REHABILITATION THERAPY

Rehabilitation therapy in lung cancer treatment can help patients maintain and restore physical and emotional well-being more quickly and more fully. A self-management rehabilitation program is structured to motivate and support patients to adopt positive health practices and to develop skills to better manage their illness.

Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is a comprehensive, evidence-based, multidisciplinary program designed to assist patients with lung cancer who are having difficulty with breathing and activities of daily living (ADLs). The primary objective of a PR program is to restore individual patients to as independent a level of function as possible with an improved health-related quality of life.

Most PR programs involve a respiratory therapist, occupational therapist, physical therapist, and dietitian. Physicians, pharmacists, and nurses may also be involved. PR programs are delivered in inpatient, outpatient, clinic, physician office, telehealth, and home settings. PR programs include assessment, exercise therapy, education, and psychological support. Some PR programs continue for an extended time, but most run for a few weeks and then provide patients individualized instructions for continuing at home.

The benefits of PR include maximizing the patient’s functional status and reducing healthcare costs by promoting self-management of symptoms. Evidence has shown that dyspnea symptoms improve in patients with lung cancer who undergo a PR regime. PR is also proven to be a cost-effective treatment model that reduces the number of hospital readmissions, although it cannot be substantiated that PR extends the life of patients with lung cancer (Harding et al., 2020).

PROGRAM PLANNING

PR programs are tailored to the needs of the individual patient. The number of sessions per week, need for nutritional counseling, need for psychological support, and need for oxygen supplementation are determined after a careful assessment of the patient’s capabilities and desired goals. The best possible benefits occur in a PR program lasting six to eight weeks. There is no evidence of any additional benefits from expanding the program to 12 weeks’ duration (GOLD, 2019).

PATIENT AND FAMILY EDUCATION

Patient and family education are central to all PR programs. In these education sessions, patients and their families learn details about lung cancer and its treatment. Education informs the patient and family in how to self-manage the disease in collaboration with the various PR disciplines. Education topics may include understanding chronic lung disease, medications, breathing control, oxygen therapy, heart health, falls prevention, diagnostic tests, and advance care planning. Increasing patient knowledge leads to essential behavior changes, although education alone does not improve outcomes (GOLD, 2019).

EXERCISE TRAINING

Pulmonary rehabilitation seeks to optimize the functional status of a patient with lung cancer via supervised, progressive exercise training and collaborative and supported self-management. Patients diagnosed with lung cancer are usually—though not always—older adults with both extensive smoking history and poor cardiopulmonary fitness. Physical inactivity related to lung cancer can lead to exercise intolerance, skeletal and respiratory muscle wasting, and decreased functional endurance.

Appropriately selected and supervised exercise is considered safe and valuable for most patients with cancer regardless of age or stage of life. While exercise does not improve lung function, it can reduce symptoms and increase exercise tolerance. Exercise has been shown to improve muscle strength/tone, range of motion (ROM), endurance, and lung capacity, and it may reduce hospitalizations for acute exacerbations. Exercise may also promote weight loss and anxiety reduction, as well as improve heart rate and blood pressure (Zeng et al., 2018; Garcia et al., 2016).

Exercise training in a pulmonary rehabilitation setting may be supervised by physical therapists, occupational therapists, exercise physiologists, advanced practice nurses, or other appropriately trained clinicians. Exercise type, frequency, and duration are individualized to patient needs, with clinicians monitoring patient status during exercises, determining when patient regimens should be advanced, and assessing patient progress. Typically, PR programs include multiple components, as described below:

• Aerobic exercises, such as walking or stationary bicycling (usually 3x/weekly). A regimen might begin with slow treadmill walking for a few minutes, with gradual increases as tolerated.
• Strength training, utilizing either free weights or machines to provide resistive exercise. Initially, a repetition range of 8–12 may be appropriate, with incremental increases added when the current workload can be performed for one to two repetitions. Recommended training frequency is approximately 2–3 days/week (Zeng et al., 2018).
• Endurance training may reduce lung hyperinflation, exertional dyspnea, and muscle dysfunction in patients with lung cancer, while promoting heart rate recovery. Endurance training, such as walking, cycling, and upper extremity exercises (if tolerated), may slow the progression of activity intolerance in patients with lung cancer (Zeng et al., 2018).
• Supplemental oxygen may be indicated during exercise for patients who experience severe exercise-induced hypoxemia. Oxygen saturations should be monitored in patients with supplemental oxygen dependency. Increased flow rates may enable oxygen-dependent patients to exercise longer and with less dyspnea.
• Ongoing support and encouragement are important components of any patient care regimen, including PR. Counseling and periodic check-ins (via e-mail, phone, or text) may help patients stay motivated and feel supported. When a functional plateau is reached in the clinical setting, patients may be assigned a home-based maintenance program (including activities such as stretching, weight training, or stationary cycling).

