Oncology rehab: Setting a new standard for cancer care

The prevailing narrative in oncology often culminates with remission, yet for many cancer survivors, this milestone marks the beginning of a new and complex phase of care. The sequelae of oncologic treatment – ranging from cytotoxic chemotherapy and radiation to surgical interventions – frequently result in persistent functional impairments that are underrecognized and undertreated within traditional cancer care paradigms.

As physiatrists, we are uniquely positioned to address the multifactorial impairments that compromise quality of life and functional independence in cancer survivors. Despite advances in oncologic therapies, a significant proportion of patients – estimated between 60% and 90% –  experience long-term physical, cognitive, or psychosocial complications. These may include neuromuscular dysfunction, fatigue, lymphedema, postural instability, and cancer-related cognitive impairment (CRCI), among others. As many as 55% to 60% of survivors report limitations in activities of daily living (ADLs), underscoring the need for comprehensive rehabilitation strategies.

“Having cancer doesn’t preclude patients from other conditions,” notes Michael Fediw, M.D., Assistant Professor of Physical Medicine & Rehabilitation (PM&R) at UT Southwestern and Medical Director of its Cancer Rehabilitation program at the Harold C. Simmons Comprehensive Cancer Center. “I take a very detailed cancer history for every single one of my patients, so I can confidently tell them this is a cancer problem, this is a chemo problem, or this is a radiation problem.”

Integrating rehabilitation into the oncologic continuum of care

At UT Southwestern, oncology rehabilitation is integrated within the broader cancer care infrastructure and focuses on maintaining and restoring the highest possible functional status and quality of life to patients with cancer, at all stages of treatment through survivorship. Our care teams facilitate a seamless transition from active treatment to functional recovery. This integrated model ensures that rehabilitation interventions are personalized as informed by a detailed oncologic history, allowing for precise attribution of symptoms to specific modalities – be it chemotherapy-induced peripheral neuropathy, radiation fibrosis, or surgical sequelae.

The program leverages a multidisciplinary team that includes:

• Oncologists with disease-specific expertise
• PM&R physicians with subspecialty training in neurologic and musculoskeletal rehabilitation
• Electrodiagnostic capabilities for evaluation of neuromuscular complications
• Interventional procedures for pain management, including nerve blocks and chemodenervation
• Behavioral health and psycho-oncology support services

This infrastructure enables tailored interventions that address the heterogeneity of post-treatment impairments.

Personalized functional restoration

Rehabilitation plans are individualized at UT Southwestern, reflecting the unique constellation of impairments each patient presents. Comprehensive assessments encompass:

• Neuromuscular strength and endurance
• Balance and coordination deficits
• Dysphagia and dysarthria
• Cognitive dysfunction (e.g., attention, memory, executive function)
• Mood disorders and sleep disturbances
• Nutritional status and physical activity levels
• Vocational and ADL reintegration challenges

By synthesizing these domains, physiatrists can identify subtle or underreported deficits that may not be captured in routine oncologic follow-up. This holistic approach enables the formulation of targeted rehabilitation strategies that not only restore function but also enhance long-term survivorship outcomes.

Electrodiagnostics for neuropathy
Neuropathic pain is a common complaint from cancer patients, as nerve damage often occurs from a tumor pressing on a nerve, surgical treatments, or other unrelated conditions. To trace the nerve symptoms to the source, we use ultrasound and electrodiagnostic testing such as:

• Nerve conduction studies (NCS), where small electrical shocks are applied to specific nerves to record their signals and see how well information travels along them.
• Electromyography (EMG), where a thin needle is inserted into several areas of specific muscles to record electrical activity.

Once we’ve identified the dysfunctional nerves, we can apply a solution that works for the patient’s precise issue, which could involve blocking sensation to specific nerves, massage therapy, or surgery.

Botox injections for radiation fibrosis

During radiation therapy, the soft tissues around the treatment site can become inflamed, tightening the nerves, blood vessels, skin, muscles, and connective tissues until they form scar tissue. For the patient, this causes many uncomfortable issues, including pain, swelling, spasms, and limited movement, even several years after treatment.

Botox injections can relax the muscles, relieving tightness and allowing tissues to function more regularly. Combined with occupational therapy, massage, or laser surgery, it can also loosen or break down scar tissue to further relieve discomfort.

Custom orthotics for bone fragility
Even with the litany of side effects associated with oncology treatments, most cancer patients don’t expect bone weakness to become an issue. Many common cancer treatments, including radiation therapy, chemotherapy, and certain medications, can lower calcium levels or otherwise reduce bone density. Lower bone volume typically affects a patient’s gait, which can in turn lead to increased risk for fracture, joint stress, and muscle pain. The oncology rehab team analyzes a patient’s walking movements and works with orthotics specialists to recommend a custom-fitted device to prevent any further injury.

Psychological services for kinesiophobia

Beyond physical limitations, a patient may face inner psychological barriers to recovery. Kinesiophobia, a fear that movement might lead to pain or injury, can cause patients to move unnaturally after treatment and counterintuitively lead to lost stamina, additional pain, or functional limitations in other areas of the body. By training to recognize the signs of kinesiophobia, cancer rehab specialists can adapt a patient’s treatment plan to one they’re more comfortable with or recommend psycho-oncology services.

Personalized support for breast cancer

Breast cancer often requires more in-depth rehabilitation, since tumors and treatment can affect multiple body systems, particularly following a mastectomy.

“I can see 10 breast cancer patients who have postmastectomy pain,” Dr. Fediw says. “They could all have the same stage tumor on the same side with the same exact treatment, and all 10 of them could have a different reason why their chest wall or shoulder hurts.”

Women frequently struggle with multiple uncomfortable conditions after a mastectomy, most of which have readily available treatments:

• Chest wall tension and tight skin are often due to muscles constricting after surgery, painfully drawing the shoulders, head, and neck inward and restricting motion. This can be relieved through targeted stretching.
• Lymphedema, where the armpit swells after a lymph node is damaged or removed, can be treated with massage or nerve blocks.
• Brachial plexopathy, when nerves in the brachial plexus are damaged or dysfunctional following surgery, could be mitigated through physical therapy, nerve blocks, or custom orthotics.

The next essential phase of care

Advocating for cancer rehabilitation as an essential component of cancer care remains a core mission for Dr. Fediw and his fellow physiatrists at UT Southwestern. While many cancer centers focus primarily on discharging patients once they are medically stable, Dr. Fediw and his team emphasize the broader continuum of care – addressing the functional, physical, and cognitive challenges patients often face after treatment. With a strong commitment to innovation and quality, the team is advancing the field with the aim of establishing a premier center of excellence in cancer rehabilitation.