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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 1  |  Page : 22-29

Physiotherapy services for cancer patients in South India: A survey


1 Srinivas College of Physiotherapy and Research Center, Mangalore, Karnataka, India
2 Department of Radiation Oncology, Medical Director, Portea Medical, Bengaluru, Karnataka, India
3 Department of Radiation Physics, KIDWAI Memorial Institute of Oncology, Bengaluru, Karnataka, India

Date of Submission03-Dec-2017
Date of Acceptance16-Mar-2018
Date of Web Publication19-Jun-2018

Correspondence Address:
Prof. Karthikeyan Guru
Srinivas College of Physiotherapy and Research Center, Pandeshwara, Mangalore - 575 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_36_17

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  Abstract 

BACKGROUND AND AIM: Cancer is a major cause of adult deaths in India and cancer incidence is projected to grow in the coming decades because of improved life expectancy. The importance of rehabilitation in cancer care received increasing recognition in medical settings; however, very little has been documented about the involvement of physiotherapists in cancer care and rehabilitation. This exploratory paper assesses the availability of physical therapy services for cancer patients and cancer survivors in South India.
METHODOLOGY: In this explorative study, 1410 cancer patients from 15 cancer centers in three South Indian states were administered a valid questionnaire presented in their native languages. Descriptive statistics were used to analyze their responses.
RESULTS: More than half of the cancer patients (54.1%) did not know that physiotherapy treatment is required in symptom management and only one-third (31%) were advised or referred to physiotherapy treatment. Two-thirds of the respondents (68.8%) were benefited by the recommended exercises. The recommended exercises were stretching (42.9%), breathing (28.6%), and strengthening (16.9%). The most commonly used evaluation method was visual analog scale for pain (29.9%).
CONCLUSION: It is found that the number of qualified physiotherapists working in the cancer centers is not sufficient to meet the demand.

Keywords: Cancer, physiotherapy, referral pattern, rehabilitation


How to cite this article:
Guru K, Manoor U, Supe SS. Physiotherapy services for cancer patients in South India: A survey. Physiother - J Indian Assoc Physiother 2018;12:22-9

How to cite this URL:
Guru K, Manoor U, Supe SS. Physiotherapy services for cancer patients in South India: A survey. Physiother - J Indian Assoc Physiother [serial online] 2018 [cited 2018 Jul 17];12:22-9. Available from: http://www.pjiap.org/text.asp?2018/12/1/22/234691


  Introduction Top


Cancer is a major cause of adult deaths in India, with more than 70% of fatal cancers occurring during the productive ages of 30–69 years.[1] Cancer incidence will continue to grow in the country as a result of increase in life expectancy and the proportion of elderly population, and the absence of cancer screening programs.[2] Impairments commonly associated with cancer and its treatments include fatigue, pain, general deconditioning, neuropathy, and lymphedema [3],[4],[5] and increased levels of disability among cancer patients and cancer survivors.[6],[7]

Fatigue is the most common cancer-related symptom, regardless of the stage of illness and type of treatment. The patients who experienced fatigue reported greater use of healthcare services and of complementary therapies.[8] Pain can have a large impact on mobility. Deficits in range of motion (ROM) or mobility may be present in patients who have undergone surgery, chemotherapy, or radiation therapy resulting from the formation of scar tissue, disuse, or fibrosis caused by treatments.[9]

Rehabilitation in relation to cancer can be preventative, restorative, supportive, and palliative.[10] Cancer patients who are referred to rehabilitation service perform poorly on tests of physical performance compared to those in control groups.[11],[12] Thorsen et al. reported that 63% cancer survivors reported the need for at least one rehabilitation service, with physical therapy being the most frequently requested need (43%), while 40% of the participants reported that their rehabilitation needs were unmet.[13] Some patients did not encounter physiotherapy services before cancer treatment and may have met the physiotherapist only after surgery.[14]

The role of the physiotherapist in palliative care covers the respiratory, neurologic, lymphatic, orthopedic, musculoskeletal, and hematologic conditions and complications.[15] Physiotherapy may include therapeutic exercises, active or passive mobilization techniques, graded and purposeful activity, relaxation, distraction, postural reeducation, positioning, mobility, transcutaneous electrical nerve stimulation, heat or cold, and massage therapy.[16]