Occupational Therapy (OT)

Occupational therapy is an important aspect of rehabilitation following lung cancer treatments and improves quality of life. OT focuses on symptom management, reduction of fatigue, respite from shortness of breath, activities of daily living, pain management, mental health, quality of life, return to work, and resumption of community participation, as applicable. OT can be conducted in a variety of venues along the healthcare continuum, including general or specialty hospitals, rehabilitation centers, hospice units, and the home.

There is strong evidence that exercise plans set up and supervised by OTs reduce cancer-related fatigue and improve the quality of life for the patient (see “Exercise Training” above). Interventions such as problem-solving and energy conservation can reduce breathlessness and allow patients to better tolerate increases in exercise and activities. Pain management is another category in which OTs work with patients via improved sleep and exercises to further improve their quality of life (Hunter et al., 2017a; White, 2016).

ASSESSMENT AND PLANNING

OTs begin with a detailed assessment and history-taking of the patient in order to develop an individualized plan of care. Established assessment tools and tests include:

• Model of Human Occupation Screening Tool (MOHOST), to identify and measure possible occupational dysfunction, including motor skills, employment, and communication
• Canadian Occupation Performance Measure (COPM), a standardized occupational profile to focus the patient on self-measurement of occupational progress
• Brief Fatigue Inventory (BFI), to measure cancer-related fatigue that may be related to pain
• Rivermead Behavioral Memory Test (RBMT), to evaluate everyday memory tasks such as names of objects, facial recognition, and recall
• Activity Measure for Postacute Care (AM-PAC), a quick assessment to measure postacute discharge outcomes
• Worker Role Interview (WRI), to explore psychosocial and environmental concerns regarding returning to work
  (Braveman et al., 2017)

ACTIVITIES OF DAILY LIVING

The need for assistance with activities of daily living (ADLs) (bathing, eating, ambulation, dressing, and grooming) may be partial or complete as well as temporary, rehabilitative, or permanent. Certain reductions in capabilities due to confusion, fatigue, weakness, or difficulty in transferring can affect the patient’s ability to perform ADLs effectively.

Patient preferences are paramount in the use of rehabilitation to improve their execution of ADLs. Patient involvement in planning ADL interventions provides buy-in and often encourages the patient to work harder for success.

Depending on the circumstances, the family and/or caregiver(s) may also need to be educated and trained to assist the patient with ADLs. A well-trained family or caregiver may be more successful than healthcare staff because of their familiarity with the patient. Availability of such caregivers may allow the patient to be discharged earlier. Having the family assist with ADLs may also be a cultural consideration.

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Occupational therapy may also address instrumental activities of daily living (IADLs) (i.e., tasks that require more complex cognitive abilities such as shopping, check-writing, cooking, housecleaning, doing laundry, taking medications, accomplishing transportation, using communication devices, home maintenance, etc.).

OTs play a vital role in helping a patient with lung cancer return to work, perform housekeeping duties, manage medications, and more. For instance, high-intensity exercise that includes strength training, interval training, and a home-based exercise program after discharge from the hospital may help to minimize any decrease in the patient’s abilities. Depending on the type of work the patient does, the OT will design exercises, suggest adaptive devices, and promote increased endurance so that the patient is able to return to work (Hunter et al., 2017b). (See also “Exercise Training” above.)

ENERGY CONSERVATION

Energy conservation assists patients in minimizing muscle fatigue, pain, and stress on involved joints. Moderating activities and ensuring a sufficient amount of rest also help patients to maintain function. Setting up the environment to make carrying out ADLs and work-related performance extends the patient’s ability to function and maximizes comfort. These changes promote independence and allow the patient to continue to be able to accomplish their desired goals throughout each day and until the end of the day (Duke University, 2020).

HEALTH PROMOTION

A health promotion program can help patients maximize their ability to perform the activities that are meaningful, enjoyable, and necessary to them. The best health promotion program serves to prevent dysfunction; promote and enact a healthy lifestyle; and facilitate recovery from injury, disease, or developmental deficits. Health promotion can improve physiologic and psychological concerns related to cancer and prolong life. Elements of health promotion programs as taught by occupational therapists include skills training in socialization, caregiving, parenting, time management, activities organization, and stress management (ALA, 2021).

