Incorporating Physical Medicine and Rehabilitation Into Palliative Care

A Conversation With Sean Smith, MD


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Sean Smith, MD

The entire field of physical medicine and rehabilitation is underresearched, and data speak louder than my talking about its merit.

—Sean Smith, MD

Although cancer rehabilitation has been a part of oncology clinical practice for several decades, it has largely gone unrecognized as an integral part of palliative medicine and survivorship care. Now, the role of physical medicine and rehabilitation in oncology care may increase as patients with cancer are living longer and need relief from residual physical, emotional, and cognitive impairments resulting from their disease or its treatment. 

A review of data by the American Cancer Society (ACS) on the complex set of issues cancer survivors often face has found that poor physical health is reported by 1 in 4 survivors, compared to about 1 in 10 of those without a history of cancer.1 In addition, poor mental health is reported by 10% of cancer survivors compared with 6% of adults without a cancer diagnosis. According to the review, the numbers suggest that as many as 3.3 million cancer survivors in the United States may have poor physical health and that 1.4 million may have poor mental health as a result of their disease.

According to the ACS report, studies show that multidisciplinary cancer rehabilitation— which often involves a team of rehabilitation professionals that includes physiatrists, physical therapists, occupational therapists, speech-language pathologists, and rehabilitation nurses—improves pain control, physical and cognitive function, and overall quality of life in cancer survivors.

It is for these reasons, said Sean Smith, MD, Director of the Cancer Rehabilitation Program at the University of Michigan Department of Physical Medicine and Rehabilitation in Ann Arbor, that survivors should be screened and treated for impairments all along the care continuum to minimize their disability and maximize their quality of life.

Cancer Rehabilitation Gains Support

Interest in the field of cancer rehabilitation is gaining momentum as hospitals and cancer centers work toward implementing new standards of patient-centered care established by the American College of Surgeons’ Commission on Cancer (CoC), which go into effect in 2015. Three of the new standards—psychosocial distress screening, patient navigation process, and survivorship care plans—significantly impact cancer rehabilitation, which is an eligibility requirement for CoC accreditation.

Physical medicine and rehabilitation is also becoming integrated into palliative care services, although limited availability in cancer centers to physiatrists and a lack of understanding on the difference between general exercise or wellness programs and impairment-driven cancer rehabilitation are preventing the gap between the need for rehabilitative care in the palliative care setting and the delivery of services from closing.

The ASCO Post talked with Dr. Smith about the use of physical medicine and rehabilitation in the palliative care setting; how cancer rehabilitation can ameliorate the effects of graft-vs-host disease in transplant patients; and how the field of physical medicine and rehabilitation can become an integral part of oncology care.

Impairment-Driven Rehabilitation

Please talk about how you are using physical medicine and rehabilitation for patients with cancer in the palliative care setting.

Many of the patients I see are survivors of breast, brain, and head and neck cancers or sarcomas or recipients of bone marrow transplantation. I determine what their impairment is, which could include a physical impairment, such as painful joints; spasticity preventing their ability to walk; back pain; neuropathy; radiation fibrosis syndrome; lymphedema; fatigue; or problems resulting from graft-vs-host disease or a cognitive impairment caused by chemotherapy or frontal lobe disinhibition from brain surgery for tumors.

From there, I create a targeted treatment program to address specific impairments. This is distinct from prescribing general exercise or generic forms of physical therapy. Because it is far more effective than more broad approaches to treatment management, impairment-driven cancer rehabilitation is specifically cited by the ACS as a valuable patient-care service. 

Exercise and physical activity are well and good, but oftentimes patients are functionally limited or unsure of what they can do physically, or it may take more than this type of broad approach to improve patient outcomes. This is where a physiatrist can be ­helpful.

Potential Problems for Transplant Recipients

What are some of the issues patients experience following a bone marrow transplant?

Nearly all of the functional problems after a transplant stem from graft-vs-host disease or its treatment. The latter includes steroids, which may cause myopathy and muscle atrophy.

Avascular necrosis of the bone, another potential complication of steroids, is treated as a form of progressive arthritis by physiatrists. If a joint replacement is not a viable option due to a patient’s age or medical condition, or if the degree of joint destruction is not yet advanced enough to warrant arthroplasty, avascular necrosis is treated with a combination of interventions, including medications, physical and/or occupational therapies, and splinting/bracing of the joint.

Other potential problems for transplant recipients are contractures of the hands and skin, which can benefit from targeted treatment approaches. I have a patient who had two fingers on each hand amputated because they were so contracted, the function of her hands was badly impaired. The amputations took place before she became my patient, and I wonder if earlier intervention would have been able to prevent them.

All of these symptoms can lessen patients’ independence, decrease their quality of life, and put them at risk for adverse events, such as falls, which can be particularly devastating in this often-thrombocytopenic population.

Role of the Physiatrist

How does physical medicine and rehabilitation differ from physical therapy in the treatment of these conditions?

Physical medicine and rehabilitation physicians have extensive medical training. To become a rehabilitation physician, individuals must graduate from medical school followed by 4 additional years of postdoctoral training in a physical medicine and rehabilitation residency. Physical therapists are trained in the clinical features of common musculoskeletal pathology, but they do not have medical degrees. This is not meant to imply that physical therapists are not skilled at what they do; they are, but the scope of physical therapy is limited in the context of cancer rehabilitation.

