Physical Therapy for Cancer Patients

M. D. Anderson Cancer Center
Date: February 08, 2009

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Physical Therapy for Cancer Patients

Naghma Ahmed, Senior Physical Therapist at M. D. Anderson's Rehabilitation Services, discusses what can be done to help cancer patients recover from physical conditions caused by cancer treatments, including:  general deconditioning, frozen shoulder, tendentious, peripheral neuropathies, and radiation fibrosis.

Lisa Garvin:

Welcome to Cancer Newsline, a weekly podcast series from the University of Texas, M. D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnoses, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today our guest is Naghma Ahmed. She is a physical therapist, a Senior Physical Therapist in the Rehabilitation Services Department here at M. D. Anderson. Welcome, Naghma.

Naghma Ahmed:

Thank you.

Lisa Garvin:

Today, our subject will be physical therapy for cancer patients. And Naghma, would it be safe to say that most cancer patients will need some form of physical therapy during their treatment?

Naghma Ahmed:

Yes. I think so. I think all individuals need some form of physical activity, and cancer patients, more so, because of their diagnoses, but also because of the treatments they receive. Sometimes you end up treating the side effects of their treatments more than you would their actual cancer diagnoses.

Garvin:

What are some of the side effects? Obviously, with some patients there is a loss of physical function due to the loss of a limb, or an eye, or whatever, so you have different stages and different needs of physical therapy.

Ahmed:

Absolutely! Probably the most common diagnoses we would see, and again, this is a bucket term of general conditioning, or muscle weakness. Now, this would result from being hospitalized for long periods, and while being hospitalized receiving chemotherapy. We also see patients, for example, in our breast population, and I see a lot of those who come to us with frozen shoulders, very, very tight shoulders, shoulder weakness, impingements, tendonitis, any and every form of shoulder pathology that you might see in the non cancer world, you will see with our breast patients, as far as their shoulders are concerned. Patients come to us with peripheral neuropathies, because of the chemotherapy they've received, radiation fibrosis, because of the radiation they've received. So again you're treating for the treatment, along with the side effects of the disease, itself.

Garvin:

I do know that one of the major side effects of all cancers is fatigue. Do you help people deal with fatigue, as well?

Ahmed:

All the time! It's difficult to explain to a patient who you see upstairs in the hospital, for example, and the first thing out of their mouths is, I'm too tired to do physical therapy and that's where education comes in. We do a lot of education, and we back this education up with research. I think it means a whole lot more to a patient, when we say studies have shown that people who have fatigue, generally, are able to lessen their fatigue levels by exercising, my moving around, by sitting up. Some patients are so tired and so fatigued. You might see this, say on the, on the stem cell transplant floors, where they're so tired, and their first requirement from physical and occupational therapy is you must be out of bed for eight hours a day. We want you sitting up in a chair. We want you standing. We don't want you lying in bed. So that's step number one. Just get out of bed. Then, we'll teach them simple bed exercises. We'll teach them to walk around the room, or to walk around the floor, and take it from there. But they realize that with this activity, their fatigue levels do decrease.

Garvin:

I know that must be hard for them to fathom, at first?

Ahmed:

It is. It's hard for them to get out of bed. That's how tired they are.

Garvin:

So in the normal world, in the general population, the whole exercise mantra is use it or lose it. I would assume that would be the same or more so in the cancer population?

Ahmed:

Absolutely! Absolutely, very much more so in the cancer population, because they're so tired, because they may lie in bed for days and days while they're receiving treatment, or after surgeries. So yes, that's when you start encouraging the patient to do the very most that they absolutely can, even if it means just tightening the knee muscle, or the muscle that lies on top of the thigh, just, you know, pushing the back of your knee down into the bed, just tightening your stomach muscle, that's, at times, that's how basic we get. We do, actually do physical therapy in the ICU, where patients are extremely sick. And we have a wonderful ICU therapist, and she will go in there, and sometimes you will see her walking right along with all the machinery that is attached to that patient, and she'll get them up and make them stand, and make them stand at the edge of the bed, if that's all she can do. But the doctors love that, because they want these patients to get strong, because as you get strong, and as you build up your endurance, you increase your chances of recovery. I think people don't realize, and I had read recently, that you lose muscle mass, and as you said, conditioning at an alarmingly fast rate.

Ahmed:

Much faster than you gain it, that's for sure. I think everyone who is trying to lose weight or trying to get stronger would know that. I'm sorry, I don't know that there's an actual statistic, and I thought about it when I left, that I would look it up, and I didn't look it up, but there is an actual statistic that tells you how much muscle mass you lose for everyday you lie in bed.

Garvin:

It's pretty immediate, as well?

Ahmed:

It's very immediate. Anyone, any non cancer individual that's has a cast on, and has walked in a cast for, say six weeks, for a broken limb, will be shocked after the cast is removed, and they see the atrophy in that limb, from not using it, just for six weeks.

Garvin:

You were talking a little bit about research. I know that they've done conditioning exercises up in the space shuttle, and that kind of thing. Do we do active research about physical therapy and occupational therapy?

Ahmed:

Oh, absolutely. The new mantra for the American Physical Therapy Association is evidence based practice. No longer do we as physical therapists and occupational therapists just take for granted what our teachers told us 10 years ago, 20 years ago, now we have research that backs pretty much everything, we practice, mostly everything we practice. This is something that physical therapy is headed towards. It's also headed towards every physical therapist receiving a doctor in physical therapy, so physical therapy is no longer a four year bachelor's degree, or a six year master's degree, which is what I have, but a Doctor of Physical Therapy, is what most schools in Texas are offering, now.

