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Literature Review: Physicians Under Prescribing Physical Therapy to Oncology Patients

Erica Hoot

Trine University


This literature review focuses on the immense benefits that stem from the use of physical activity

in the rehabilitation of cancer patients. Multiple different studies are mentioned providing

evidence of this correlation for not only cancer survivors, but also patients going through

treatment, such as chemotherapy. Regarding physical activity for cancer patients, physical

therapists are qualified to provide professional care. Physical therapists are trained individuals

that can educate, assist and supervise patients performing an exercise plan that puts the patient in

a safe range while still reaming the benefits of physical activity. However, despite this positive

correlation oncologists are underutilizing physical therapists in the rehabilitation process of

cancer entirely.

Keywords: cancer, physical therapy, physical activity

Literature Review: Physicians Under Prescribing Physical Therapy to Oncology Patients

Cancer is an incredibly devastating disease that impacts millions around the world every

day. Medical professionals continuously attempt to become more efficient at treating cancer

every day. Exhibiting cancers prevalence in our society, Stout (2009) points out that men have a

1 in 2 chance of developing cancer, women 1 in 3. A disease with this type of prevalence in our

society should be put at the highest priority regarding prevention and treatment. Any

improvement in the rehabilitation plan could have a positive impact on one of the many cancer

patients worldwide with hope to someday call them a cancer survivor. Physical activity has been

shown in countless studies to not only prevent certain cancers, but also be effective throughout

the entire cancer rehabilitation process.

Two main things are almost always associated with a healthy lifestyle, a balanced diet,

and adequate amount of physical activity. However, as people age, and life gets busy and

complicated, physical activity is often put on the back burner. A cancer diagnosis can be

extremely scary, and disrupt a patients lifestyle. Through research performed by Holmes

(2005), it was uncovered that physical activity decreases in a woman by 2 hours per week

immediately after being diagnosed with breast cancer. Evidence exhibited that this number was

even greater in obese women. This decline in physical activity is especially dangerous for these

women during their cancer fight, because Holmes also discovered that women who engaged in

physical activity as small as walking 1 or more hours per week had better survival rates

compared to those who exercised less or did not exercise at all. Optimal results in lowering the

risk of death were reached when women walked 3 to 5 hours a week at an average pace. Another

example that illustrates the positive results that stem from physical activity was a study

completed by Van Weert et al (2010). This study compared different rehabilitation programs
involving physical training and cognitive behavioral therapy. The three different programs

involved physical activity and cognitive behavioral therapy together, physical training alone, and

neither. Both physical training combined with cognitive behavioral therapy and physical training

alone exhibited benefits regarding a decrease in cancer related fatigue. The program with only

cognitive behavioral therapy, and without any physical training or cognitive behavioral therapy

did not experience these benefits. Cancer related fatigue is a common negative symptom of

cancer, and Watson et al (2004) defines it in the article Exercise as an Intervention for Cancer-

Related Fatigue as persistent, subjective sense of tiredness related to cancer or cancer

treatment that interferes with usual functioning. Watson et als research also demonstrated

evidence of a decrease in cancer related fatigue in women being treated for breast cancer. When

comparing the different programs in Van Weert et als data there was no significant difference

between the one program that incorporated the use of cognitive behavioral therapy, and the

program that did not. This indicates that cognitive behavioral therapy did not exhibit the same

beneficial effects that physical training had on cancer patients.

Cancer patients can experience physical impairments and functional limitations through

the cancer they may be facing, and the area of the body it effects. Alappattu et al (2014) points

out a couple common examples that are experienced by oncology patients. Men who have been

diagnosed with prostate cancer often experience urinary and sexual dysfunctions. Common

issues for women with breast cancer include upper extremity dysfunction and lymphedema.

Patients with head and neck cancer can commonly experience problems while eating and

swallowing. Alappattu et al also researched what were the most common cancers to visit

outpatient physical therapy clinics, and his results revealed that Genitourinary cancer types

(40.4%) were the most common, followed by breast cancer (21.5%) and head or neck cancers
(10.3%). Research also showed that the most common problems noticed by physical therapists

of cancer patients were in strength and soft tissue. Although strength and soft tissue were the

main problems acknowledged by the physical therapist, it was mentioned earlier how incredible

benefits arouse from physical therapy without the cancer being directly treated.

Regarding patients participating in physical therapy during chemotherapy, Irwin (2008)

refers to a study performed by Courneya, who researched the benefits of aerobic and resistance

training during chemotherapy treatment. Benefits experienced by subjects included improved

self-esteem, fitness, body composition, and an increase in completion rate of chemotherapy

compared with no physical activity. Another study performed by Knols (2005) also experienced

many benefits from exercise during breast cancer treatment. These benefits included body

composition, overall body function, muscle strength, and walking distance. Other self-reported

benefits included quality of life, mood, and psychological well-being. Symptom relief was

another extremely beneficial outcome of exercise. These symptoms included nausea, fatigue,

and difficultly sleeping. Also, as mentioned earlier, Watson et als research demonstrated a

decrease in cancer related fatigue in cancer patients who participated in physical activity and

physical therapy. In conclusion, accumulations of research have demonstrated that physical

activity is not only safe for cancer patients and survivors, but it also reams many benefits for

patients going through treatment to counteract the adverse conditions that cancer may enact.

