Cancer Rehabilitation Assessment

Perspective
LS Gilchrist, PT, PhD, is Associate A Framework for Assessment in

Professor, Doctor of Physical Ther-
apy Program, College of St Cather-
ine, 601 25th Ave S, Minneapolis,
Oncology Rehabilitation
Downloaded from https://academic.oup.com/ptj/article/89/3/286/2737735 by guest on 07 September 2021

MN 55454 (USA), and Clinical Re-
Laura S Gilchrist, Mary Lou Galantino, Meredith Wampler, Victoria G Marchese,
search Scientist, Children’s Hospi-
tals and Clinics of Minnesota, Min- G Stephen Morris, Kirsten K Ness
neapolis, Minnesota. Address all
correspondence to Dr Gilchrist at:
[email protected]. Although the incidence of cancer in the United States is high, improvements in early
diagnosis and treatment have significantly increased survival rates in recent years.
ML Galantino, PT, PhD, is Professor
of Physical Therapy, Richard Stock- Many survivors of cancer experience lasting, adverse effects caused by either their
ton College of New Jersey, Pomona, disease or its treatment. Physical therapy interventions, both established and new,
NJ, and Adjunct Research Scholar, often can reverse or ameliorate the impairments (body function and structure) found
University of Pennsylvania, Philadel- in these patients, improving their ability to carry out daily tasks and actions (activity)
phia, Pennsylvania.
and to participate in life situations (participation). Measuring the efficacy of physical
M Wampler, PT, DPTSc, is Physical therapy interventions in each of these dimensions is challenging but essential for
Therapist, Harrison Medical Cen- developing and delivering optimal care for these patients. This article describes the
ter, Bremerton, Washington.
acute and long-term effects of cancer and its treatment and the use of the World
VG Marchese, PT, PhD, is Assistant Health Organization’s International Classification of Functioning, Disability and
Professor, Department of Physical Health (ICF) as a basis for selection of assessment or outcome tools and diagnostic or
Therapy, Lebanon Valley College,
screening tools in this population.
Annville, Pennsylvania, and Assis-
tant Professor of Pediatrics, Penn
State Hershey College of Medi-
cine, The Pennsylvania State Uni-
versity, Hershey, Pennsylvania.
GS Morris, PT, PhD, is Director of

Clinical Research in Rehabilitation
Sciences, The University of Texas
MD Anderson Cancer Center,
Houston, Texas.
KK Ness, PT, PhD, is Assistant

Member, Department of Epide-
miology and Cancer Control, St
Jude Children’s Research Hospital,
Memphis, Tennessee.
[Gilchrist LS, Galantino ML, Wam-

pler M, et al. A framework for as-
sessment in oncology rehabilita-
tion. Phys Ther. 2009;89:286 –306.]
© 2009 American Physical Therapy

Association
Post a Rapid Response or

find The Bottom Line:
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286 f Physical Therapy Volume 89 Number 3 March 2009

Assessment in Oncology Rehabilitation
C
ancer has a high incidence in tion interventions designed to re- influence how and when such rou-
the United States, where 46% store the integrity of organ structure tine measures are used. Thus, the
of all males and 41% of all fe- and function, to remediate func- second purpose of this article is to
males can expect to develop either tional loss, and to adapt to the envi- provide greater understanding of
an invasive or in situ cancer.1 An ronment so as to allow full participa- the clinical issues common to the
estimated 1.4 million new cases of tion in daily activities and life roles. oncology population. Collectively,
cancer are diagnosed each year, with In the current medical environment, we hope to improve clinical care,
nearly 13,500 of these cases occur- demonstrating treatment efficacy by facilitate communication across dif-
ring in individuals younger than 20 means of quantifiable outcome mea- ferent rehabilitation disciplines, and
years of age.2 In years past, survival sures is increasingly important. As encourage further study in the area
following a diagnosis of cancer was such, the expansion of interventions of oncology rehabilitation.

