The Role of a Physical Therapist in Cancer Care, with Sharlynn Tuohy, PT, DPT, MBA and Jean Kotkiewicz, PT, DPT, CLT

September 23, 2014
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Many people are familiar with physical therapists, or PTs, for sports injuries or for issues with muscles, joints, and bones, but PTs can treat a variety of functional problems. In this podcast, we discuss how seeing a PT can help a person with cancer, including how to know if you should visit a PT and what to expect during your visits. 



ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology known as ASCO, the world's leading professional organization for doctors that care for people with cancer.

Many people are familiar with physical therapists, or PTs, for sports injuries or for issues with muscles, joints, and bones, but PTs can treat a variety of functional problems. In this podcast, we discuss how seeing a PT can help a person with cancer including how to know if you should visit a PT and what to expect during your visits.

This podcast will be led by Dr. Sharlynn Tuohy and Jean Kotkiewicz. Dr. Tuohy is the director of rehabilitation at Memorial Sloan Kettering Cancer Center, and Dr. Kotkiewicz is the supervisor of inpatient PT also at Memorial Sloan Kettering Cancer Center. ASCO would like to thank Dr. Tuohy and Dr. Kotkiewicz for discussing this topic.

Sharlynn Tuohy: Hello, my name is Sharlynn Tuohy. I'm the director of rehabilitation at Memorial Sloan Kettering Cancer Center in New York City and I'm with my colleague Jean.

Jean Kotkiewicz: Hi, my name is Jean Kotkiewicz. I'm one of the physical therapy supervisors in the rehabilitation department at Memorial Sloan Kettering Cancer Center in New York.

Sharlynn Tuohy: All right, so we were invited to speak about the role of physical therapy in oncology rehabilitation. So we're here to give an overview of how a physical therapist can help a person who has been diagnosed or survived a cancer diagnosis. So, Jean, people are familiar with physical therapists for sports injuries or issues with muscles, joints, and bone pain. However, physical therapists can treat a variety of functional problems. Can you explain what other functional problems physical therapists treat for patients or people that have cancer?

Jean Kotkiewicz: Sure. There are many issues that physical therapists can address, besides the ones that you have mentioned, for patients who have a diagnosis of cancer, whether it's from the cancer itself or from a result of treatment such as radiation or chemotherapy. Many of these issues are a result of patients who have undergone treatment which actually causes a multi-system issue. Many of the treatments are often toxic. They are aimed at killing the cancer cells, but they actually affect the healthy cells as well. Just to list some of the things that patients may experience, we have peripheral neuropathy, balance issues, they may have an increase in falls, there may be sensation issues, they may experience fascial restriction, they may have lymphedema or cording, they may also develop lung issues or any issue where they're not able to expand or breathe properly, and they may also experience fatigue. So although a lot of these treatments are specific to cancer, there are a lot of things that physical therapy can do to intervene with it.

Sharlynn Tuohy: So you mentioned fascial restrictions, can you explain what you mean by that?

Jean Kotkiewicz: Fascial restrictions are a result of usually chemotherapy, and more so radiation, where the fibrosis from treatment or spot treatment from radiation actually becomes restricted and the tissue itself can become hardened or thickened, almost similar to scar tissue, which results in a binding down of the tissue. And if that's over a joint, there's often a loss of range of motion or pain that can occur over that muscle where the fascial restriction resides.

Okay, so radiation changes the structure of the tissue so it's hardened and you can't move as well. Some of the things that we do to treat that is use a special tape, such as kinesio tape or a manual technique where they use their hands to soften the tissue, promote circulation, and just make it easier for somebody to move when it was painful or restricted because of the treatments that they received from cancer.

So fatigue is also another one of those big issues that results from a cancer diagnoses or the treatment. Some of the ways which we treat fatigue are to encourage an exercise program and where that's seems counter intuitive is that if someone is fatigued or tired they're not necessarily going to be feeling up to doing more. But we've actually found that exercise, and even gentle stretching or a walking program can actually combat cancer-related fatigue, and patients end up feeling better in the long run. We also teach them energy conservation techniques and ways to help mobilize and take care of their bodies in a better way.

