CANCER REHABILITATION

Presented By
Shivani Kature
 CONTENTS
1) INTRODUCTION
2) TYPES OF TUMORS
3) BREAST CANCER
4) CLINICAL FEATURES
5) DIAGNOSIS
6) EARLY POST DIAGNOSTIC PHASE
7) MEDICAL MANAGEMENT
8) SURGICAL MANAGEMENT
9) OT EVALUATION AND ASSESSMENT
10) OCCUPATIONAL THERAPY MANAGEMENT
 Introduction
Cancer:-It is an abnormal growth of cells which tend to
proliferate in an uncontrolled way and sometimes gets
metastasize(spread).
It is described by the type of tissue in which they arise:-
a) Carcinoma (within the organ or epithelial tissue)
b) Sarcoma (within connective tissue)
c) Chondroma (within Cartilage)
d) Lymphoma (within lymphatic tissue)
e) Leukemia (it is the blood forming tissue)
The Grading System used to convey
the spread of malignancy is the
TNM system

• A) ‘T’ refers to the extent or size of the primary

tumor.
• B) ‘N’ identifies whether the cancer cells are detected
in regional lymph nodes.
• C) ‘M’ reports the presence or absence of metastases.
Types of tumor
❖Carcinoma of breast is the most common malignancy in
women in India.
❖No. of factors are associated with breast cancer like:-
a)Hormonal regulation of breast which is related to
development of breast cancer.
b) External factors can also contribute like diet, obesity ,
viral infection and use of alcohol.
c) Environmental factors such as chemicals and radiations.
d) Early positive family history .
e) Genetic predisposition.
CLINICAL FEATURES:-
▪ New lump or mass.
▪ Swelling of all or part of a breast (even if no distinct
lump is felt).
▪ Skin irritation or dimpling (sometimes looking like an
orange peel).
▪ Breast or nipple pain.
▪ Nipple retraction (turning inward).
▪ Redness, scaliness, or thickening of the nipple or breast
skin.
▪ Nipple discharge (other than breast milk).
DIAGNOSIS:-
I. BLOOD TESTS ( which look for chemicals such as tumour
markers)
a) Fine needle aspiration
b) Vacuum- assisted biopsies
c) Surgical biopsy.
d) Lymph node biopsy
II. BONE MARROW BIOPSY( for lymphoma or leukemia)
III. CHEST X-RAY (MAMMOGRAMS)
IV. COMPLETE BLOOD COUNT (CBC)
V. CT SCAN
VI. LIVER FUNCTION TEST
VII. MRI SCAN
[Link] ULTRASOUND
 EARLY POST-DIAGNOSIS PHASE
❖ During this phase as the client begins cancer treatment, adverse health effects such
as impaired physical or psychosocial functioning may be experienced.
❖ The needs often go unmet, particularly in those who have had changes in
employment status secondary to the cancer and are also receiving chemotherapy.
❖ The initial intervention for cancer may involve a series of treatments, including
surgery, chemotherapy, radiation therapy, or immunotherapy, each of which has
side effects.
❖ Surgery may include removal of mass, more resection of tissue in addition to the
mass (for staging of the disease or for complete removal of tumor-invaded tissue),
reconstructive surgery to correct cosmetic or functional defects or the surgical
resection, or amputation.
❖ Before surgery , the therapist can be involved in client education and training to
prepare the client for what to expect after the surgery.
 Medical management
[Link] Agents [Link] Products
• Cytoxan • Vincristine