SLEEP THERAPY

Sleep deprivation is a common problem for patients with cancer and may be related to stress, pain, and the physical effects of the disease and its treatments. Lack of sleep is a possible cause of automobile accidents, workplace accidents, increased healthcare visits, poor work productivity, and diminished quality of life. Occupational therapists assess and address the implications of sleep insufficiency in patients (AOTA, 2021).

Assessing the sufficiency of patient’s sleep involves evaluating difficulties in sleep preparation; sleep participation; and how long it takes to fall asleep, sleep duration, the ability to stay asleep, or daytime sleepiness.

Work, shift work, school, caregiving responsibilities, pain, and excessive fatigue may affect the ability to sleep well. Disturbances in balance, vision, strength, skin integrity, and sensory systems are also contributing factors. Psycho-emotional status, including depression, anxiety, and stress, may prevent patients from falling and staying asleep. Substances such as caffeine, nicotine, drugs or alcohol, smoking, or certain medications may need to be withheld to improve sleeping patterns (AOTA, 2021).

Occupational therapists use the following interventions to help patients prevent sleep deprivation:

• Educating clients and caregivers on sleep misconceptions and expectations
• Addressing secondary conditions that may precipitate diminished sleep quality (e.g., pain, decreased range of motion, depression, anxiety)
• Encouraging health management behaviors such as smoking cessation, reduced caffeine intake, a balanced diet, and adequate exercise
• Establishing predictable routines, including regular times for waking and sleeping
• Managing pain and fatigue
• Addressing performance deficits or barriers to activities of daily living, particularly for bed mobility and toileting
• Establishing individualized sleep hygiene routines (e.g., habits and patterns to facilitate restorative sleep)
• Teaching cognitive-behavioral and cognitive restructuring techniques, such as leaving the bedroom if awake and returning only when sleepy, or exploring self-talk statements regarding sleep patterns
• Increasing coping skills, stress management, and time management
• Addressing sensory disorders and teaching self-management or caregiver management
• Modifying the environment, including noise, light, temperature, bedding, and technology use while in bed
• Advocating on a state or national level for laws that protect workers from excessive work schedules that threaten their health or public safety
  (AOTA, 2021)

Smoking Cessation

Smoking cessation is the most important measure a patient can take preoperatively to prepare for lung cancer surgery and prevent complications postoperatively. Since the vast majority of patients with lung cancer have some history or current use of cigarettes, smoking cessation is prioritized, particularly if the patient is to undergo surgical resection. Coughing and secretion production will improve and be much less of a problem postoperatively.

Counseling and medications are effective in assisting a patient with smoking cessation. Information about telephone helplines and brochures can be given to the patient and family or caregiver(s) to support stopping smoking. Non-nicotine medication such as oral varenicline (Chantix) acts as an agonist at the nicotine receptors to ease the withdrawal symptoms. The antidepressant buproprion (Zyban) causes a reduction in the urge to smoke and reduces some withdrawal symptoms. Nicotine replacement medications may be used, such as Nicorette gum, Nicotrol nasal spray, or Habitrol or NicoDerm skin patches. Organized cessation programs can be effective. These include hypnosis, acupuncture, behavioral interventions, aversion therapy, group and individual therapy, and self-help opportunities.

Most smokers resume smoking within three months of quitting. Therefore, it is important to teach ex-smokers to identify their own triggers that might cause them to resume smoking. These could be drinking alcohol (which lowers inhibition), being around other smokers, having cigarettes or other smoking devices easily available, stress, or depression (Harding et al., 2020).

Nutritional Therapy

A patient with lung cancer tends toward submaximal weight and body size for many reasons. The disease itself can cause a loss of appetite based on symptomatic ill-feelings. Malignant cells and the body’s other cells are in competition for nutrients. Cancer treatments such as chemo- and radiation therapy may cause anorexia, nausea and vomiting, and altered taste. These all interfere with the patient’s ability to take in a sufficient amount of nutrients. Patients with malnutrition have an increase in morbidity and mortality.

A stable nutritional status promotes healing and improves a patient’s quality of life. A registered dietitian (RD) can provide dietary recommendations based on the patient’s food preferences, other dietary needs, and individual caloric requirements. These recommendations are shared with any caregivers who may be responsible for shopping and cooking for the patient.

Systemic therapies are more likely than other treatments to cause nausea and vomiting, depending on the particular medication and dose. Higher doses are not tolerated as well. The symptoms can start immediately or up to 24 hours after the dosage has been completed. Radiation therapy affects the epithelial cells lining the GI tract, causing GI symptoms such as anorexia, diarrhea, intestinal stricture, xerostomia, and pain. Targeted therapies and immunotherapy also have nausea and vomiting as an adverse effect.

