risk factors (table 2).
We agree with the CORE guidelines, which suggest that cancer patients who receive the following therapies be evaluated for CORE:
●High-dose RT (≥30 Gy) when the heart is included in the treatment field
●Lower dose anthracycline or trastuzumab plus either age ≥60 years at cancer treatment or the presence of ≥2 cardiovascular risk factors
●Low-dose anthracycline plus trastuzumab
Not all patients are eligible for immediate CORE. As an example, cardiology consultation is appropriate for patients with cardiac symptoms or a history of compromised cardiac function (eg, myocardial infarction, borderline or low left ventricular ejection fraction, or moderate valvular disease). In addition, PT and/or occupational therapy may be appropriate before considering CORE in cancer patients with musculoskeletal impairments, neurologic or cognitive issues, bone loss, lymphedema, ostomy, or risk factors for infection, and in those actively receiving cancer therapy. (See 'Accessing rehabilitation services' below.)
Further detail about the surveillance and treatment of cardiac and respiratory issues among cancer survivors is discussed elsewhere. (See "Cancer survivorship: Cardiovascular and respiratory issues".)
ACCESSING REHABILITATION SERVICES — The rehabilitation needs of the cancer survivor are dictated by the physical impairments present, including (but not limited to) pain, loss of strength, or reduced mobility. Once a diagnosis of cancer has been established, patients should be evaluated periodically for potential physical impairments that may be exacerbated during or after treatment.
●If such impairments are identified, then enrollment in a formal rehabilitation program with experience treating cancer survivors (including those with previous chemotherapy and/or radiation therapy [RT] exposure) may help improve function and slow or prevent physical deterioration. Comprehensive access to services (eg, physical therapy [PT], occupational therapy [OT], speech-language pathology [SLP], lymphedema therapy, pelvic floor therapy, cognitive rehabilitation, etc) should be available and offered based on patients' needs to ensure that every effort is made to maximize their function and quality of life.
●If no impairments exist, then a short course of rehabilitative therapy may still be helpful to educate and guide patients to anticipate potential functional deficits arising from their cancer treatment.
●For patients undergoing treatment that places them at risk for dysphagia, preemptive swallowing exercises administered by speech therapy may be useful .
●For individuals who have completed treatment, careful monitoring (prospective rehabilitation) should take place in order to identify various impairments as early as possible. (See "Overview of cancer survivorship care for primary care and oncology providers".)
Criteria for rehabilitation in various settings — The most appropriate location for rehabilitation services is dictated by the patient's functional status at the time of referral. Common criteria that help to reflect the level of support required for rehabilitation include the following:
According to the medical inpatient rehabilitation criteria task force under the auspices of the American Academy of Physical Medicine and Rehabilitation , inpatient rehabilitation is considered medically necessary when all of the following criteria are met:
●The patient has significant functional deficits and medical/nursing needs regardless of diagnosis.
●There is a need for close medical supervision by a clinician trained or experienced in rehabilitation medicine.
●The patient requires 24-hour accessibility to nursing care.
●Time-intensive collaborative treatment by licensed rehabilitation professionals such as physical therapists, occupational therapists, speech language pathologists, and psychologists is indicated.
If not all of the needs outlined above are satisfied, then the patient should be referred for outpatient rehabilitation. Such patients are stable from a medical perspective and are cleared by their medical team to resume or begin a rehabilitation program independently several times per week.
For patients who are functional within the home but at risk for complications with community-based rehabilitation (eg, due to heightened risks for infection, falls, and medical decompensation), home-based rehabilitation services may be most appropriate.
SUMMARY AND RECOMMENDATIONS
●Cancer rehabilitation is a specialty of physical medicine and rehabilitation that aims to meet these needs for cancer survivors. (See 'Introduction' above.)
●Cancer rehabilitation plays a role throughout the continuum of cancer survivorship. General cancer rehabilitation is often categorized as preventative, restorative, supportive, and palliative. However, these services do not necessarily occur independent of each other. Instead, they may be offered within a single program, allowing patients to transition to different services as dictated by their needs. (See 'Models of rehabilitation' above.)
●Once a diagnosis of cancer has been established, patients should be evaluated for potential physical impairments that may be exacerbated during or after the treatment phase. (See 'Specific impairments' above and 'Accessing rehabilitation services' above.)
•If such impairments are identified, enrollment in a formal rehabilitation program with expertise in treating cancer survivors may help to prevent greater functional deficits in the future. If no impairments exist, then a short course of rehabilitative therapy may still be helpful to educate patients to anticipate potential functional deficits arising from their cancer treatment.
•Rehabilitation services often assist in pain management and allow cancer survivors to minimize or avoid the use of narcotic pain medication. (See 'Upper extremity pain' above and 'Postmastectomy pain syndrome' above and 'Aromatase inhibitor-associated musculoskeletal syndrome' above and 'Neuropathy' above and "Overview of cancer survivorship care for primary care and oncology providers", section on 'Physical and psychosocial well-being'.)
•A subset of patients may benefit from cardio-oncology rehabilitation (CORE) to prevent or mitigate cardiovascular events. (See 'Cardiotoxicity' above.)
●For individuals who have completed treatment, careful monitoring should take place in order to identify and treat various impairments as early as possible. (See 'Accessing rehabilitation services' above.)