problematic; however, dramatic provided to patients with cancer and
progress in the ability to diagnose survivors of cancer must be accom- The ICF Function
cancers earlier and to provide more- panied by the appropriate applica- Classification Framework
effective and targeted treatments has tion of new and existing measures. The ICF was developed by the
led to substantial increases in sur- Because the information generated World Health Organization24 to pro-
vival. The National Cancer Institutes by these tools may be seen by many vide a framework to describe health
Surveillance, Epidemiology, and End health care professionals and can ex- and health-related states and to sug-
Results Program estimates that 65.3% tend across broad spans of time, the gest standardized language to de-
of adults diagnosed with cancer be- utility of such information is greatest scribe these states. The ICF frame-
tween the years 2001 and 2005 will when it is presented within a framework (Figure) is increasingly being
survive for at least 5 years.1 In addi- work of standardized language and used in the rehabilitation field and
tion, about 80% of people younger concepts. Such a framework can be has recently been endorsed by the
than 19 years of age who are diag- found in the International Classifi- American Physical Therapy Associa-
nosed with cancer today are ex- cation of Functioning, Disability tion (APTA) House of Delegates for
pected to survive for 5 years or long- and Health (ICF).24 This classifica- incorporation into all relevant Asso-
er.1,3 All told, an estimated 10 million tion system is designed to describe ciation publications, documents, and
people are living in the United States health and health-related status from communications.25
today who have or have had a diag- biological, personal, and societal per-
nosis of cancer.1 As the population spectives. Disorders across the do- Based on the work of Nagi,26,27 the
ages and treatments improve, these mains of body structure and func- ICF model shifts the focus of disable-
numbers are expected to continue to tion, activities, and participation are ment from cause to impact, from dis-
rise. Currently available medical in- referred to as impairments, limita- ability to health and function, and
terventions for cancer are designed tions, and restrictions, respectively. from a static process to a dynamic
to eliminate or control disease by “Functioning” is an umbrella term process.24,28 As stated previously,
suppressing cell growth (chemother- that encompasses these 3 domains. the ICF defines 3 domains of human
apy, irradiation) or directly removing Health conditions or disease states, function (Figure): body function and
the tumor (surgery).4 –15 These treat- personal factors, and the environ- structure, activity, and participation.
ments may lack specificity and can ment interact with these constructs Body function and structure refers
damage normal tissue.16 –19 Thus, to determine whether disordered to the anatomical and physiological
cancer is no longer an acute disease, functioning will result in disability.24 function of the body systems, and
with mortality as the primary out- these body functions and body struc-
come. Rather, treatment successes The primary purpose of this article is tures are categorized into the sub-
have made cancer a chronic disease, to use the ICF framework and its domains listed in the Figure. Deficits
with many survivors developing sig- language to describe outcome mea- in this domain are called “impair-
nificant sequelae to either the dis- sures and diagnostic screening tools ments” (eg, muscle weakness, re-
ease itself or to the treatment.20 –23 that the rehabilitation therapist will stricted joint motion, poor cardio-
find useful in assessing patients with respiratory fitness) and often are
Oncology rehabilitation has long an oncology diagnosis. Some of these identified, measured, and treated by
been a part of the management of outcome measures may be new to physical therapists. The activity do-
cancer, but with increased survivor- therapists; others may already be main describes the ability of an indi-
ship, these efforts have evolved from part of their routine assessment. vidual to perform specific tasks such
simple supportive and palliative care However, factors unique to a diagno- as sweeping the floor, raking the
to now include complex rehabilita- sis of cancer or to its treatment may yard, or putting away groceries. Dec-
March 2009 Volume 89 Number 3 Physical Therapy f 287


Figure.
International Classification of Functioning, Disability and Health (ICF) model24 modified for populations of people with cancer. Modified
and reprinted with permission of the World Health Organization from: International Classification of Functioning, Disability and Health:
ICF. Geneva, Switzerland: World Health Organization; 2001.
rements in the activity domain are school, or work; on the athletic field; develop unresolved peripheral neu-
called “limitations” and describe the or in any community setting. The ropathy and ankle weakness,31 this
difficulty an individual has perform- activity and participation subdo- patient may have a limited ability to
ing a particular task.24 Physical ther- mains are given as a single list (Fig- walk (limitation) and may require
apy goals often are aimed at revers- ure), and their use will be discussed long-term use of an ankle brace. Lim-
ing or normalizing such activity in the “Measurement of Activity and ited ability to walk could result in an
limitations. The participation domain Participation” section of this article. employment restriction for a fire-
describes the ability of a person to fighter, but not for a computer pro-
be involved in life situations. Partic- In the ICF model, health conditions, grammer. Participation restrictions
ipation restrictions describe the re- personal factors, and the environ- occur when activity limitations can-
duced ability of a person to maintain ment interact dynamically across the not be sufficiently overcome to
normal role functions and interact 3 domains of body function to help maintain role functions in the per-
with society.24,29,30 Physical therapy determine whether disordered func- son’s normal environment.29,30
interventions are designed, directly tion results in disability. For exam-
or indirectly, to enhance participa- ple, if a cancer treatment (eg, che- Formal work is emerging that uses
tion levels for every client at home, motherapy) causes a patient to the ICF classification scheme to de-

scribe overall function of popula- view the primary goals of the inter- The therapist also will want to select
tions who have specific chronic vention and determine how these an instrument that is capable of de-
health conditions, including, but goals fit into the ICF domains. That tecting change resulting from an in-
not limited to, multiple sclerosis,32 is, which of the ICF domains is the tervention (responsiveness).51 In-
stroke,33,34 osteoarthritis,35 diabetes,36 intervention intended to affect? If struments that place individuals into
low back pain,37 obesity,38 osteo- the intervention is designed to make a limited number of categories,51
porosis,39 and rheumatoid arthri- a change at the tissue level, then the such as the Functional Indepen-
tis.40,41 This growing body of litera- appropriate measure would assess a dence Measure,52 tend not to be re-
ture uses the ICF framework to specific change at the body function sponsive because very large changes
identify measurements relevant to a and structure level. For example, a are required to move from one cate-
specific illness. The ICF Core Sets patient with restricted shoulder mo- gory to another. Additionally, instru-