Cancer patients comprise 51% of those who enter hospice and palliative care settings where physical therapy treatments such as transfer and mobility training, caregiver education, pain management, and assistive device recommendations are provided to promote and maintain function.[17] The exercise training appears to be safe for most patients and improvements in physiological, psychological, and functional parameters can be attained with regular participation in moderate intensity exercise.[18] A 12-week exercise program is helpful for improving fatigue, blood pressure, insomnia, physical function, overall musculoskeletal symptoms, mental health, social support, and physical activity in cancer survivors.[19]

A physician's recommendation to exercise or the perceived approval of the physician was associated with higher level of physical activity, suggesting that health-care providers have an influential role in promoting exercise among their patients.[20],[21] Referrals by physicians, who understand the principles and methods that physiotherapists use in cancer rehabilitation, will lead to timely care and the functional return of the patient. It should also be noted that patients themselves can exert pressure on physicians to refer them to physiotherapy.[22]

The importance of rehabilitation in cancer patients is being recognized in recent times. However, there is an enormous discrepancy between the incidence of disabling physical impairments among cancer patients and the provision of medical rehabilitation services for them in developing countries. The inadequacy of the service is even more apparent when one considers the number of cancer survivors who did not receive any physiotherapy despite referral.[23] For instance, there are differences between the provision of cancer rehabilitation services during acute care and those provided for outpatients. However, the extent to which presence of advanced cancer has accentuated the magnitude of the differences between inpatient and outpatient rehabilitation service delivery is unclear.[24] It was also found that more cancer patients were dissatisfied with the quality of treatment; they received for their cancer symptoms.[8]

Collecting data on the current physiotherapy practices and services in cancer rehabilitation may be beneficial in influencing the provision of the future services and ultimately help improve patient care. The data may also lead to the development of educational and research opportunities in this geographical area. In this regard, the present study aims to assess the availability of physiotherapy services for cancer patients and cancer survivors in South India. The study also aims to describe the patient satisfaction with the available treatments and services and their reliability and efficiency.


  Methodology Top


Since India is a large country with diverse languages, cultures, and medical services, it would be an expensive and difficult undertaking to study the availability of physiotherapy treatments for the cancer patients and cancer survivors. Therefore, this exploratory research focused on three geographically contiguous South Indian states to gain an insight into the current physiotherapy practices in cancer treatment.

Participants

The population for the study was the cancer patients and survivors in cancer rehabilitation centers three states of South India which are Tamil Nadu, Karnataka, and Kerala. Total population size for the cancer patients was obtained from the hospital-based cancer registries of Bangalore, Chennai, and Trivandrum. A total of 1410 cancer patients from over 15 cancer centers around the three states were contacted. The sample size for margin of error 0.05 was obtained based on the previous literature by population-based sample size calculation method.[25]

The participants were male and female cancer patients and cancer survivors over 18 years of age who were either getting in-patient treatment from the hospitals or approached the hospitals for follow up care. Severely ill, uncooperative and mentally affected patients and those with speech and/or comprehension impairments were excluded from the study and also excluded were those who did not want to take part in the study by refusing to sign the consent forms.

Survey instrument

An earlier study to assess the physiotherapy practice pattern in cancer rehabilitation was employed a self-administered, validated, questionnaire.[10] The questionnaire had three sections and included 31 questions. All three sections consisted of a mixture of open-ended and closed-ended questions. The first section (10 questions) was related to the patients' demographic characteristics and personal details such as the disease symptoms and treatment history. The second section (13 questions) asked the patients about their physiotherapy assessment and treatment. The final section (8 questions) referred to the patients' satisfaction with services provided and their ability to use the information they had learned. The survey questionnaire was translated into three South Indian languages, Tamil, Malayalam, and Kannada and had been validated as described in a previous study by the same authors.[26] The questionnaire was approved by a panel of experts and institutional ethical committee.

Procedure

Cancer population size was determined from the cancer registries of three states: Tamil Nadu, Karnataka, and Kerala. The cancer centers, including Bangalore hospital in Bangalore, Father Muller hospital in Mangalore, Karnataka cancer institute in Hubli, Amala cancer institute in Trichur, Amrita Cancer centre, Malabar cancer centre, Regional cancer centres in Calicut and Kottayam, Government hospitals in Chennai, Ambilikai cancer centre, Govt hospitals in Kancheepuram, Trichy, Coimbatore, and Madurai and from International cancer centre in Neyyoor were contacted for the samples. Some of the centers required the presentation of the synopsis of the study to their Institute Scientific Review Boards and Ethical Committees. These organized approved the patient consent forms designed by the researchers. After permissions to contact the patients were obtained from the institutional boards and committees, the data collection was undertaken. All the participants of the study were presented with the consent forms for their signatures and agreements to participate in the study. Then, the questionnaires were administered to the participants, and the language questionnaire was chosen that was in the native language of the participants. The completed questionnaires were collected back after a couple of hours. Those patients who could not read the questionnaires were interviewed to get their responses.