The role of the physiatrist is to manage the medical issues of patients as they go through the rehabilitation process. A physiatrist will assess patients and diagnose conditions using imaging studies, electromyography (physiatrists are often also Board-certified in electrodiagnostic medicine), and laboratory tests.

In some cases, specific targeted physical therapy prescribed by a physiatrist is warranted; in other cases, interventions including medications, nerve and neuromuscular blocks for pain management, a home exercise program designed by a physiatrist, occupational therapy, rehabilitation psychology, or speech-language therapy may be prescribed.

One example I can give that reflects the difference between the role of physical therapy and physical medicine and rehabilitation in impairment-driven cancer rehabilitation is a patient of mine with breast cancer who was suffering from radiation fibrosis, which pulled her pectoralis and posterior shoulder muscles tightly, causing headaches. Prescribing exercise or generic physical therapy would not have fixed this problem; it takes specialized treatment.

For a patient like this, I would start her on a nerve-stabilizing medication to stop the muscle contractions and cramping and perhaps do a nerve block for the headaches. And if those interventions didn’t work, I would add a different medication or inject botulinum toxin (Botox) into the muscles to alleviate the tightness and prevent the headaches. In addition, I would prescribe condition-specific exercises to do at home. Determining treatment is a big process, and it all depends on the cause of the impairment.

Cognitive Dysfunction

Please talk about how you treat patients with cognitive impairments.

Cognitive dysfunction can include changes in short-term memory or concentration and may cause fatigue. Usually, prescribing a gentle central nervous system stimulant such as methylphenidate or amantadine, along with working with a speech-language pathologist, can help to restore memory and concentration. Methylphenidate can also help with fatigue, which is one of the most common symptoms cancer survivors’ have. I’ve had multiple patients tell me how life-changing getting over their fatigue was for them.

To determine the exact problem, we have patients assessed by a rehabilitation psychologist, who offers a more sophisticated and in-depth way of evaluating cognition. This approach is helpful for patients who wish to return to work or other high-level activities.

Evaluation for symptoms of depression and anxiety is an essential component of the workup of patients with cognitive impairment. These symptoms may be addressed pharmacologically or through work with the psychology members of the team.

Our main concern is to identify the issues patients are having, determine their goals for treatment, and then prescribe the most effective therapy.

Referral Process

Are physiatrists becoming part of the palliative care team in cancer centers? And how are patients referred to cancer rehabilitation specialists?

Here at the University of Michigan, patients are referred to me when a provider identifies a need. I have support from the clinical director at our cancer center, and that helps get the word out. At other centers, there are referral algorithms that are followed if a patient has a certain function score on an intake questionnaire, but that process is not well defined, and it is something that we in this field need to address to improve patient care.

For example, I would like to see any physical or emotional symptom flagged on a survivorship care plan and then have patients referred to cancer rehabilitation if appropriate. I think that would be an easy way to get patients the services they need to improve their quality of life.

One of the challenges we face is that palliative care teams have been around in an institution longer than have physiatrists specializing in cancer, so it is difficult to become incorporated into the palliative care team.

Underappreciated Service

Are more cancer institutions starting to recognize the importance of cancer rehabilitation for survivors and implementing similar programs?

I can’t say whether that is true, but I think that more physical medicine and rehabilitation physicians are realizing that we should be engaging more with oncology providers, and so from our end, the interest is growing.

A survey of 15 prominent cancer centers has found that only 28% of cancer centers even mention cancer rehabilitation on their websites, and most of the time, it is in reference to physical therapy.2 I think many cancer centers still believe that recommending exercise to address physical impairments or a therapist for problems like lymphedema, for example, is adequate to resolve these issues, when in fact cancer rehabilitation is much more involved.

Kevin C. Oeffinger, MD, Chair of ASCO’s Cancer Survivorship Committee and Director of the Adult Long-Term Follow-Up Program at Memorial Sloan-Kettering Cancer Center, told The Washington Post in an interview,3 “Rehabilitation services are probably the single most underappreciated service among cancer survivors right now.” And I’m glad that experts outside of the physical medicine and rehabilitation field are recognizing this deficiency in patient care.

Need for Collaboration

What can the field do to make more oncologists aware of the need and benefits of cancer rehabilitation for palliative care patients?

One thing we can do is to reach out to societies like ASCO to see how we can collaborate to integrate cancer rehabilitation into palliative care services. Another way we can improve utilization is to do more research to show the effectiveness of cancer rehabilitation on survivors’ well-being and quality of life. The entire field of physical medicine and rehabilitation is underresearched, and data speak louder than my talking about its merits.

Our field’s national organizations also need to work with the Commission on Cancer and the National Cancer Institute to improve patient-centered care. Until, we show that we as physiatrists are interested in collaborating with oncologists, we won’t be seen as legitimate contributors in the continuum of cancer care to organizations like ASCO or oncology providers in general. ■

Disclosure: Dr. Smith reported no potential conflicts of interest.

References

1. Silver JK, Baima J, Mayer RS: Impairment-driven cancer rehabilitation: An essential component of quality care and survivorship. CA Cancer J Clin 63:295-317, 2013.

2. Smith SR, Reish AG, Andrews C: Cancer survivorship: A growing role for physiatric care. PM R. December 18, 2014 (early release online).

3. Aschwanden C: How to get healthy after the cancer treatments are done. The Washington Post. July 29, 2013.

Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science and Professional Development Department.



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