Garvin:

You and I were chatting a little bit before the interview about the fighting nature of cancer patients, and you said that you're always amazed at how they really want to get back to, as close to normal as they can?

Ahmed:

Yes. They want to go back. They want to go back to work. They want to go back to working in their yard. Some of our younger patients want to go back to playing soccer. They just want their lives back. They just want to be pre-cancer. M. D. Anderson is, it's so amazing because you see patients from all over the world. Just for these people to be here, to give up their lives, in their hometowns, with their children, their grandchildren, their relatives, and to move, bag and baggage across the country, across the oceans to come to M. D. Anderson for treatment, right there, that was the beginning of the fight. And they've given up everything, everything to just come here and get well. I think that's what makes them such amazing patients, is because they come here ready to fight.

Garvin:

I think sometimes the stereotype of a physical therapist is a drill surgeon. How much of your job is motivation and tough love?

Ahmed:

Almost, 99.9%! I've known as a drill surgeon. I expect a lot out of my patients, because I give them a lot and I expect a lot in return, and I know that they want to get well, they just don't feel good enough to help me out, sometimes. So sometimes you have to pull them aside and have that talk with them, or sometimes, you know, you have to say, you can do this, just do this. And I've had all kinds of, you know, tears, I've had people just broke down and cry. When you're in physical therapy with the kind of therapy that I do, you're one on one in a curtained off room with a particular patient, depending on the diagnoses of the patient, and all of a sudden, you've become their friend, you've become their counselor, you've become their cheerleader, and they talk about things that they, you know, wouldn't talk about, say in their visit with a physician, or, so lots of tough love.

Garvin:

How important is it for them to take the things they've learned here at M. D. Anderson during their rehabilitation, to take that home with them and keep doing it after treatment has ended?

Ahmed:

Very, very important, and we emphasize that. We tell them that they're coming to physical therapy three hours, three hours a week, you know, cause most patients come three times a week to our outpatient department, and we say that your real therapy is done at home, when you repeat what I'm teaching you here, your time here is to learn what to do at home, and the real therapy is done at home. Some do it, some don't, some get complacent, some get tired. So you just, you kind of hope that everyone does do it. When I first started, I was very enthusiastic, and I just expected everyone to compromise with me, you know, and agree with me and do what I asked them to do a 100% of the time, but I've learned it doesn't quite work that way.

Garvin:

What about the more serious things, like, amputations, blindness, that kind of thing, do you deal with that a lot? Is it a different…

Ahmed:

Well...

Garvin:

Approach?

Ahmed:

Yes. The orthopedic patient is a very different approach. First of all, we see a lot of the sarcomas, that we might see, and the bony tumors that we might see, are of the younger patient. That means you're dealing with an adolescent, or the younger adult, and sometimes even, you know, younger children. And it's very sad, and it's heartbreaking, and you, and that's where a lot of the tough love comes in. And the tough love has to come from the parent as well as the therapist, because a lot of times whatever the therapist ask the patient to do is negated by what the patient does, so there's, you know, counseling of the parents as well, when you pull them aside and say, make them do it.

Garvin:

But it must be fun when they finally reach their goal and for you to watch that?

Ahmed:

Oh, it's awesome. It's awesome. What's fun is when they've done their, you know, their four to six weeks of therapy, and they're coming in, and someone who with a frozen shoulder, raises their arm up in the air, and says, I can do this, I can do this. And I've had some patients tell me, you gave me my life back. You know, these little things are very important to them, the fact that they can reach the back of their head, or undo their bra, or climb stairs, these little things matter a lot to them, and it's so, so amazing to see them finally achieve that and walk out of there on their own.

Garvin:

And in closing, what would be the one thing you would want to tell cancer patients about physical therapy and physical activity?

Ahmed:

Well, first, I'll go the research route. Research is showing that physical activity does indeed, along with good, clean, living, prevent cancer, heart disease, diabetes, lots of things. Physical activity is very important to healthy and cancer patients, or patients with heart disease. And also it doesn't have to be boring. It doesn't have to be a drill. Go out and do anything. Go for a walk with your dog. Just do something. And that's one of the philosophies we have in our department. We don't care what you do or how much you do, as long as you do something. Go for a walk. Go roller-skating. Take up yoga. Do Tai Chi. Do Pilates. I don't like to exercise, I'll be honest with you, I hate to exercise, and I tell my patients that, but you know what, I do it. I make myself go to the YMCA, and I make myself get on that darn elliptical trainer and I exercise. And I think I can literally relate to a lot of these people, and after I'm done, I feel great. I have energy, and I can do so much more after an exercise session than after I drag myself off of the couch and try and run some errands. So I just tell people go out and do it, and I hate to sound corny, I sound like a Nike commercial, but it's true, it's absolutely true.

Garvin:

Just do it.

Ahmed:

Just do it.

Garvin:

The endorphin rush is worth it, at the end.

Ahmed:

It's absolutely worth it. It's absolutely worth it. And it's there, and makes you feel better. It makes you healthier, and it helps you prevent a lot of things just so easily.

Garvin:

Great. Thank you so much.

Ahmed:

You're welcome.

Garvin:

If you have any questions about anything you've heard today on Cancer Newsline, contact AskMDAnderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.

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