According to the American Academy of Physical Medicine and Rehabilitation (2011), physical medicine and rehabilitation, or physiatry, is the branch of medicine emphasizing the prevention, diagnosis, and treatment of disorders, particularly those related to the nerves, muscles, bones, and brain. Physiatry is concerned with quality of life, with a focus on function. Rehabilitation physicians, or physiatrists, may also perform electromyograms and subspecialize in a number of areas, including pediatrics, sports medicine, palliative care, spinal cord injury, and pain management. Physiatry is a relatively new specialty; the American Board of Physical Medicine and Rehabilitation was formed in 1947.

Cancer rehabilitation has become increasingly important in the young field of physiatry. The major goal of cancer rehabilitation is to improve quality of life by minimizing the disability caused by cancer and its treatment and decreasing the “burden of care” needed by cancer patients and their caregivers (Fu and Shin 2011). Dietz (1980) classified cancer rehabilitation into four categories: preventive, restorative, supportive, and palliative.

Preventive rehabilitation occurs before or immediately after a treatment to prevent loss of function or disability. An example of preventive rehabilitation is teaching a patient with a lower-extremity sarcoma about stump care and walker ambulation prior to amputation. Courneya and Friedenreich (2001) described a concept called “buffering,” in which a cancer patient performs exercises and undergoes therapies to increase physical and functional reserves before treatment. The concept of “prehabilitation” is similar to preventive rehabilitation.

Restorative rehabilitation occurs in patients who are believed to be disease-free or in whom a stable disease course is anticipated. An example of this is postamputation prosthetic rehabilitation in a patient with a lower-extremity sarcoma and no known metastatic disease. Preventive and restorative cancer rehabilitation are not substantially different from conventional nononcologic rehabilitation. However, as cancer survivorship has increased, restorative rehabilitation has become more prominent. Issues commonly addressed include disability, return to work, and lymphedema management.

Supportive and palliative rehabilitation occur in patients whose disease has not been fully cured. Supportive rehabilitation is performed in patients with persistent ongoing disease. Palliative rehabilitation is done to reduce discomfort and improve independence in patients with advanced disease (Dietz 1980).

Improvements in cancer survivorship over the past two decades have largely been due to improved detection, surgeries, chemotherapeutic agents, and radiation therapies (Kevorkian 2009). Improved survival has led to increasing attention to the quality-of-life implications of cancer and its treatment. Physiatry’s emphasis on quality of life and return of function has made it an important piece of cancer survivorship care. The definition of a cancer survivor can include a broad range of patients; this chapter will focus on restorative rehabilitation in cancer survivors with no evidence of disease who are not undergoing active treatment. However, many of the concepts and topics discussed here are applicable to cancer survivors receiving ongoing treatment as well. We will discuss the issues that a physiatrist encounters in the cancer survivor population.

Chronic pain is a common symptom in the general population but it is very pervasive in the cancer population. Chronic pain is the third largest global health problem, the most common cause of disability in the United States, and the second most common reason for physician visits (Greenberg et al. 2003). Sixty percent to 85% of patients with advanced cancer and 40% of 5-year cancer survivors report pain (Caraceni 2001; Nelson et al. 2001). When assessing pain in this patient population, physiatrists should never overlook the possibility of cancer recurrence or metastasis. A conscientious physical examination is invaluable. Imaging studies such as x-rays can also often be useful to evaluate the possibility of bony metastasis.

Fatigue is the most common symptom in patients with cancer (Zeng et al. 2012), and physiatrists often encounter complaints of fatigue and deconditioning among cancer survivors. There are many causes of fatigue in cancer survivors, and workup is similar to that used for patients complaining of fatigue who do not have cancer. However, deconditioning, depression, inadequate nutrition, chronic pancytopenia, infection, hormonal changes (such as adrenal insufficiency after prolonged use of steroids or testosterone deficiency after treatment for testicular cancer), and medications are among the most common causes of fatigue in cancer survivors. The standard laboratory panel used to assess chronic fatigue at the MD Anderson fatigue clinic includes complete blood count, electrolytes, blood urea nitrogen, creatinine, calcium, magnesium, phosphorus, thyroid-stimulating hormone, free T4 cortisol, vitamin B12, vitamin D, and C-reactive protein. Testosterone and prostate-specific antigen levels are also tested in men.

A self-perpetuating cycle may develop in which fatigued patients avoid activity to reduce fatigue, but the reduced activity leads to worse deconditioning and fatigue (Winningham et al. 1994). An important step to combat this cycle is to encourage activity and use therapy to insure continued activity, especially during treatment for cancer. Educating patients and caregivers regarding the importance of staying active is just as valuable as therapy. Patients should be encouraged to sit in a chair whenever possible and avoid lying in bed for extended periods of time during the day. Keeping blinds open to help maintain sleep-wake cycles and avoiding excessive napping may also help.

Cessation of sedating medications should be considered. Stimulant medications may be an option, if a reversible cause for the fatigue is not found. Methylphenidate (Ritalin) and modafinil (Provigil) have been studied as treatments for fatigue, with mixed results (Portela et al. 2011). Other treatment strategies include brief steroid boluses and other neurostimulants such as amantadine and carbidopa/levodopa (Sinemet).

Rehabilitation of patients with fatigue should focus on improving patients’ conditioning and activity. Motivation is often a difficult obstacle. Physical therapy may be useful to develop a home exercise program that the patient can maintain. Having the guidance of a therapist can be helpful, especially for a poorly motivated patient. It is important to emphasize that reconditioning takes time and persistence. Recovering from deconditioning can take up to two to three times longer than the period of deconditioning (Choi et al. 2006). Typically, the patient is advised to gradually increase the distance walked or time spent exercising. Often the analogy of training for a marathon is useful, describing the technique of gradually increasing distances, speed, and conditioning. Incorporating the patient’s hobbies into the therapy can also help motivate the patient. The effectiveness of exercise for reducing fatigue and increasing physiologic conditioning has been well studied. Exercise leads to reduced body fat, improved lean mass, increased bone mass, and increased well-being in patients with cancer (Courneya and Friedenreich 2001; Irwin et al. 2009).