An Oncology Physical Therapist Explains Why Movement Matters Most During Cancer Treatment

When someone is diagnosed with cancer, the instinct for patients and loved ones alike, is often to slow down and rest. But according to oncology physical therapist Dr. Leslie Waltke, that instinct can work against recovery. In this interview, Dr. Waltke explains how multidisciplinary care teams can identify patients who need intensive rehab support before treatment even begins, why the words "take it easy" can do more harm than good, and what's really standing between cancer patients and the physical therapy that could improve their outcomes.

Cure: How can a multidisciplinary team identify high-risk patients who need intensive physical therapy versus those who can follow a generalized exercise protocol before surgery or systemic therapy?

Waltke: "With the multidisciplinary team, it's really important that everybody is asking the question: who is at high risk? I'll start by saying that anyone exposed to surgery, chemotherapy, or radiation is going to be at high risk for loss of musculoskeletal, cardiopulmonary, and functional strength — so everyone should get a rehab consult.

"But identifying high-risk people ahead of time, where medical intervention may cause them to lose their functional status — where they can't go home, or can't get up the stairs, or need a lot of outside help — it's important to pull those people out. We're looking for people who may live alone, who are over the age of 75 to 85, or who have physical, functional, or metabolic comorbidities that put them on the edge of losing independence.

"We want everybody to think about exercise ahead of time, but are we pulling out the people who need to see a physical therapist before we start treatment, to make sure they're safe at home — that they can remove their rugs, that they have a support system both physically and functionally? We want to make sure that when we begin these pretty intensive treatments, they have the functional stability and safety to do it, so they don't end up back in our ED or back in the hospital."

How can a multidisciplinary team deliver a unified message that overcomes a patient's instinct to rest, and how should fatigue be assessed during treatment?

"I think there's this really unique presence of psyche when somebody's diagnosed with cancer — 'there's something wrong with me, I'm going to break, I shouldn't move.' People just close down, young, old, all types of people, and people who have been active and have exercised almost always suddenly just stop.

"I think some of the most damaging words in healthcare are 'take it easy.' People say it just to protect patients from potential things. Family members say it because they want to help, 'let me do that for you, I can do that for you', and that just perpetuates the thought of 'there's something wrong with me, I'm going to break if I try something.' We know that movement, activity, exercise, and rehab are all good for people, and it's exceptionally important for people in cancer care.

"We also know from research that when physicians and nurses say the word 'exercise,' the word 'activity,' people are ten times more likely to do it. So incorporating that language into conversations from the very beginning, with the pathologist, the radiologist, everyone matters. 'I know this is happening to you. There may be movement restrictions from surgery or after getting your port in, but we need to keep you moving. Movement is good, movement is healthy.' That message needs to infuse through the entire team, along with bringing a physical therapist in from the beginning, around the time of diagnosis, so people know: 'I'm going to put you through a triathlon, but I've got somebody to make sure you stay strong, that you stay healthy, and that movement is okay.' Because once people start moving, it feels good, it gives them power and some control over their symptom package.

"The team loves it too. When somebody comes in for surgery after neoadjuvant chemotherapy and the patient is strong and healthy, I love it. It's good for everyone, and it's good for the team as well, because it gets them moving too."

What barriers to access exist for patients trying to do rehabilitation and exercise after treatment, and how can they be addressed?

"Barriers to rehabilitation are way more perceived than they are actual. There's obviously a preponderance of evidence that rehab is good for people with cancer, and we all know that if you have a stroke, you go to physical therapy. If you have a knee replacement, you go to physical therapy. People don't automatically associate cancer with physical therapy, and we need to change that. That's literally barrier number one.

"Barrier number two is that many oncology professionals and physicians medical oncologists, radiation oncologists, surgeons don't get a lot of physical therapy education in medical school. That's a barrier, because they don't know the breadth and depth of what a rehabilitation therapist can provide their patient. And on the flip side, physical therapists and occupational therapists don't get a lot of oncology training either. So there's a major gap where we have two fantastic healthcare groups that don't fully know what the other one does, and patients are falling down the middle. Combine that with patients not associating rehab with cancer in the first place, and those are the biggest barriers we really have.

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