Data obtained from the surveys were entered into and analyzed with SPSS (version 20.0). Frequency distributions (number and percentage) were calculated for each question. For the Likert-type scale questions, frequency distributions were calculated for each item in the question and for each level of response.


  Results Top


A total of 745 surveys were partially or fully completed and were used in the study. Some surveys were returned but were excluded from the study. The excluded questionnaires consisted of 21 incomplete questionnaires. Another 33 questionnaires were unusable because those patients were just admitted to the hospitals and did not complete any part of the cancer treatments.

Respondent demographics

[Table 1] shows the demographic characteristics of the respondents. Out of 745 patients, 435 respondents were male, and 310 were female. The mean age of the respondents was 30.51 ± 4.3 years. Nearly 565 (75.8%) respondents were receiving inpatient treatment, and 180 (24.2%) were receiving outpatient treatments. The number of patients from Tamil Nadu were 281 (37.7%), 253 (34.0%) were from Kerala, and the remaining 211 (28.3%) were from Karnataka. The cancers for which the respondents were getting treatment for were Head and Neck cancer (22.2%), breast cancer (20.1%), pelvic organ cancer (15.0%), abdomen cancer (13.6%), bone cancer (13.0%), and lung cancer (8.7%). Nearly 71% of the patients were suffering from cancer for more than 1 year while the rest (29.1%) were aware of their cancer symptoms for < 1 year. The number of patients who were admitted to the hospital for the first time was 127 (17.1%), 327 (43.9%) patients were visiting the hospital for regular treatments, 124 (16.6%) patients came for the treatment for recurrent symptoms, and 167 (22.4%) came for follow-up care. The number of patients who experienced severe pains was 572, and the remaining 173 did not experience any pain before seeking the cancer treatment.
Table 1: Demographic characteristics of the respondents

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Cancer symptoms and treatments

The most common cancer-related symptoms reported by the respondents were fatigue (37.2%) where the patients were tired and weak, lymphedema (15.8%), general weakness (15%), cough (12.8%), muscle pain (12.1), and shortness of breath (10.5%). The least common symptoms experienced by the patients were joint pain (5.4%), fracture (3%), back/neck pain (2.4%), paralysis (1.6%), and decreased sensation (0.3). Around 6.4% of patients reported difficulty in sleeping, walking and doing daily activities, and other symptoms. However, 54.4% of the respondents were unable to identify their cancer-related symptoms.

Among those participants who received anticancer treatments, 701 received radiotherapy, 618 received chemotherapy, and 311 underwent surgeries. At the time of the survey, a number of patients were continuing to receive treatments. They included 307 patients who were receiving chemotherapy, 423 were receiving radiotherapy, 77 patients were scheduled for chemotherapy, 210 were on waiting list for radiotherapy, and 72 were scheduled for the surgery.

Physiotherapy treatment for cancer patients

Over half of the respondents (54.1%) did not know that physiotherapy treatment is beneficial in cancer-related symptom management while 25.4% knew that it was required and the remaining respondents (20.5%) thought that physiotherapy was not required in the cancer-related symptom management [Table 2].
Table 2: Physiotherapy treatment knowledge among cancer patients

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How did physiotherapy help the patients? The responses from 189 patients who said physiotherapy was required in cancer-related symptom management helped in the following areas: reduced pain (40.7%), reduced swelling (27%), improved quality of life (QOL) (20.1%), improved physical function (1.6%), and helped in all areas (two patients). The remaining 10.1% respondents did not know how exactly physiotherapy helped.

More than two-thirds of the patients (514, 69%) were not referred to physiotherapy to treat their cancer-related problems while the remaining 231 patients (31%) were indeed advised/referred to physiotherapy. Among those patients referred for the physiotherapy, swelling was the most common symptom (30.7%) followed by muscle tightness/breathing difficulty (22.5%), joint stiffness (20.8%), and difficulty in activities of daily living (ADL) (16.9%), pain (11.7%), general weakness (7%), and other problems (4.8%). Further, a quarter of respondents (25.5%) had taken physiotherapy for chest-related symptoms followed by the shoulder (21.2%), head and neck (20.4%), and abdomen (17.3%). Lower back, knee, hip, and ankle and foot regions were treated the least [Graph 1].