provide clinicians and researchers bility (decreased range of motion ments should not have a ceiling ef-
with comprehensive but concise mea- [ROM]) after a mastectomy may be fect. If many respondents initially
surement categories that describe a treated with a regimen of stretching score at the highest level, there is no
patient’s global function from a bio- and scar tissue mobilization where room for improvement, and change
psychosocial view. Some investiga- the intended outcome is lengthened will not be detected.51
tors42– 46 have used the ICF Core Sets tissue, making ROM an appropriate
as the comparison standard for the measure. By increasing ROM, this It is important to understand that the
assessment of function and disability intervention also may improve the psychometric properties of validity
when evaluating the content of a patient’s ability to reach overhead, for diagnostic and screening mea-
previous or newly developed mea- making certain daily tasks possible sures are different than for outcome
surement tool. (an activity-level measure), which, in measures.53 Clinicians need to know
turn, may increase the patient’s abil- how accurate the diagnostic tool is
A limited number of ICF Core Sets ity or willingness to engage in life in identifying the presence or ab-
have been developed for patients activities such as work or education sence of the target condition. Often
with head and neck cancer47 and (a participation-level measure). In a new tool is compared with a gold
breast cancer.48 Although the ICF this example, outcome measures at standard, and its validity is described
Core Sets have not been widely used each level would be appropriate, and using sensitivity and specificity. Sen-
in the US physical therapy or oncol- such information would speak to the sitivity, often referred to as a “true
ogy communities, the ICF frame- efficacy of the intervention across positive rate,” is defined as a test’s
work is a useful model for describ- functional domains. ability to correctly identify the target
ing global function in patients with condition when the target condition
a new or previous cancer diagno- Selecting an outcome measure also is present. A high sensitivity is desir-
sis.49 Consideration of the interac- requires consideration of the psy- able, as it will rarely miss someone
tion among cancer as a health condi- chometric properties of the instru- who has the condition. Specificity
tion, impairments in body function ment or tool the therapist is plan- describes a test’s ability to identify
and structure, activity limitations, ning to use. Validity, reliability, and those without the target condition
and participation restrictions in the responsiveness are 3 properties the who really do not have the target
context of the person and the envi- therapist should consider.51 The condition, a “true negative rate.” If
ronment are essential to the design measure should make sense (face an instrument has a high specificity,
of an effective oncology rehabilita- validity), be accepted by experts in then this instrument will rarely test
tion intervention.50 the field (content validity), and cor- positive when a person does not
relate with an expected outcome have the disease (ie, a low chance of
Selecting Appropriate (predictive validity) and with other false positive predictions).
Measures measures that evaluate the same con-
In this article, we describe measures struct (concurrent validity). The in- In this article, we provide examples
as potential descriptors of particular strument should yield the same re- of measures that are relevant to par-
ICF function domains. We encour- sults (reliability) when repeated by ticular impairments, limitations, and
age therapists to use this schema to separate examiners (interrater reli- restrictions experienced by patients
assist them in deciding which mea- ability), by the same examiner on the with cancer or survivors of cancer.
sures to include in their baseline, same patient (intrarater reliability), The list is not exhaustive and is not
continuing, and final outcome assess- or on separate occasions within a restricted by documented reliabil-
ments of their patients and clients. time period when no changes would ity, validity, or responsiveness of the
To do this, the therapist should re- be expected (test-retest reliability). particular instrument; however, it

does include instruments commonly though an array of more-complex of balance for patients with these
used by physical therapists, some and detailed neuropsychological tests impairments (see the “Neuromuscu-
specifically developed for oncology are available to measure the various loskeletal and Movement-Related
populations. When choosing a mea- domains of cognitive function, infor- Functions and Structures” section
surement tool, the therapist should mation is lacking regarding the sen- for more information on balance
investigate its psychometric proper- sitivity and specificity of the tests to measures).
ties in relation to the population of detect changes in cognitive function
interest. The references given in from chemotherapy. The identifica- Treatment-induced peripheral nerve
Tables 1, 2, and 3 provide a starting tion of sensitive neuropsychological impairments are common. Several
point for those searches. tests is crucial to further understand- chemotherapy drugs (ie, taxanes,
ing of chemotherapy-induced cogni- platinum agents, vinca alkaloids, and
Measurement of Body

