Residency · Residency · Physical Medicine Rehabilitation
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. 
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. 
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. 
Key Clinical Pearls
- 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
- 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.
- 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.
- 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.
- 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.