A majority of the patients (50.7%) received physiotherapy by physician's referral, 42.4% were referred to by surgeons, 3.9% were referred by physiotherapists, and 3% of the patients went directly to the physiotherapists. The types of physiotherapy treatments received by patients are [Graph 2]: stretching (42.9%), breathing exercises (28.6%), strengthening (16.9%), massage (13.9%), and aerobic exercises (10.8%). The least commonly provided treatments were advice on ADL (6.9%), electrotherapy modalities (6.1%) and manual therapy (0.9%). A few of the patients were referred to departments/services other than physiotherapy. These services included diet therapy (34.2%), yoga/meditation (7.4%), and speech therapy (2.2%). The remaining 58.4% of the patients were not referred to any other therapies.



Monitoring

Out of 231 patients who received physiotherapy treatments, 71 patients said that physiotherapists evaluated their problems completely, 94 said they were evaluated only partially, and 66 patients were not evaluated by the physiotherapists before their cancer treatment.

The parameters evaluated before and after the physiotherapy treatment for the patients are presented in [Graph 3]. Out of 231 patients received physiotherapy, 96 stated that edema was measured (41.6%) followed by ROM (30.7%), heart rate (21.2%), strength (13.4%), blood pressure (11.7%), and respiratory rate (11.3%). The least common evaluation parameters were ADL (9.1%), fatigue, and QOL (5.2%). More than half of the patients (51.1%) were not evaluated using any of these parameters before receiving the physiotherapy treatment.



The parameters used to evaluate the patients before their physiotherapy treatments included visual analog scale (VAS) for pain (29.9%), goniometer (16%), sphygmomanometer (11.7%), reflex hammer (6.5%), questionnaire (5.2%), and stethoscope (2.2%). However, more than two-thirds (73.2%) of the patients were not evaluated by any of these parameters before subjecting them to physiotherapy treatments.

After the physiotherapy treatments, the parameters which were used to monitor the progress of the patients included VAS for pain (34.2%), goniometer (29%), sphygmomanometer (10.8%), questionnaire (7.4%), and stethoscope (2.2%). As in the case of prephysiotherapy treatment, a majority of patients (64.9%) were not evaluated using any of these measures after their physiotherapy treatments [Table 3].
Table 3: Physiotherapy monitoring methods used in the treatment for cancer patients

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Professional approach and satisfaction

To assess the professional approach of the therapists toward their patients and the patient satisfaction toward the care they received, eight items based on Likert scale scoring system were used [Table 4]. These items are satisfaction by physiotherapists' explanations (55.4%), treatments (63.6%), advices on lifestyles (44.2%), patient health after physiotherapy (48.5%), physiotherapists' consideration (72.3%), and attitude (68.8%). These factors helped patients' rehabilitation. Even the acceptance of positive benefits of the exercises (68.8%) and idea of referring to the known cancer patients to get physiotherapy (58.4%) also were agreed by most of the patients. At the same time, few respondents reported that they disagree such things in their part of their rehabilitation.
Table 4: Patients' Response towards the physiotherapy treatment and approach

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  Discussion Top


Cancer rehabilitation has received relatively little attention in Indian physiotherapy research and education. Evidence indicates that physical exercise has the potential to improve QOL for those undergoing cancer treatment,[20],[27] but little is known about exercise promotion within cancer rehabilitation services.[28] The number and type of cancer survivors who might benefit from physiotherapy interventions are unclear as the research on this subject is sparse. This study presents novel data about current perceptions of the cancer patients and cancer survivors on the role of physiotherapy in cancer rehabilitation patients in south India.

The response rate in this study was 100% as we have adopted in-person survey/interview for the survey. More than 75% of the total individuals were approached in the inpatient departments of various cancer centers in South India. However, the results indicate that 69% of participants were never referred to the physiotherapy treatment for their cancer-related symptoms and treatments. As the percentage is more, to avoid any bias, the cancer patients who had been referred till now only were allowed to fill the questions regarding the physiotherapy treatment modalities for the impairments.

The survey found that only a few physiotherapists were exclusively working in the cancer centers. This could be a reason for the smaller number of cancer patients receiving physiotherapy treatment as a part of their cancer rehabilitation. In South India, a majority of the major cancer centers are operating without physiotherapy departments or qualified physiotherapists on staff. The reasons for the underrepresentation of physiotherapists on staff in cancer centers, despite huge cancer patient load, are not unclear.