tive impairments.71 thalidomide) can damage peripheral
Function and Structure axons and nerve cell bodies.76
The specific tests and measures used Emotional functions also may affect Chemotherapy-induced peripheral
by the physical therapist to measure the ability of a patient to participate neuropathy (CIPN) is characterized
body function and structure in pain the physical therapy interven- by sensory impairments, including
tients with a cancer diagnosis often tion. A tool that has been used to paresthesias, dysesthesias, decreased
are not unique to the assessment of evaluate emotional functions in pa- touch thresholds, decreased vibra-
this population. However, these tients with cancer is the Profile of tion thresholds, and reduced deep
measures provide relevant informa- Mood States.72,73 This self-report in- tendon reflexes.77–79 As CIPN wors-
tion about cancer-related impair- strument is easy to use and may pro- ens, muscle weakness and limb
ments, prognostic considerations, vide insight into our patient’s ability movement disorders, such as foot
and safety factors. This section high- to respond to and participate in a drop, may develop and require the
lights some common cancer-related physical therapy program. use of an orthosis. Multidimensional
changes in body function and struc- tests, such as the modified Total
ture and suggests some appropri- Sensory Functions and Pain Neuropathy Scale, may be benefi-
ate measurement tools for assessing Table 1 (Sensory Functions and Pain) cial in fully describing the severity
these impairments. describes several potential measures of CIPN (Tab. 1).77,80,81 Anesthesia
for vestibular, somatosensory, and or dysesthesias may occur when
Mental Functions pain impairments. These impair- compression or surgical dissection
Mental functions (Tab. 1, Mental ments are common in patients who of a nerve occurs.82 Radiation plex-
Functions), although not the primary are undergoing cancer treatment or opathies also may occur but are
interest of most physical therapists, have a history of cancer. much less common, as radiation
play an important role in determin- oncologists have developed tech-
ing how best to interact with and pro- Hearing and vestibular functions niques to shield delicate neural
vide interventions for our patients. can be affected by tumor growth or structures.83
Both radiation and chemotherapy by chemotherapy. Although audi-
can alter the structure and function tory impairments are infrequently Many patients with cancer, particu-
of the central nervous system and targets of physical therapy assess- larly those with advanced or meta-
may result in impaired mental func- ment, vestibular impairments and static disease, have increased levels
tion in patients during or follow- their relationship to balance dysfunc- of pain.84 Cancer-related pain may
ing treatment for their cancer.54 – 65 tion should be considered. Vestibu- arise from the tumor itself or as a
Specific mental function sequelae, lar schwannoma, a relatively rare be- side effect of treatment. Some forms
including impaired memory and dif- nign tumor, can impair vestibular of cancer are inherently more pain-
ficulty with sustained attention (con- function, usually unilaterally. Cispla- ful, specifically any cancer originat-
centration), may be evident years tin, a chemotherapy drug used to ing in or metastasizing to the bone.
after treatment.58,66 Proposed mech- treat many types of tumors (eg, lung, Pain can have a large impact on mo-
anisms for these impairments include breast, ovarian) has been associated bility, and some researchers have
chemical toxicity, oxidative damage, with both vestibular toxicity and even established cut-points for mod-
inflammation, and destructive autoim- ototoxicity.74,75 Tests of vestibular erate and severe pain based on its
mune responses.67– 69 The Mini-Mental function can help physical therapists interference with daily activity.85
State Examination70 is a simple tool for document change during or after Evaluation of pain in this population
screening mental functions and has treatment (Tab. 1). It also is impor- is essential and should be multifac-
been used by physical therapists. Al- tant for therapists to use a measure eted (Tab. 1, Pain). Although many

Table 1.
Measurement Tools for Body Function and Structure, With International Classification of Functioning, Disability and Health (ICF)
Code (Alphabetic Chapter and Numeric Second-Level Domains) in Parentheses
Representative Studies in
Populations of Patients
a
Construct Measurement Tool Measurement Characteristics With Cancer
Mental functions
Specific mental functions High-sensitivity cognitive screen An interview-based instrument Prostate cancer149
(b140–b152) designed to assess 6 major
domains of neuropsychological
performance: memory,
language, attention/

concentration, visual/motor,
spatial, and self-regulation and
planning148
Mini-Mental State Examination An 11-item questionnaire that is Brain tumor150

used to screen for dementia70
Functional Assessment of A 38-item questionnaire that All populations of patients with

Cancer Therapy–Cognitive addresses cognitive issues cancer; prostate cancer149
Function (FACT-COG) related to treatment. This
instrument assesses an array of
generic and targeted measures
and has multiple benefits,
including validity, ease of
administration and
interpretation, and global
application.151
Perceived Cognition A self-report scale that rates an Breast cancer152

Questionnaire individual’s perception of
change in cognition since the
inception of chemotherapy152
Profile of Mood States Measures 6 mood or affective Prostate cancer,153

states: tension-anxiety, advanced cancer,154
depression-dejection, breast cancer,155,156
anger-hostility, vigor-activity, non–small cell cancer,157
fatigue-inertia, and head and neck cancer158
confusion-bewilderment72,73
Sensory functions and pain
Hearing and vestibular Dizziness Handicap Inventory A 25-item questionnaire that Vestibular schwannoma160,161
functions (b230–b249) Questionnaire allows for self-assessment of the
impact of disequilibrium on
functional activity159
Computerized gaze stabilization/ A mechanical test that assesses Vestibular schwannoma161

visual acuity tests (eg, patient difficulty in coordinating
NeuroCom inVision System) eye movements with head
movements. Deficits may
indicate problems with
vestibulo-ocular reflex.162,163
Additional sensory functions Modified Total Neuropathy Multidimensional test of Breast cancer79
(b250–b279) Score peripheral nerve function79
Semmes-Weinstein Mechanical test that quantifies Breast cancer79

monofilaments touch thresholds164
Biothesiometer Mechanical test that quantifies Breast cancer79

vibration thresholds164,165
Pain (b280–b289) Visual analog scale Unidimensional measure of pain Lung cancer167
intensity166
Numeric rating scale Unidimensional measure of pain Pediatric cancers168,169; mixed

intensity86 adult population170
Faces Pain Scale–Revised171 Intensity measure appropriate for Pediatric cancers168,169

children and patients with
cognitive decline171
(Continued)