Therefore, a patient with lung cancer who is undergoing these therapies requires special attention to maximize their intake of necessary fluids and nutrients. A special protein and calorie-rich diet can be set up for the patient, prioritizing their food and drink preferences to encourage them to eat and drink more. Chilled foods and drinks are often more palatable, as are frequent, small portions and snacks (ACS, 2020c; Potter et al., 2019).

The patient’s participation in food-related activities such as shopping, cooking, and meal preparation can also minimize the risk of disease progression and resultant disability. The federal Supplemental Nutrition Assistance Program (SNAP) is one source of financial aid available to ensure the patient has access to an adequate amount of healthy food. The patient may need additional assistance beyond financial support, such as help with transporting, preparing, and cooking food, to promote optimal nutritional intake. These needs are often addressed by the occupational therapist (Juckett & Robinson, 2019).

Integrative Oncology (IO)

Integrative oncology is a holistic therapy that combines traditional medical cancer treatments such as surgery, systemic therapies, and radiation therapy with alternative therapies such as yoga, meditation, music therapy, support groups, journaling, tai chi, and crafts. Alternative therapies are often effective for preventing and treating nausea, joint and other pains, lack of sleep, and loss of appetite. These therapies can also relieve stress in patients and their families. Nutritional therapy (see above) is an important part of integrated oncology and is included in the patient and family education (Ironwood Cancer & Research Center, 2020).

ACUPUNCTURE

Acupuncture is a traditional Chinese therapy that extends back thousands of years. Multiple thin, sterilized, solid needles the diameter of a hair are carefully inserted into points along the body’s meridians (energy channels) to stimulate healing energy known as qi or chi, according to Chinese medical theory. Acupuncture sites can also be stimulated by heat (moxibustion), acupressure, friction, suction (cupping), and electromagnetic energy impulses. Accessing this flow of energy is believed to make acupuncture treatments effective.

However, an invasive procedure such as acupuncture may be contraindicated where there is an active cancer.

While some consider the practice to be controversial, National Institute of Health (NIH) studies have demonstrated that acupuncture is evidence-based and effective in treating a wide range of conditions:

• Nausea caused by surgical anesthesia and systemic therapies
• Dental pain after surgery
• Addiction
• Headaches
• Menstrual cramps
• Tennis elbow
• Fibromyalgia
• Myofascial pain
• Osteoarthritis
• Low back pain
• Carpal tunnel syndrome
• Asthma
  (JHM, 2020b)

MASSAGE

Massage is deep or superficial pressure over skin, muscles, tendons, and ligaments for relaxation of the body parts. Examples of massage therapy include Swedish, deep tissue, sports, and trigger point. Massage has been found to be effective for:

• Anxiety
• Digestive disorders
• Fibromyalgia
• Headaches
• Insomnia related to stress
• Myofascial pain syndrome
• Soft tissue strains or injuries
• Sports injuries
• Temporomandibular joint pain
  (Mayo Clinic, 2020c)

It is possible for massage to cause deleterious effects on patients with deep vein thrombosis (DVT) because of the possibility of dislodging the clot, patients with bleeding disorders, patients on anti-coagulation therapy because of an injury causing bleeding, and patience with burns, skin wounds, severe osteoporosis, bone fractures, and thrombocytopenia.

YOGA

Yoga is recognized for its ability to promote physical and mental well-being. Different aspects of yoga include physical postures (asanas), breathing techniques (pranayama), and meditation. Yoga performed by patients has the benefit of contributing to mental health, quality of life, improved sleep, and a greater sense of well-being. It also contributes to deep relaxation and decreases stress (Hunter et al., 2017a).

Yoga can be used to:

• Treat low-back pain and neck pain
• Relieve menopause symptoms
• Manage anxiety or depressive symptoms associated with difficult life situations (but yoga has not been shown to help manage anxiety disorders, clinical depression, or posttraumatic stress disorder [PTSD])
• Help people quit smoking
• Help people who are overweight or obese to lose weight
• Improve quality of life
  (NIH, 2020a)

GUIDED IMAGERY

Guided imagery is a concentrated type of relaxation that balances the mind and body. In this practice, the imagination is used to create calm, peaceful images in order to provide an escape from worries or stress. Guided imagery may:

• Enhance coping skills
• Lower and regulate heart rate
• Lower blood pressure
• Lower and improve respirations
• Provide inner strength, hope, and courage
• Promote relaxation
• Help control pain
  (Cleveland Clinic Foundation, 2020)