• These types of drugs usually • These drugs interfere with cell
damage the programs that control structure as well as cell division.
the growth in tumor cells.
[Link]
[Link]
• Prednisone
• Methotrexate & 5-fluorouracil
• These affect the growth of
• This type of drug interferes with hormones and usually enhances
the making of nucleotides, which the effects of other cytotoxic
are the substances that make up drugs.
DNA.
 CHEMOTHERAPY
• It is the use of a variety of toxic chemical substances to kill the cancer
cells in the body
• Some of the most common side effects that occupational therapists
encounter are :-
a) Alopecia (hair loss)
b) Peripheral Neuropathy
-Leads to wrist drop, foot drop
-Hyperthesia (tingling, numbness, burning)
-Changes in sensation of hands and feet
Eg- patient unable to hold objects, loss of fine motor skills and
unable to stand on there feet when pain is serious
c) Thrombocytopenia
 Eg- bleeding gums on brushing so patient uses toothete or glycerine swabs
d) Fatigue may limit the level of participation because a person who is fatigued may
not be able or sufficiently motivated to participate in daily occupations.
e) Changes in the red blood cell composition of blood (e.g anaemia)
f) Functions limiting anxiety and fear.
g) It can also compromise sensory system, and the person may experience
diminished or loss of vision or hearing.
h) People who undergo chemotherapy contract opportunistic infections because it
causes immunosuppression. [Link] Candida Albicans :- which causes dysphagia
(inability to swallow safely).
i) In the acute phase of hospitalization, clients treated by chemotherapy may be
referred to OT because they have been on prolonged bed rest and may have stopped
initiating or participating in their self-care.
 HORMONE THERAPY
• Eg:- Some tumors thrive on estrogens.
• The hormones can be used to block estrogen receptors or to prevent
the body from producing estrogen.
• This hormone often have side effects including menopause, mood
swings and hot flashes.
 IMMUNOTHERAPY
• It is the use of substances that block the response of the immune
system or that heighten the response.
• For eg:- WBCs Phagocytose (ingest) cancer cells and carry them
through the lymphatic system to the other areas of the body.
• This response can spread cancer locally or carry the cancer cells to
other places of the body.
• For eg:- Immunotherapeutic Agent (interferon) is used to fight this
spread.
 RADIATION THERAPY
• It is the use of radioactive materials directly in tumors or the
surrounding tissue to kill the cancer cells.
• It is effective when the cancer cells are sensitive to its effect.
• Radioactive seeds can be directly implanted for a short time in a body.
• Radiation may also be used in a late disease as a form of palliative
treatment ,particularly to reduce pain.
• Burns are the possible side effect of radiation therapy.
• An Otist may work collaboratively in some settings with the radiation
oncology staffs to mould the body positioners from thermoplastic
(splinting) material.
• People may need assistance with ROM to prevent complications such
as frozen shoulder.
SURGICAL MANAGEMENT