Individuals undergoing cancer treatment often develop functional deficits from pain, movement restrictions, fatigue, lymphedema, skin and soft tissue breakdown, and difficulty breathing.[29] The problems that occur in relation to the cancer disease and its treatment vary with the type of cancer, disease stage, and type of medical treatment. Difficulties may develop in the period between diagnosis and primary treatment, during primary treatment, and during follow-up.[30] Most of the respondents in this study reported fatigue, lymphedema and general weakness, and breathing difficulties.

Regarding the knowledge about physiotherapy in cancer rehabilitation, only 25.4% of the respondents were aware of physiotherapy treatment in cancer rehabilitation and most of them reported that physiotherapy helped to reduce pain, swelling, and to improve their QOL. Likewise, most of the respondents among those referred for physiotherapy had suffered from swelling, breathing difficulty, soft-tissue tightness, pain, joint stiffness, and difficulty in ADL which were indicated for physiotherapy management. It is known that physiotherapy in oncologic rehabilitation helps in restoring function, reducing pain, reducing disability, increasing conditioning and mobility, and ultimately improving QOL.[31]

The most common interventions used in cancer rehabilitation were strengthening, ROM, energy conservation, and breathing treatments.[32] A Canadian survey suggested that most of the patients preferred to receive exercise counseling face-to-face from a specialist affiliated with a cancer unit.[33] The availability of specialized physiotherapy services resulted in significantly higher functional levels on follow-up assessment.[34] Regarding interventions, larger numbers of patients received stretching, strengthening exercises, breathing exercises, ROM exercises, and chest clearance techniques. At the same time, patient education on ADL, electrotherapy modalities, and aerobic exercises were least commonly used for the rehabilitation. A change in the functional component of QOL and significant improvements in fatigue, pain, and appetite were noted in patients who received optimized levels of physiotherapy time and resources.[34]

Individuals who undergo chemotherapy or radiation treatments are at risk for developing cardiovascular and pulmonary toxicities and therefore require monitoring of vital signs to assure safety during physiotherapy interventions.[35] Among the respondents, 28.6% were not evaluated by the physiotherapists for their symptoms for which they have been referred. Pain, edema, ROM, and heart rate were most commonly measured as a monitoring procedure while 51.1% were not monitored using any of the monitoring procedures. More importantly, 73% patients were never evaluated before the beginning of the physiotherapy treatment and about 64.9% patients were never evaluated after the completion of physiotherapy treatment.

Physiotherapy may influence patient satisfaction in cancer rehabilitation setting. It involves physical contact and the therapy requires the patient's active participation. The patient-therapist interaction often takes longer than a routine medical visit; however, the therapy may cause pain and may be perceived as physically threatening. It is known that the efforts are required to improve exercise compliance in cancer patients.[36] The provision of early intervention and community follow-up may contribute significantly to the functional independence, patient satisfaction, and QOL among patients requiring palliative care. A physiotherapist to inpatient ratio of 1:12 is recommended to produce such results.[34]

Patient satisfaction is a crucial aspect of the quality of cancer care,[37] and patient satisfaction is increasingly used to monitor the quality of healthcare services.[38] In this study, eight items were used to investigate the patient satisfaction toward the physiotherapy treatment in cancer rehabilitation. The increased time available to the physiotherapist to patient would have influenced the ability to ensure understanding of advice and instructions by the patients.[39] This study reports that most of the patients who received physiotherapy were satisfied with the therapists' professional approach. Only a few of them were dissatisfied with the approach, treatment, and behavior of the physiotherapists. Likewise, only a few patients did not think that exercise and physical activity were beneficial to them. This study had some limitations regarding generalizations from this study to other geographic locations are restricted as it is done only in South India that too only three limited states.


  Conclusion Top


Although individuals with oncology-related functional deficits appear to benefit from physical therapy interventions, this study found some shortcomings regarding referral and delivery of the physiotherapy treatment. The commonly used treatment modalities in cancer rehabilitation and the professional approach by the physiotherapists practicing in South India appear to be effective. However, monitoring physical and physiological parameters of the cancer patients during and after the physiotherapy treatment in South India were inconsistent.

It is found that the availability of the physiotherapy departments and numbers of qualified physiotherapists working in the cancer centers is inadequate considering the increasing demand for their services for cancer patients. It is surprising that some regional cancer centers in South India do not have physiotherapy facilities and staff to serve their patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  Introduction
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