# Cancer Rehabilitation: Prehabilitation Through Survivorship

## Introduction

Cancer rehabilitation addresses the physical, functional, cognitive, and psychosocial impairments that affect up to **75% of cancer patients** at some point during their disease trajectory. The physiatrist plays a central role in identifying and treating functional deficits across the cancer continuum, from prehabilitation through survivorship or palliative care.

## Cancer Rehabilitation Framework

### Dietz Classification
**Preventive**: Prehabilitation before treatment; minimize expected functional losses. **Restorative**: Return to pre-morbid function when cure is expected. **Supportive**: Maximize function despite ongoing disease or treatment. **Palliative**: Comfort and quality of life in advanced disease.

| Dietz Category | Timing | Goal | Example |
|---------------|--------|------|---------|
| Preventive | Before treatment | Minimize expected functional losses | Prehabilitation exercise before surgery |
| Restorative | After curative treatment | Return to pre-morbid function | Post-mastectomy shoulder rehab |
| Supportive | During ongoing treatment | Maximize function | Exercise during chemotherapy |
| Palliative | Advanced disease | Comfort and quality of life | Energy conservation, mobility aids |

### Prospective Surveillance Model
Screen for impairments at **diagnosis and at regular intervals** throughout treatment. Early identification and intervention improve outcomes. Standardized screening tools at each oncology visit. Referral triggers for rehabilitation services.

## Prehabilitation

### Definition and Rationale
Structured exercise, nutrition, and psychological preparation **before cancer treatment**. Improves baseline fitness and resilience for treatment. Reduces postoperative complications and shortens hospital stays.

### Components
**Aerobic exercise**: 150 minutes/week moderate-intensity. **Resistance training**: Major muscle groups 2-3 times/week. Nutritional optimization (protein intake, weight management). Psychological preparation and anxiety reduction. Smoking cessation. Best evidence in colorectal, lung, and bladder cancer surgery. ![Cancer rehabilitation continuum from prehabilitation through survivorship care](images/cancer-rehab-continuum.jpg)

## Common Impairments by Cancer Type

### Breast Cancer
**Lymphedema** (15-30% of patients after axillary dissection). Shoulder ROM restriction and adhesive capsulitis. Aromatase inhibitor-related arthralgias. Axillary web syndrome (cording). Cancer-related fatigue.

### Head and Neck Cancer
Dysphagia and aspiration risk. Shoulder dysfunction from **spinal accessory nerve injury**. Trismus and cervical ROM restriction. Lymphedema of head and neck. Communication impairments.

### Lung Cancer
Deconditioning and reduced cardiopulmonary reserve. Post-thoracotomy pain syndrome. Dyspnea management. Pulmonary rehabilitation principles apply.

### Brain Tumors
Cognitive deficits, hemiparesis, visual field cuts. Seizure precautions during exercise. Rehabilitation approach similar to stroke with modifications. Ongoing surveillance for tumor progression.

## Lymphedema Management

### Staging
**Stage 0 (subclinical)**: Impaired lymphatic transport without visible swelling. **Stage I**: Reversible edema; pitting present; reduces with elevation. **Stage II**: Non-pitting; tissue fibrosis developing. **Stage III (lymphostatic elephantiasis)**: Severe with skin changes.

| Lymphedema Stage | Characteristics | Pitting | Reversibility |
|-----------------|-----------------|---------|---------------|
| 0 (Subclinical) | Impaired transport, no visible swelling | N/A | Pre-clinical |
| I | Soft edema, reduces with elevation | Yes | Reversible |
| II | Fibrotic tissue, does not reduce with elevation | No | Partially irreversible |
| III (Elephantiasis) | Severe, skin changes (papillomas, hyperkeratosis) | No | Irreversible without surgery |

### Treatment
**Complete decongestive therapy (CDT)**: Gold standard. Manual lymphatic drainage (MLD). Compression bandaging (short-stretch bandages). Exercise with compression.

Skin care. Compression garments for maintenance phase. Pneumatic compression devices as adjunct. Surgical options for refractory cases (lymphovenous bypass, vascularized lymph node transfer).

### Exercise and Lymphedema
**Progressive resistance training is safe** and does not worsen lymphedema (PAL trial). Gradual progression with compression garment wear during exercise. Aerobic exercise beneficial for lymphedema prevention and management. ![Complete decongestive therapy components for lymphedema management](images/lymphedema-cdt.jpg)

## Exercise During and After Cancer Treatment

### Evidence Base
Exercise is safe during active treatment (chemotherapy, radiation). Reduces cancer-related fatigue by **40-50%** (most effective intervention). Improves physical function, quality of life, and treatment tolerance. Emerging evidence for improved disease-specific and overall survival.

### Prescription Guidelines (ACSM)
**Aerobic**: 150 minutes/week moderate or 75 minutes vigorous. **Resistance**: 2-3 sessions/week; 2-3 sets of 8-15 repetitions. **Flexibility**: Stretching on days of activity. Individualize based on treatment phase, side effects, and comorbidities.

### Precautions and Contraindications
Bone metastases: Avoid high-impact activities; modify resistance training. Thrombocytopenia (platelets <50,000): Avoid contact sports and heavy resistance. Neutropenia (ANC <500): Avoid public gyms; home exercise preferred. Active infection or hemodynamic instability: Defer exercise. **Indwelling catheters**: Avoid water activities and resistance in affected area.

## Bone Health in Cancer

Screen for **bone metastases** before initiating exercise programs. Metastatic bone disease: Activity modification based on Mirels scoring system. Cancer treatment-related bone loss (hormonal therapy, corticosteroids). Fall prevention in patients at fracture risk.

## Survivorship Care

Transition from oncology-focused care to long-term wellness. Address persistent impairments (fatigue, neuropathy, cognitive changes). Exercise as medicine for recurrence prevention. Return-to-work planning and vocational rehabilitation. Screening for late effects of treatment. Psychosocial support and community reintegration. ![Exercise prescription algorithm for cancer patients across treatment phases](images/cancer-exercise-prescription.jpg)

## Key Clinical Pearls

1. **Prehabilitation** before cancer surgery improves postoperative outcomes and should be standard of care, particularly for major abdominal and thoracic procedures. 2. Progressive resistance training is safe and does not exacerbate lymphedema; the PAL trial definitively demonstrated this. 3. Exercise is the most effective intervention for cancer-related fatigue, superior to pharmacological treatments. 4. Screen for bone metastases using Mirels scoring before initiating exercise programs to guide activity modification.

## References

1. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. *CA: A Cancer Journal for Clinicians*. 2013;63(5):295-317.
2. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. *Medicine and Science in Sports and Exercise*. 2010;42(7):1409-1426.
3. Schmitz KH, Ahmed RL, Troxel A, et al. Weight lifting in women with breast cancer-related lymphedema. *New England Journal of Medicine*. 2009;361(7):664-673.
4. Carli F, Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. *Current Opinion in Clinical Nutrition and Metabolic Care*. 2005;8(1):23-32.