Table 1.
Continued
Construct Measurement Toola Measurement Characteristics With Cancer
Pain (b280-b289) Brief Pain Inventory Multidimensional measure of pain; Adult pain clinic participants,172
continued includes intensity and impact prostate cancer,173 bone
on function88 metastases174
Pain Treatment Satisfaction Scale A 5-item questionnaire that None

measures patient satisfaction
with pain management89
Neuromusculoskeletal

and movement-
related functions
and structures
Functions of the joints Goniometry Mechanical measure, with Breast cancer,90,91,177 head and
and bones published normal values175,176 neck cancer,92–94
(b710–b729) leukemia,178 osteosarcoma179
Sit-and-reach Performance test of generalized Lymphoma,21 breast cancer181
flexibility180
Muscle functions Manual muscle testing Standardized performance test Osteosarcoma101

(b730–b749) that measures the patient’s
ability to resist against
therapist-applied force
Handheld dynamometry Mechanical measure of force Leukemia178,182

output, with published normal
values98
Grip strength Mechanical measure of force Osteosarcoma,101 breast

output, with published normal cancer,183,184 lymphoma185
values97
Structures related to National Cancer Institute’s This scale provides standardized Uterine cancer186
movement–other Common Terminology language to describe fibrosis of
(b750–b789) Criteria for Adverse Events, tissue due to postsurgical
version 3 (Fibrosis Scale) scarring or radiation therapy121
Motor reflex functions Deep tendon reflexes A mechanical test that can be Breast cancer104
(b750) performed in isolation, but
often is included in
multidimensional peripheral
nerve tests such as the Modified
Total Neuropathy Score
Involuntary movement Computerized posturography Computer-based, quantitative Breast cancer,104 vestibular

reaction functions (eg, NeuroCom Sensory assessment of postural stability schwannoma,188,189 prostate
(b765) Organization Test) under various sensory cancer,190 cerebellar tumor191
conditions187
Gait pattern functions Gait speed Performance measure of gait Pediatric sarcoma101
(b770) requiring little equipment
Kinematic gait analysis Quantitative analysis of joint and Pediatric brain tumor,103 bone
limb positions and movement tumor99
during gait; can require
expensive equipment
Functions of the
cardiovascular,
hematologic,
immunologic, and
respiratory systems
Cardiovascular system Heart rate Standard vital sign, with normal Hospice193
functions (b410–b429) values192
Blood pressure Standard vital sign, with cut-points Survivors of childhood cancer,194
for hypertension and leukemia,195 testicular
prehypertension192 cancer,196 brain tumor197
(Continued)

Table 1.
Continued
Construct Measurement Toola Measurement Characteristics With Cancer
Respiratory system Respiratory rate Standard vital sign, with normal Hospice,193 general cancer
functions (b440–b449) values192 population198
Oxygen saturation Indirect measure of Lung cancer199

oxyhemoglobin level
Pulmonary function tests Direct measures of lung volume General cancer population,198
and flow rates post-lung irradiation,200 lung
cancer,199 Hodgkin disease201

Medical Research Council Self-report rating of shortness of None
Dyspnea Scale breath111
Additional functions and Graded exercise testing Estimate of maximal oxygen Breast cancer202–204
sensations of the consumption based on exercise
cardiovascular and performance192
respiratory systems–
Duke Activity Scales Inventory Estimate of maximal oxygen None
aerobic capacity
consumption based on self-
(b455)
reported activity205
2- or 6-minute walk test Performance-based assessment of Osteosarcoma,101 leukemia,182

exercise tolerance and prostate cancer,190 lung
functional capacity110 cancer199
9-minute run-walk Performance-based assessment of Osteosarcoma207
exercise tolerance206
Borg Rating Scale of Perceived Self-report of physical effort None

Exertion during exercise or activity112
Additional functions and Multidimensional Fatigue A 20-item questionnaire with 5 Head and neck cancer209
sensations of the Inventory subscales that assesses
cardiovascular and self-reported fatigue208
respiratory systems–
Functional Assessment of Chronic A 13-item questionnaire that Patients with cancer and severe
fatigue (b455)
Illness Therapy–Fatigue assesses fatigue and the impact pain115
of fatigue210
Piper Fatigue Scale A 26-item multidimensional Leukemia,212

fatigue assessment breast cancer213
instrument211
Brief Fatigue Inventory A 9-item rapid screening tool for Lung cancer,136 leukemia,215
fatigue severity and impact on lymphoma,21,215 rectal
function214 cancer216
Immunological system Limb volume: water Direct, mechanical quantitative Breast cancer117–119
functions (lymphatic displacement measurement of limb
system) (b435) volume117–119
Limb volume: infrared Direct, quantitative measure of Breast cancer120

optoelectric technology limb volume using computer
analysis of a scanned image to
document the diameter of the
extremity along its length217
Limb volume estimates: limb Indirect, quantitative measure of Breast cancer117,118

circumferences using a limb volume117,118
truncated cone formula
National Cancer Institute’s Numeric scales that use Survivors of cancer20

