Best Uses of Physical Medicine and Rehabilitation in Patients with Cancer

A Q&A with Val Jones, MD, Medical Director of Admissions, Saint Luke’s Rehabilitation Institute, Spokane, WA

Originally published February 1, 2017

Q: Your principal practice in Spokane, Washington is physical medicine and rehabilitation (PM&R). What do you find to be the best uses of PM&R in patients with cancer at your facility?

A: Rehabilitation medicine is one of the best-kept secrets in healthcare. Although the specialty is as old as America’s Civil War, few people are familiar with its history and purpose. Born out of compassion for wounded soldiers in desperate need of societal re-entry and meaningful employment, “physical reconstruction” programs were developed to provide everything from adaptive equipment to family training, labor alternatives and psychological support for veterans.

Physical medicine and rehabilitation (PM&R) then expanded to meet the needs of those injured in World Wars I & II, followed closely by children disabled by the polio epidemic. In time, people recognized that a broad swath of diseases and traumatic injuries required focused medical and physical therapy to achieve optimal long term function. Today, cancer patients frequently benefit from comprehensive rehabilitation as they recover from the effects of chemo (neuropathy, weakness, and cognitive impairments), radiation (scarring and range of motion limitations), surgery (flaps, plastics procedures, tumor resection, amputations), and brain injuries (edema, debulking, gamma knife and neurosurgery). Continue reading…


Cancer Pain and the Opioid Epidemic

A Q&A with Kevin Sevarino, MD, PhD, President-elect of the American Academy of Addiction Psychiatry and Consulting Psychiatrist at Gaylord Hospital in Wallingford, CT

Q: Opioid abuse, addiction, and overdose are huge American problems right now. Many cancer patents experience chronic pain. What is the best way to use opioids to manage chronic pain?

[Note: The views expressed below represent the opinion of the author, and do not necessarily reflect the views of the American Academy of Addiction Psychiatry nor those of Gaylord Hospital.]

A. We live in amazing times. Targeted immunotherapies, stem cell transplants of transfected cells, identification of unique molecular targets in cancer cells through differential gene expression profiling—all promise to expand survival rates (or cures!) with diminished adverse effects compared to the “blunt hammer” approach of chemotherapy, radiation treatments, and more. Continue reading…


Radium-223 Benefits Survival, Not Just for Palliative Care

“Despite what many believe, not all radiopharmaceuticals are just for pain palliation, says Phillip J. Koo, MD, a radiologist of Memorial Hospital and University of Colorado Hospital.

“The ALSYMPCA trial, which was the basis for the 2013 FDA approval of radium-223 dichloride (Xofigo) showed a median overall survival (OS) of 14 months with radium-223 versus 11.2 months with placebo (HR, 0.70; P = .00185) in patients with metastatic castration-resistant prostate cancer (mCRPC).

“Despite the fact that it has been 3 years since the pivotal ALSYMPCA trial and the coinciding FDA approval, many oncologists still need to be educated regarding radium-223’s benefits, says Koo.”


Short-Course Palliative RT Cuts Cancer Pain

“Short-course palliative radiotherapy provided pain relief equivalent to that of conventional protocols, and allowed patients with advanced cancer to spend more time at home, investigators reported.

“Half as many patients underwent more than five treatment sessions and hospital length of stay decreased by 50% following implementation of a palliative radiation oncology service. At the same time, significantly more patients completed the planned course of radiotherapy, which resulted in a trend toward better pain relief.”


Doctors Often Overtreat with Radiation in Late-Stage Lung Cancer

“Almost half of patients with advanced lung cancer receive more than the recommended number of radiation treatments to reduce their pain, according to a new study published in the Journal of the National Cancer Institute.

“Radiation therapy that is palliative, or not intended to cure, can reduce the pain from  and improve quality of life. But unnecessary treatments add to costs and require needless trips to the hospital—and can lead to radiation toxicity and difficulty in swallowing.