Sharlynn Tuohy: So fatigue is a common complaint and I've definitely seen patients benefit from an exercise program and a commitment to a daily walk, or to perform an activity each day that they may not feel up to. And it's difficult at times to motivate yourself when you don't feel well. And by seeing a physical therapist, the physical therapist can help decide what level of activity is appropriate for you, and you can create a relationship of accountability where you are participating in a program and you receive encouragement. You also receive the skilled instruction of the exercise prescription, but you also are empowered because you can do something to help yourself. There's something that you can do to help yourself feel better and that's really important, I find, for people who are going through cancer because they often feel out of control of what's going on. So one of the things that physical therapists do is to help empower patients and people to own some of their care. So what are some of the other issues that you typically treat or manage? You mentioned peripheral neuropathy and falls.

Jean Kotkiewicz: Peripheral neuropathy is a loss of sensation usually in the toes, or the hands, or the feet, or areas far from the center of your body where you may feel a burning, a tingling, or a numbness. And this is a result of damage to the nerves that go to those parts of your body, and usually that's a result of chemotherapy. So because of the medication itself and how it acts and interacts with your body, the nerves can become damaged, causing a patient to feel any of those sensations: burning, tingling, numbness. A lot of times they'll say they have a feeling of water sometimes trickling down their fingers or their feet. And a lot of times it can be quite painful and actually limit their mobility, and cause them to not really know where their hands or their feet are. More so their feet in space, which is what tends to trigger some more falls for patients because they're not sure of their footing.

Sharlynn Tuohy: Okay. So can you actually take away the neuropathy? Or what do you typically do? Do you just help people manage it better?

Jean Kotkiewicz: Yeah. There's nothing from a physical therapy-specific standpoint that we can do to actually help the nerves specifically regenerate. However, we can teach patients measures in order to be safer so that they decrease their risk of having falls. A lot of these things include compensatory techniques, increased awareness of where their feet are in space. We can also give them an assistive device, or any other equipment that's actually going to help make them safer, especially with their footing. We can teach techniques also for doing transitions in areas where there may be an uneven surface, or a hill, or an incline, or different textures of surface, so that they are educated as to best handle the situations in order to be safe.

Sharlynn Tuohy: So we practice a lot of the different types of surfaces with our patients. We'll have them walk on different types of surfaces such as stones, or a flat surface, or grass, or up and down a ramp. So that can really help somebody learn how to negotiate those environments. Also, I think that there are some things that I've seen in the clinic where maybe some compression or wrapping of a limb, a hand or a foot, can help manage some of the pain, or those altered sensations, the tingling and the burning. Some different techniques where we help patients to identify something that will help alleviate those feelings. As Jean said, we can't change the nerve physiology, but we can help to manage those feelings that patients are having. And a lot of people don't realize that there is something that can help them. They are just told that the chemotherapy has these effects and they just have to either live with it or take medication to help with it, and we just want to make sure that people know that physical therapists can address some of these issues that people experience. So another area that physical therapists treat is lymphedema, which is swelling as a result of disruption to the lymph nodes in somebody's body. So Jean is certified in treating lymphedema. Do you want to talk a little bit about what lymphedema treatment involves and how patients can recognize maybe that they have it and access a physical therapist for that?

Jean Kotkiewicz: Sure. A lot of times after surgery or treatment where lymph nodes are damaged or removed, most commonly in the groin area on either side, or under the armpit on both sides, there can be a resultant swelling or heaviness or tightness that patients may experience. This is what we call lymphedema and it results when the lymphatic system, which is almost like another circulatory system of your body that helps to filter waste and proteins and white blood cells, becomes occluded. And it becomes occluded because some of the lymph nodes are actually damaged or removed. So this results in a back up of fluid into the extremities, so into the arm or into the leg. It can occur right after surgery or it can occur several months after. There is no specific research that determines whether one person, after surgery, will develop lymphedema or not. However, your risk for developing lymphedema will increase with the more lymph nodes that you have removed, the type of procedure specifically. There are many things that we do here at Sloan Kettering to reduce and help patients cope with lymphedema. Either in the acute care setting and also transitioning over to the outpatient setting. The basic things that we teach patients are CDT, which is complete decongestive therapy. There are many components of this type of therapy. Major ones being bandaging, or manual lymphatic drainage, which is basically a light massage that we can do to help assist pushing the lymphatic fluids past the lymph nodes that are damaged and to the other areas of lymph nodes in your body that can help recirculate the fluid. Another component is skin care, and another component is also exercise. If a patient receives referrals for lymphedema therapy while they're in the hospital our team will go to see them to start the program and assist with whatever we can do at that time and what they can tolerate. We'll also have them transition over to outpatient where they may be able to receive more intensive therapy, which would include daily massage and daily compression wraps. And eventually with the goal of having the patient be independent with their massage and also with compression techniques.