Common Terminology Criteria standardized language to
for Adverse Events, version 3 describe impairments in the
(lymphatic, integument, and lymphatic, integument, and
phlebolymphatic cording phlebolymphatic systems121
scales)
a
Not intended to be an all-inclusive list of measures, but as examples of measures that have been reported in the oncology literature.

scales, such as visual analog scales moval of the spinal accessory taxane-induced peripheral neuropa-
and numeric rating scales,86,87 specif- nerve.92–94 thy have limitations in postural sta-
ically focus on pain intensity, other bility.104 It is important for physical
scales are multidimensional and in- Muscle strength deficits can arise therapists to measure postural con-
clude questions on interference with from tumor-produced inflammatory trol in a variety of challenging posi-
daily activity88 or acceptability of intermediates that are catabolic, re- tions to detect and treat balance lim-
pain treatments.89 sulting in muscle wasting (cachex- itations in patients, especially after
ia).95 Surgical interventions also chemotherapy. Because the oncol-
Neuromusculoskeletal and may damage muscle groups and pe- ogy population often is at risk for
Movement-Related Functions ripheral nerves, leading to loss of falls,105 screening for balance disor-
and Structures strength. Radiation and chemother- ders is very important. We have in-

Table 1 (Neuromusculoskeletal and apy (especially the vinca alkaloids, cluded measures that are intended to
Movement-Related Functions and taxanes, and platinum agents) can identify balance impairments and
Structures) describes useful measures reduce strength by damaging muscle their underlying structural problems
for evaluating potential changes in or peripheral nerve tissue.91 Cortico- in Table 1 (Measurement Tools for
neuromusculoskeletal and movement- steroids preferentially damage prox- Body Function and Structure: Invol-
related functions and structures. Pa- imal limb muscles, limiting activities untary Movement Reaction Func-
tients with cancer or a history of such as sit-to-stand and overhead tions) and tests that use mobility
cancer may experience a number reaching.96 Additionally, pain, fear, skills to rate the level of balance dys-
of impairments in this subdomain, and fatigue lead to inactivity, which, function in Table 3 (Measurement of
including loss of ROM, decreased in turn, causes further loss of muscle Activity and Participation: Mobility–
strength (force-generating capacity), strength and aerobic capacity. Al- Changing and Maintaining Body Po-
gait pattern abnormalities, and bal- though techniques for manual mus- sitions). In either case, in the ICF
ance deficits. cle testing are widely used by thera- model, a balance disorder is classi-
pists to measure strength, measures fied as a body function and structure
Deficits in ROM may be present in of dynamometry and grip force pro- impairment.
patients who have undergone sur- vide quantitative documentation of
gery, chemotherapy, or radiation ther- strength deficits.97,98 Functions of the Cardiovascular,
apy. Such deficits may result from Hematologic, Immunologic, and
the formation of scar tissue follow- Cancer or cancer treatments can al- Respiratory Systems
ing surgery, disuse of a joint follow- ter gait characteristics by adversely Cardiotoxicity is a well-known late
ing chemotherapy or surgery, or affecting the function and structure effect of several chemotherapeutic
fibrosis caused by irradiation. De- of the lower extremity or the ner- agents, particularly the anthracyclines
creased ROM may occur coincident vous system. The few studies that (Adriamycin*) and trastuzumab (Her-
with treatment or after the comple- have assessed these changes have ceptin†). These compounds may dam-
tion of treatment. Seemingly less- shown deficits in patients with bone age cardiac myocytes and ultimately
invasive surgeries (lumpectomy ver- tumor lesions of the lower extremity can result in congestive heart fail-
sus mastectomy) can affect ROM as and tumors of the nervous sys- ure.106,107 Similarly, radiation striking
much as more-invasive procedures.90 tem.99 –103 Traditional gait evaluation the heart can cause cardiac and coro-
Decreased ROM also should be con- tools, such as kinematic analysis or nary artery scarring, leading to re-
sidered if radiation treatment has in- gait speed measurements, are appro- strictive cardiac disease and coronary
volved a joint.91 This loss of ROM priate for patients with cancer. artery disease.108 In older patients,
may occur after radiation is com- these cardiovascular changes may be
pleted and can extend beyond the Balance can be disrupted in many superimposed on already existing car-
immediately irradiated joint. For ex- patients with cancer or a history of diovascular disease, further amplifying
ample, patients who have completed cancer and may arise from impair- the impairments associated with this
surgery or radiation for a head and ments in multiple body systems. disease. It is important for therapists to
neck tumor may have impaired Problems with sensory input, central ask the patient’s physician for the re-
shoulder abduction and flexion in ad- processing of balance-related infor- sults of cardiac testing, performed
dition to the more obvious loss of mation, ROM limitations, orthostatic
cervical ROM. These problems are hypotension, and muscle force pro-
more severe after surgeries involving duction can all contribute to this
* Pharmacia Inc, Kalamazoo, MI 49001.
radical neck dissections and the re- multifactorial issue. Specific to the †
Genentech Inc, 1 DNA Way, South San Fran-
neuromuscular system, patients with cisco, CA 94080-4990.