In regards to the type of cancer patients currently receiving physical therapy care,

Alappattu et al (2014) researched the comparison between patients receiving physical therapy

and those that are not. His research revealed that patients performing physical therapy while

receiving chemotherapy had the highest average physical therapy attendance to sessions, and

also a pattern of increasing the number of chemotherapy sessions completed. The positive
correlation between exercise and an increase in cancer patients being able to complete certain

cancer treatments like chemotherapy should put the need for physical therapy on the fast track

for cancer patients right away.

However, it seems there is a gap in the process of informing patients on the benefits of

exercise and how to best do it in their particular condition of health. Through a qualitative study,

Sander et al (2012) researched breast cancer survivors, and their feelings toward exercise. Effects

of cancer treatment, fatigue, neuropathy, body image, fear of injury to the involved arm, and fear

of lymphedema all were mentioned by breast cancer survivors as issues that contribute to an

avoidance of exercise. According to the Mayo Clinic, lymphedema is swelling that occurs in the

arms or legs. This dangerous condition is a common fear to breast cancer patients and survivors

(2017). However, Irwin (2008) addresses this fear and points out that there is no increased risk

of lymphedema for women with breast cancer from aerobic or resistance training. Despite these

barriers, most of the participants in Sander et als (2012) research demonstrated a known value

for exercise on improved overall health and the prevention of cancer recurring. However, the

participants still exhibited a fear of exercise and expressed a desire for more specific guidelines

about safe and effective exercise programs from health care providers. Physical therapists need

to be aware of these barriers that are preventing patients from performing physical activity in

survivors of breast cancer so patient education and guidelines can be expressed to create a

program that is individualized and goal directed. A professional and safe setting for physical

activity exists in the office of a physical therapy clinic, and needs to be valued more throughout

the cancer rehabilitation process.

Despite the well-researched benefits of physical therapy and exercise on oncology

patients, there is still an obvious gap between the referral of physical therapy by oncologists. As
oncologists neglect the physical therapy aspect of a patients rehabilitation program, patients are

missing out on valuable experiences that could be monumental during and after treatment. In the

article Physical Interventions for Cancer Survivors, Irwin (2008) explains that because of

many different factors cancer survivors are not meeting the recommended levels of physical

activity. In fact, he claims that only 30-47% of cancer survivors meet physical activity

recommendations. However, Irwin does not place the blame solely onto to the patient. He shifts

the blame to the oncologist, and exclaims that these professionals need to not only do a better job

at acknowledging the benefits of exercise during and after cancer treatment, but also need to

refer their patients to professionals that can serve as exercise guides. These guides are physical

therapists. According to the American Physical Therapy Association, 70% of people believe a

referral or prescription is required to be evaluated and treated by a physical therapist. However,

throughout the United States there is no such requirement. (2017). Meaning, a patient could go

on to be treated by a physical therapist without a referral from the oncologist. However, patients

are not seeking out physical therapists in their treatment plan, because they are unaware of the

immense benefits that stem from physical therapy. Without the oncologist communicating the

benefits of physical activity, many cancer patients stay in the dark. Irwin (2008) refers to a study

completed by Jones, which says that 42% of patients discussed physical activity with their

oncologist, and only 14% were referred to a specialist, like a physical therapist. With less than

half of cancer patients being recommended physical activity and even less being referred to a

professional, the underutilization of physical therapists in the cancer rehabilitation process is

noticeable and possibly hindering cancer patients.

To continue the rise in decreasing chronic diseases like cancer, changes must be made in

the health care system. Oncologists must educate their patients on the overall benefits of
physical activity, and refer them to professionals, like physical therapists that can carry out

exercises in a safe and structured environment. Steps like these will initiate the transition our

society needs to move toward to preventing diseases with treatments such as physical therapy.

Stout (2009) refers to the importance of preventing certain diseases, and emphasizes that 34% of

cancer is preventable, and emphasizes this need by commenting that 90% of health care

resources focus on treating chronic disease, like cancer. In order to make the shift to preventing

certain diseases, especially cancer, there needs to be a positive health provider attitude. In order

to acquire this attitude there needs to be a conscious effort to move towards a disease

preventative society with the use of physical therapists in the treatment of oncology patients.

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characteristics of patients with cancer referred for outpatient physical therapy. Physical

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Holmes, M. D. (2005). Physical activity and survival after breast cancer diagnosis. Jama,

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Irwin, M. L. (2008). Physical activity interventions for cancer survivors. British Journal of Sports

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Knols, R., Aaronson, N. K., Uebelhart, D., Fransen, J., & Aufdemkampe, G. (2005). Physical

exercise in cancer patients during and after medical treatment: A Systematic Review of

Randomized and Controlled Clinical Trials. Journal of Clinical Oncology, 23(16).


Lymphedema. (2017). Retrieved March 21, 2017, from http://www.mayoclinic.org/diseases-


Sander, A. P., Wilson, J., Izzo, N., Mountford, S. A., & Hayes, K. W. (2012). Factors that affect

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