Sharlynn Tuohy: And sometimes we prescribe garments for patients because they cannot have physical therapy ongoing. The goal is to reduce the swelling in the limbs and to teach a patient to be independent with their self-management program at home, whether they're doing it or perhaps a caregiver or family member is helping them. And the garment is provided to maintain limb volume, to make sure that the swelling stays at bay and it doesn't return. So that is another modality that we can offer patients to help with this chronic issue. The good news is, if you do find a physical therapist or other certified lymphedema therapist, such as occupational therapist or certain massage therapists might be certified in CDT, it's nice to create that relationship because then you kind of have a go-to person if there is a flare-up of the condition after you've completed your physical therapy. So this is an important thing to be able to access for patients who are dealing with this type of condition. All right. So there's just, in general, some modalities or other types of treatment that physical therapists can offer patients. I've heard a lot about the low-level laser for lymphedema treatment. Are you using that?

Jean Kotkiewicz: Yes. We have used it both in inpatient and outpatient, although it's more common in our outpatient facility. There are some other restrictions that don't always allow us to use those facilities there while the patient is actually in the hospital. But when we can, we do utilize it. We found that it's helpful with swelling, it's helpful with relieving some of that discomfort or heaviness feeling.

Sharlynn Tuohy: And you mentioned cording?

Jean Kotkiewicz: And it's also helpful for cording. It's usually moreso used in the outpatient setting.

Sharlynn Tuohy: What is cording, Jean?

Jean Kotkiewicz: Cording goes along with something that's called axillary web syndrome. There's a lot of discussion about it in the news and what it is basically is an inflammation or an injury to the lymph vessels in that area. Either under the arm where it almost causes the lymph vessels to somewhat spasm and become tight, and it can stick out under the skin.

Sharlynn Tuohy: I think it feels like - I've heard it mentioned - it feels like guitar strings.

Jean Kotkiewicz: Right, or like a cord. So if you're actually playing an instrument and it actually tends to work that way as well. So it will start even deeper from the armpit and actually come down your arm. It can be shown through by your elbow, by the front side of your elbow, and even down into the wrist. I've had many woman say that when they move in a different way it can kind of pull. And even if it's not totally visible, they may still feel that band-like tightness throughout their arm. So how would a patient know if they needed to see a physical therapist in general? How would they get in touch with them, and what would they do if they felt like they wanted to go to physical therapy?

Sharlynn Tuohy: So I think the most important thing to ask patients and for people to recognize is, how are you functioning since you've been diagnosed with cancer? And even if you're years after completing treatment, how are you functioning and how does it compare to the way you functioned prior to your cancer diagnosis? So oftentimes I'll ask patients that exact question and they look at me and say, "Nobody's asked me that and so I haven't really thought about it, but I did use to walk further," or, "I played tennis and I no longer play tennis," or, "I was able to walk up and down stairs a lot easier and now I can't do that," or, "I get short of breath but I never got short of breath before I was treated for cancer." So I think it's just really important for people to take an assessment of how they're doing, how they're moving, how they're managing in their daily life and in their roles. So even in your role as a parent, or a spouse, or a caregiver for somebody else, are you able to do the things in that role that you used to be able to do? And if not, is there something that can be done for me to help me get back to that prior level that I had functioned at before? So I think that's a really good comparison. Now obviously, for some patients, you're not going to be able to return necessarily to the prior level of function that you enjoyed prior to cancer diagnosis. But what if we can get you halfway there? Or what if we can give you some compensatory techniques or strategies to help you to be able to do some of the things you were able to do before?

So I think that that's one way that a person can recognize that they might benefit from seeing a physical therapist. What you typically would think of is pain, loss of motion in a joint, you're not able to bend your knee as far or lift your arm as high. One other thing is, if you have a scar, and the scar is really tight - say you had a surgical procedure to remove cancer - or maybe you had a mediport or a peg placement, and there's a scar that's left behind that's giving you some trouble; we can address that. We can help mobilize the tissue in that area and free it up. And that really is so helpful for so many patients, and they don't even realize that it's the scar that might be contributing to the problem that they're having. So I think that those are really important. The other thing is, falls are very common as people get older, and if you've been treated for cancer, falls are accelerated. Meaning people will start to tend to fall earlier than they may have if they didn't go through cancer treatments. So most people don't like to admit that they fall, or they feel silly so they just brush it off and keep going. I think it's really important that if you are falling or you're having trouble negotiating some uneven services when you're walking, that you do bring it up to your physician or you do request the consult for a physical therapist. There's a lot of assessments and outcome tools that we use to look at your risk of falls and to see where you are at and we will provide exercises, balance activities, overall strengthening, and different strategies and techniques to help you so that you don't continue to fall, or that we can help stop that progression of falling more often. And falls are a huge issue in just healthcare, so anything that we can do to help you not fall we're happy to help.