It falls into two broad categories:-

1)MASTECTOMY:-

a) Simple Mastectomy:-
This involves removal of entire and some of all of the axillary lymph
nodes.

The pectoralis minor may be removed or transected but is usually

preserved.

Although it involves the removal of entire breast, the modified radical

mastectomy is less morbid than the radical mastectomy.
b)Radical Mastectomy:-
o It is the end block removal of breast, the skin overlying the tumor,
pectoralis major & minor muscles and all the axillary contents,
leading to significant muscle weakness & impaired shoulder function.
o Breast reconstruction is more easily performed after modified radical
mastectomy.
o Post – Operatively the patient may experience pain which may vary
from one patient to another patient and may be due to:-
a) Specific nerves being served during surgery:- Initially pain
occurs on the chest wall of axilla , arm, and sometimes radiating to the
back. As time passes , the pain becomes numb or only a dull ache ,
which may extend down the arm.
b) Pectoralis muscle spasm :- this reduces passive movements
performed at shoulder joint. It is important to help the patient to
relax during exercises/ activities.
c) Phantom breast pain:- Here the patient experience the sensation
of the presence of resected breast. This is thought to be influenced
by emotional factors and is temporarily.
d) Paraesthesia:- patient usually feel paraesthesia in axilla and
posterior aspects of arm and rarely it persist chest tenderness which
is again a common complaint which resolves slowly and can be
symptomatically controlled using NSAIDs.
2)BREAST-CONSERVING
SURGERIES:-
a) Lumpectomy:- It involves excision of the mass
and a margin of healthy surrounding breast tissue, or
segmental mastectomy( also known as quadrectomy),
which is excision of the affected quadrant of the breast.
b)Lymphadenectomy:- it is the dissection of
axillary lymph nodes, it is a surgical procedure to
remove one or more lymph nodes or group of lymph
nodes, which are then evaluated for the presence of
cancer.
COMPLICATIONS RELATED TO BREAST
CANCER TREATMENT:-
1) POSTOPERATIVE PAIN
a) Incisional Pain
b) Posterior Cervical And Shoulder Girdle Pain
2) POSTOPERATIVE VASCULAR AND PULMONARY COMPLICATIONS
3) LYMPHEDEMA
4) CHEST WALL ADHESIONS
5) DECREASED SHOULDER MOBILITY
6) WEAKNESS OF THE INVOLVED UPPER EXTREMITY
a) Shoulder Weakness
b) Decreased Grip Strength
7) POSTURAL MALALIGNMENT
8) FATIGUE AND DECREASED ENDURANCE
9) PSYCHOLOGICAL CONSIDERATIONS
 OT evaluation and assessment

Occupational therapists establish rapport with a client by

adressing immediate needs & by understanding who this person
is, was & wants to be through his or her narrative.
The clinician needs to understand the clients-
• Medical history
• Previous response to a side effects of treatments
• Prognosis
• Current & potential impact of the disease and performance
areas
Occupational therapy evaluation should consist of
• Demographics
Name
Age/sex
Address
Occupation
Diagnosis
Date of evaluation
• chief complaints
• history of present illness:
onset: When patient first noticed lump/symptom
Progression: Increase in size? Pain developed later?
Associated symptoms: nipple retraction, bleeding/discharge, skin involvement, arm swelling
Date of surgery
Side involved (right/left/bilateral
Wound healing status (infection, delayed healing, scar issues)
Ongoing or completed: chemotherapy, radiotherapy, hormonal therapy
Any acute side effects (nausea, vomiting, fatigue, mucositis, skin burns, hair loss)
• past history
• family history
• medication
• personal history
• On observation
1. General built and nourishment
2. Posture
3. Pain
4. Oedema
5. Scar
Site
Extend
Healed/unhealed
Skin colour
• On palpation
1. Tenderness
2. Edema
3. Temperature
4. Scar mobility- adherent/ non adherent
- scar length
• On testing
1. ROM ( Range of motion)
2. MMT ( Manual Muscle Testing)
3. ADL scale- ( OPD- FIM Scale , IPD- Barthal Index Scale)
4. Sensation
5. Hand function test
6. Girth measurement or volumetric measurement for lymphedema
7. Vocational evaluation –( occupation, type of work ,work environment )
8. Psychological evaluation
OCCUPATIONAL THERAPY
GOALS:-
• Early rehabilitation may play an important role in preserving
function and returning the patient to her previous level of
activity. The main goal are :-
• Restore pain free ROM
• Assist in preventing oedema.
• Scar management
• Pain management
• Help to restore self – esteem.
• Help to restore patient to previous vocations.
MANAGEMENT
POST OPERATIVE PHASE ( immediate – first few weeks)
• Rapport building
- talk, develop confidence, educate patient about present
concerns.
• Psychological counseling
- helping the patient for acceptance of condition.
- psychological adjustment by providing education and
psychological support.
-interdisciplinary patient education involving all aspect of
potential impairments and functional limitations such as edema.
• Prevent post operative pulmonary complications and
circulatory complication.
Post operative instruction in deep breathing, emphasizing
maximum inspiration and effective coughing.