Table 2.
Physician-Performed Diagnostic Measures of Body Structure and Function Indicating “Red Flags” or “Yellow Flags” for Physical
Therapists, With International Classification of Functioning, Disability and Health (ICF) Code (Alphabetic Chapter and Numeric
Second-Level Domains) in Parentheses
Representative Studies
Measurement Characteristics and in Populations of
Construct Measurement Tool Importance to Physical Therapy People With Cancer
Structures of the
nervous system
Nervous tissue Magnetic resonance imaginga Preferred method to detect Patients with vertebral
(s110–s199) compression of neurologic tissue, metastases or spinal
(ie, spinal cord, nerve roots, or cord compression123,218

nerve plexus) by tumor or unstable
vertebral fractures123
Structures related to
movement
Skeletal system Dual-energy x-ray Diagnostic test for osteopenia and Leukemia,182,219 prostate
(s710–s770) absorptiometrya osteoporosis cancer190
Radiography or computed If 25%–50% of the cortex of bone is Multiple myeloma220

tomography scana degraded, then partial weight-
bearing precautions should be
instituted. If greater than 50% bone
degradation, then touch-down or
non–weight-bearing precautions are
recommended.220
Functions of the
cardiovascular,
hematologic,
immunologic, and
respiratory
systems
Hematologic system Complete blood count (ie, Diagnostic test to detect anemia, Patients with stem cell
functions (b430) hemoglobin, hematocrit, neutropenia, and transplant221
white blood count, thrombocytopenia. These values
platelet count)a also are useful in exercise
prescription, particularly in
choosing safe mode and intensity of
exercise.
Cardiovascular system Echocardiograma Assesses ventricular function, Hodgkin disease,222 breast

functions including ejection fraction, wall cancer223
(b410–b429) movement, and cardiac output
a
These tests are performed by a physician, but yield important information for the physical therapist.
both before and after treatment with to cardiac and vascular compression chest wall irradiation can damage
cardiotoxic agents (Tab. 2). and cause upper-extremity musculo- the lining of the alveoli, leading to
skeletal injury secondary to brachial toxicities such as pneumonitis and
Primary tumors of the lung are fre- plexus compression and infiltration. fibrosis,109 as well as causing fibrosis
quent, with 215,020 new cases esti- of integumentary and musculoskele-
mated for 2008 in the United States.1 The respiratory system also can be tal structures that contribute to
These space-occupying tumors cause adversely affected by chemotherapy ventilation.
respiratory impairments by limiting and radiation treatment for cancers
the expansion of the thoracic cavity, not involving the lung. Chemothera- Measurements of vital signs (heart
compressing the airways, and reduc- peutic agents such as bleomycin, rate, blood pressure, respiratory rate,
ing the surface area of the lungs methotrexate, and docetaxel can and oxygen saturation) provide in-
available for gas exchange. As these damage pneumocytes and the pul- sight into the cardiorespiratory sta-
tumors grow and impinge on other monary parenchema.109 Such dam- tus of patients with cancer. The
mediastinal structures, they can de- age can lead to obliteration of alveoli presence of hemodynamic instability
crease cardiac function secondary and dilation of air spaces. Likewise, at rest (altered blood pressure, tachy-

cardia, light-headedness, cyanosis) Such swelling compromises the in- mentary toxicity (ICF subdomain
suggests that action should be taken tegument by increasing the likeli- “skin and related structures”). There
to protect the patient. Impairments hood of inflammation, infection, skin are separate scales for volume of
in cardiorespiratory status may man- breakdown, limits in joint ROM, and lymphedema in extremities, trunk
ifest themselves only with increased decreased ability to move the af- and genital region, head and neck,
exertion. For this reason, assess- fected limb. Lymphedema may be and viscera. In addition, there are
ment involving testing under condi- most associated with surgical resec- scales to grade the severity of skin
tions of increased exertional demand tion of the breast and surrounding color changes, lymph leakage, lym-
(Tab. 1) is preferred and may involve lymph nodes; however, surgical re- phocele, fibrosis, and phlebolym-
formal exercise testing, self-report of section of a variety of tumors, includ- phatic cording.121 A weakness of
activity levels, or results from a ing head and neck, genitourinary, these scales is that the categories