Jean Kotkiewicz: A lot of these patients also need to have a good communication with their oncologist and their medical team and alert them as to what's going on. Like Sharlynn was saying, a lot of times it's difficult to be honest with yourself as to what you're able to do and versus what you were previously able to do. It's a hard thing that you have to accept because it's a change in your functional status. It's a change in your life that impacts everything that you're doing. So it's important to have good conversations with those around you and be open and honest, especially with your medical team, your oncology team, and even your family, your loved ones.

Sharlynn Tuohy: I think too you just have to advocate for yourself. Oftentimes the oncologist's primary role is to address the cancer. It's not their primary role, necessarily, to look at the whole picture of quality of life. Although many do, they're busy and they have a lot going on. They might be perfectly fine with sending you to a physical therapist, but oftentimes you just have to ask or bring it up. So we would definitely encourage people to seek that out. In many states there is direct access, which means you can see a physical therapist without a referral from a physician. So depending on the state that you live in - and most states do have direct access now - you can just go see a physical therapist. Call them up and make an appointment. If you want a recommendation you certainly could call your physician, whether it's your oncologist or your primary-care physician, and they could potentially let you know who they work with in the area that they really like to work with. There are also resources on the American Physical Therapy Association Website. It's, and on that website you can click on a link that says Find a PT and then I think you just type in your zip code and maybe your town, and it will give a list of physical therapists in your area, so you can find a physical therapist near you.

Jean Kotkiewicz: So when a patient does decide that they need to go to physical therapy, what should they expect during their first visit when they go to see the therapist? And usually how long can they expect to work with a therapist? Or is there any set guideline?

Sharlynn Tuohy: So when you go to see a physical therapist for the first time they're going to ask you a lot of questions. And they're also going to do an evaluation of your range of motion, your strength, balance, just in general how you move, how you walk, how you stand up and sit down from a chair, and they're going to do a number of objective measures to get a lot of information and data. So, oftentimes patients may not be treated at that first visit. And that's because the physical therapist really needs to do a thorough and comprehensive assessment. As Jean said, cancer treatments can cause a multi-system hit to the body and physical therapists are skilled at assessing multiple systems. So we're looking at your sensation. We're looking at your musculoskeletal system. We're looking at your neurological system. We're looking at your integumentary, or skin, system. We're looking at your cardiopulmonary status. And we're creating a picture of how you're functioning. So we're going to use all of that information to develop a treatment plan.

One of the things that physical therapists are really good at is asking the patients what they want to do, and what they think that they can do. So we always incorporate the patient's goals and desires into our treatment plan, because it doesn't work if the patient isn't on board. If they have a different plan than the physical therapist, it makes it really difficult to achieve the goals that the patient and the physical therapist want to achieve. So we collaborate with the patient and it's a partnership. We provide treatments, and the patient needs to show up for therapy and they need to commit to the program, and they need to do their program at home. We typically always give some exercises or some sort of home management program to a patient. So what they should expect is the evaluation with a physical therapist and then at the end of that they'll talk about the goals and come up with a treatment plan. And then, typically you would see a physical therapist anywhere from one time a week to two or three times a week. It just depends on many factors. We individualize the program for each patient. So it just depends on what you're going for and what you and your therapist decide. Most insurances do cover physical therapy. All plans provide a different benefit. So some have caps on how much physical therapy you can receive, and that's just something important to keep in mind when you are discussing a treatment plan with your physical therapist to make sure that you're utilizing the visits that you have wisely.

All right. Well, Jean, thank you so much for having a discussion. I think it's so important to educate patients and individuals on the role of physical therapy in the cancer setting and just to know that we can help anywhere along the way. Whether it's at diagnoses, during treatment, after treatment, right after treatment, and many years after treatment. It's really just been a pleasure to have this opportunity to share, and we hope that the information here has been helpful. Thank you.

Jean Kotkiewicz: Thank you.

ASCO: Thank you, Dr. Tuohy and Dr. Kotkiewicz. More information on the role on a physical therapist in cancer care can be found at

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