• Prevent postural deformities

Posture awareness training
Encourage the patient to maintain an erect posture when sitting
or standing to minimize rounded shoulder posture.
Posture exercises with an emphasis on scapular retraction
exercises.
• Lymphedema prevention
1. Positioning encourages patient to keep her arm in
abduction (about 30°) and external rotation. A pillow
may be used.
2. Wearing compressive garments while exercising.
3. Avoid wearing clothing that restrict circulation such as
sleeves with tight elastic bands. Do not wear tight
jewelry such as rings or watches.
4. Avoid hot environment or use of local heat.
5. Pumping exercises of the arm on the side of the
surgery. Early ROM exercises.
• To increase ROM or prevent restricted mobility of upper
extremity.
The following exercises should be done 3 times a day. Exercise only
till the level of patients endurance and it should be 10 repetitions of
each:-

a) active assistive and active ROM exercises start with hand wrist
elbow progressing to shoulder as soon as possible but cautiously
usually on first post operative day.
b) Over Head Reach
c) Reach
NOTE:- Exercise maybe initiated even when the drainage tubes and
sutures are still in place.
• Increase Muscle Strength:
Muscle strength of patient can be increase by giving
Resistive Active exercises initially against minimal and later
moderate resistance.
Use of involved extremity for light functional activities.

• Energy conserving techniques:

Ask patient to take frequent breaks during any activity.
Any new task should be simplified before starting It.
Group similar task together.
Do not overplan a day
 REHABILITATION PHASE
• Continue ROM and strengthening exercises
• Continue work simplification and energy conservation techniques
• Scar Management:
-Keep surgical site clean and dry.
-Give massage with any kind of moisturizer or oil. It will provide lubrication to the skin and will
flatten the Scar.
-Massage the scar gentlly in
1. Linear motions: Massage along the length of the scar to reduce skin tension.
2. Circular motions: Use circular movements to break down scar tissue and promote better
alignment.
3. Cross-friction motions: Gentle massage perpendicular to the scar to improve mobility and
break up adhesions.
-Frequency and duration:
Massage for at least 10 minutes, twice a day, for several months. You may need to adjust the
duration and pressure based on your scar’s sensitivity.
-Compression garments
• Pain Management:
Ask the patient to take proper rest.
Use of different modalities like TENS to reduce the
pain.
Deep breathing exercises.
• Vocational rehabilitation
Graded return to work program
Workplace modification.
Eg place all required objects below shoulder level so
that patient does not need to reach overhead iin case of
restricted ROM
Educating employer/family about patient’s limitations and abilities.

• Home Program / Patient Education

Daily exercise schedule for ROM & strengthening.
Lymphedema precautions.
Energy conservation strategies.
Self-care strategies for independence.
Importance of follow-up OT session to prevent further
complications.
• Prosthesis
It has a great positive impact on women’s self –esteem and an
overall sense of well being. There are three types available:-