“Guidelines developed from clinical trials recommend no more than 15 radiation treatments be given for pain in stage 4 . The guidelines recommend that patients not receive chemotherapy at the same time, to reduce the risk of toxicity.”


When Pain Persists After Breast Cancer Surgery

“I could hear the anxiety in my sister’s voice. A week after her double mastectomy and breast reconstruction for breast cancer, she had developed a burning sensation under her right arm where her surgeon had removed several dozen lymph nodes for a postoperative biopsy. The throbbing and itching were so intense it felt ‘like poison ivy lit by a blowtorch.’ ”

“The physician assistant at her reconstructive surgeon’s office told her it was probably “neuropathic in origin” — probably arising from nerve damage during surgery — and that the condition, known as postmastectomy pain syndrome, or PMPS, would subside over time. And luckily for my sister, five weeks out from surgery, the pain began to wane.

“But for many of the estimated 20 to 50 percent of women who develop pain after a mastectomy, it may never go away.”


Dabrafenib plus Trametinib Improves Health-Related Quality of Life in Metastatic Melanoma

“The addition of trametinib to dabrafenib improved health-related quality of life and reduced pain in patients with BRAF V600-mutated metastatic melanoma, according to results of a randomized phase 3 study.

“The combination of dabrafenib (Tafinlar, GlaxoSmithKline) and trametinib (Mekinist, GlaxoSmithKline) received accelerated approval from the FDA in 2014 based on the results of a phase 1/2 study that compared the combination with dabrafenib monotherapy. Results from a phase 3 trial later demonstrated significantly improved PFS and objective rate response with the combination vs. dabrafenib monotherapy in patients with BRAF V600 metastatic melanoma.

“In the current analysis, Dirk Schadendorf, MD, of the department of dermatology at the University Hospital Essen in Germany, and colleagues sought to evaluate the effect of the combination on health-related quality of life among patients treated in the phase 3 study.”


One in 3 Women Could Potentially Be Spared Chronic Pain after Breast Cancer Surgery

“One in every three women undergoing a mastectomy could potentially be spared chronic post-operative pain if anesthesiologists used a regional anesthetic technique in combination with standard care, according to a new study.

“Standard care for mastectomies is a general anesthetic, whereby anesthesiologists use gas to keep the patient asleep and narcotics to control pain. Up to 60 per cent of women may experience chronic pain three months after they’ve had the surgery and at least half of those will still suffer from this pain one year later

” ‘Sadly, the pain these women experience can be so severely debilitating that it may require treatment by a pain specialist and pain killers,’ said Dr. Faraj Abdallah, lead author of the study and an anesthesiologist at St. Michael’s Hospital.

“The regional anesthetic technique Dr. Abdallah examined when added to standard care -called ultrasound-guided paravertebral blocks- is similar to a dental freeze. Trained anesthesiologists use a local anesthetic to freeze nerves in the breast area. Paravertebral blocks allow excellent pain control immediately after surgery and help with long-term pain reduction.”


Women's Pain: Common, Treatable and Often Overlooked or Mismanaged

“Despite the variety of effective treatments, and physicians who specialize in treating pain, women often suffer unnecessarily from conditions ranging from backaches to pain after cancer surgery, and also treat their pain with medications that may be ineffective and possibly harmful, according to a review of research related to women and pain by the American Society of Anesthesiologists® (ASA®).

“ASA conducted the literature review and issued the Women’s Pain Update to help raise awareness of the many options available to women for controlling both acute and chronic pain, and how a pain medicine specialist can help them choose the right treatment. Among other things, the studies showed that remedies such as music, yoga and rose oil are proven effective for several types of pain, that opioids are often used inappropriately, and that the type of anesthesia used during breast cancer surgery can affect how quickly and comfortably a woman recovers from the operation.

“Physician anesthesiologists are doctors who focus on anesthesia and critical care medicine and are among the medical specialists who are experts in the subspecialty of pain medicine, seeing patients in private practices and pain clinics.”