a) SIMPLE SPONGE PROSTHESIS:- it can be given

immediately after surgery. This can be clubbed inside with
sterile gauge to prevent any injury to the site of incision.
b) LATEX:- this can be fitted once the wound is healed. It can
be fitted inside innerwear or can be worn by itself. It is
washable and suitable for Indian climate.
c) SILICON PROSTHESIS:- it gives a feeling of normal
breast which is most sophisticated .
Lymphodema management
• Elevation:
Gravity plays a role in lymphedema symptoms. You should
try to keep the affected area of your body elevated as much
as possible.
• Compression garments:
Compression garments may be socks, sleeves or wraps that
have pressure to move fluid from your tissues into
circulation. This reduces swelling and your risk of
lymphedema complications.
• Manual lymphatic drainage (MLD)
1. It involve slow very light repetitive stroking and circular
massage movement done in specific sequence with
involve extremity elevated whenever possible.
2. Proximal congestion in the trunk, groin, buttock axilla is
cleared first to make room for fluid from more distal
area.
3. The direction of the massage is towards specific lymph
node and usually involve distal to proximal stroking.
4. This method is extremely labour and time intensive,
methods of self massage are taught to the patient as
soon as possible in a treatment program.
• Exercise Regimen
1. Deep breathing and relaxation exercises
Abdominal diaphragmatic breathing assist in the movement of
lymphatic fluid as diaphragm decent during the deep
inspiration and abdominal contract during a control maximum
expiration.
2. Flexibility exercises
Gentle self stretching exercises particularly in proximal areas
that may contribute to static posture and lymph congestion to
minimize soft tissue and joint hypomobility.
3. Strengthening and muscular endurance exercises
both isometric and dynamic exercises using self resistance,
elastic resistance and weight.
Cardiovascular conditioning exercises
30 minutes of aerobic endurance exercises
Activities such as upper extremity ergometry, swimming
cycling and walking increase circulation and stimulate
lymphatic flow.
Lymphatic drainage exercises
Refer as pumping exercises
Active repetitive ROM exercises are perform throughout the
session
• Total body relaxation
• Posterior pelvic tilt and partial curl ups
• Unilateral knee to chest movements
• Cervical ROM.
• Scapular exercises.
• Active circumduction of arm.
• Exercises on a foam roll.
• Bilateral hand press.
• Unilateral arm exercises with arm elevated.
• Bilateral horizontal abduction adduction.
• Overhead wall press.
• Wrist and finger exercises.
• Partial curl ups.
• Raised in supine position with involved arm elevated on
pillow for 30 minutes after completing exercise sequence.
Body Image Training in Breast Cancer
Introduction
• Breast cancer and its treatments (mastectomy, lumpectomy,
chemotherapy, radiation) often alter physical appearance.
• Patients may experience scarring, loss of breast tissue, alopecia
(hair loss), lymphedema, fatigue, and weight fluctuations.
• These changes can lead to body image disturbance, low self-
esteem, depression, and social withdrawal.
• Occupational therapists address these issues through structured
body image training programs.
OT Interventions in Body Image Training

A) Psychoeducation & Counseling Support

• Educating patient about normal emotional reactions post-treatment.
• Normalizing grief, anger, or shame about body changes.
• Encouraging open expression of feelings in therapy.

B) Mirror Therapy & Gradual Exposure

• Guided exercises for looking at scars or surgical area in the mirror.
• Done step-by-step to reduce fear/avoidance and increase comfort.

C) Prosthesis & Cosmetic Training

• Educating on external breast prosthesis and proper fitting of mastectomy bras.
• Training in use of wigs, scarves, makeup techniques, or skin-care routines post-
radiation.
D) Role Play & Social Skills Training
• Practicing conversations for handling questions in
social/public settings.
• Building confidence in returning to work, family gatherings,
and community life.
E) Relaxation & Body Awareness
• Techniques like progressive muscle relaxation, yoga,
breathing exercises,guided [Link]-based mindfulness
to reconnect with the body without judgment.
F) Group Therapy
• Psychologic and Emotional Aspects of Living
With Cancer

People with cancer may face social, psychological, and

emotional challenges that affect daily functioning.

Acquaintances may avoid them due to fear, stigma, or

misconceptions (e.g., thinking cancer is contagious).

Many people, regardless of stage, assume they are

dying – but survival rates are improving.
Coping & Pain
• Coping skills are vital to manage stress and the painful side
effects of treatments like surgery, chemotherapy, radiation, and
metastasis.
• Techniques such as meditation, self-hypnosis, and occupational
therapist–guided relaxation have been shown to improve daily
functioning and quality of life.

Support Groups
Support groups provide emotional strength and a sense of shared
experience.
Studies show that even patients with advanced cancer, such as
women with stage IV breast cancer, lived better and longer when
involved in support groups, as social support positively influences
both mental health and immunity.
• Reference
1. Pedretti’s Occupational Therapy: Practice Skills for
Physical Dysfunction 7th edition
2. Therapeutic Exercise Textbook by Carol Kisner 5th edition
3. [Link]