6-minute walk test or similar aero- and reproductive tumors, can result are broad and, therefore, not sensi-
bic capacity test.110 Failure to meet in lymphedema. Localized swelling tive to small differences that may be
normal range values for these assess- is the most common impairment of clinically important. However, they
ment tools suggests impaired cardio- lymphedema; therefore, measures do provide standardization of lan-
vascular and respiratory function. Pa- of this impairment focus on quanti- guage to describe changes to lym-
tient report of breathing difficulties fying limb volume (Tab. 1, Immuno- phatic tissues and integumentary
(Dyspnea Scale111) and of exertional logical Systems Functions). The wa- that may be clinically useful, particu-
demand (Borg Rating of Perceived ter displacement method is a highly larly for long-term goals and clear com-
Exertion112) during a 6-minute walk reliable method for determining the munication among colleagues.
test provide further insight into volume of an extremity with lymph-
these impairments. edema.117–119 However, this method Diagnostic Measures of
requires specific equipment and Body Function and
Fatigue is a well-documented, multi- precise methods to obtain reliable Structure Indicating “Red
system impairment commonly re- measurements. Methods using light-
ported in a wide variety of cancers, emitting diodes to calculate limb vol-
Flags” or “Yellow Flags” for
both acutely and long after cancer ume have shown early evidence in Physical Therapists
treatments have ended.113 Exercise is detecting subclinical lymphedema, Body function and structure impair-
an effective intervention for cancer- allowing for early intervention and ments identified through diagnostic
related fatigue, and it is recom- prevention of symptomatic lymph- tests performed by a physician may
mended that a multidimentional edema.120 Volume estimates made have significant implications for the
measure be used to capture the phys- by a truncated cone formula using examination by a physical therapist
ical, emotional, and mental aspects several limb circumference measures and the physical therapy plan of care
of fatigue.114 One such measure is correlate highly with those deter- (Tab. 2). Conversely, the therapist
the fatigue subscale of the Func- mined by water displacement.117,118 may identify concerning “red flags”
tional Assessment of Chronic Illness Limb circumference measurements or “yellow flags” during the exami-
Therapy (FACIT-F), which initially may be more practical for some cli- nation that would warrant recom-
was developed for the oncology pop- nicians, given its simplicity and min- mending that the patient return to
ulation and has been used in patients imal equipment requirements. An his or her physician for further diag-
with a variety of cancer types115 and important component to early detec- nostic testing. Both situations affect
in survivors of cancer.116 tion is the timing of volume measure- patient safety and, therefore, are de-
ments. It has been shown that pre- scribed below and in Table 2.
In the ICF, the function of the lym- operative measurements assist with
phatic vessels and nodes are classi- early detection and successful treat- Some tumors cause neural impair-
fied under immunologic function. ment of lymphedema.120 ment by compressing or infiltrating a
Defects may involve tumor obstruc- peripheral nerve, nerve plexus, or a
tion of lymphatic vessels, but they Volume measures are only one nerve tract or nucleus within the
more likely occur secondary to sur- method used to describe the severity central nervous system. The impair-
gical resection of lymph nodes or of lymphatic impairments. The Na- ment may be sensory, motor, or au-
radiation-induced fibrotic changes tional Cancer Institute’s Common tonomic, depending on the location,
that affect lymphatic vessels. In any Terminology Criteria for Adverse size, and structure of the tumor.
case, regional lymphatic drainage is Events, version 3,121 has expanded Physical therapists must consider
reduced, leading to lymphatic fluid the number of scales to grade the common neurological sites at in-
accumulation and regional swelling. severity of lymphatic and integu- creased risk for tumor compression.

For example, breast and lung tumors gist, using advanced imaging tech- the general acute care population,
can compress the brachial plexus, niques. Table 2 summarizes specific as—to our best knowledge—there
and the lumbosacral plexus is some- weight-bearing guidelines. Tumor are no evidence-based recommenda-
times affected by colorectal tumors, invasion of the vertebrae also can tions specific for patients with can-
gynecologic tumors, sarcomas, and affect the physical therapy plan of cer.129,130 In addition to checking for
lymphomas.122 Regardless of the site, care. If the tumor invades the ver- anemia, patients not tolerating aero-
the cardinal sign of neural compres- tebral arch, the segment may be- bic exercise should be screened for
sion is unrelenting pain, particularly come unstable and possibly com- current or past use of cardiotoxic or
at night and later focal sensory dis- press the spinal cord or adjacent pneumotoxic chemotherapy medi-
turbances or weakness in the distri- nerve roots, creating a medical emer- cations and referred as appropriate
bution of the plexus or spinal cord gency. Unrelenting back pain often for further testing (see cardiovascu-

segment involved.122,123 These signs is the primary or presenting symp- lar and respiratory discussion above).
and symptoms are particularly im- tom of these lesions, and if a thera- Patients should avoid exposure to
portant to consider in patients with a pist suspects neurologic involve- infectious pathogens while neutro-
history of cancer who may enter the ment, a segmental motor, sensory, penic (eg, avoid public gyms, health
clinic with a seemingly unrelated and autonomic examination should caregivers should avoid patient con-
musculoskeletal problem. If neural be performed.123 If neural impinge- tact if they are ill). If the patient
compression from a tumor is sus- ment is suspected, the medical team is thrombocytopenic, high-impact
pected, the therapist needs to refer should be notified immediately.125 activities or contact sports should
the patient back to the primary phy- be avoided to prevent excessive
sician so that further medical tests, Osteonecrosis and reduced bone bleeding.
such as magnetic resonance imaging, mineral density are common among
and appropriate treatment may be patients with cancer. Both cancer Measurement of Activity
performed. and cancer treatments increase the and Participation
risk for developing osteonecrosis in The activity and participation do-
Skeletal impairments often accom- a variety of locations, including mains encompass the ability to exe-
pany a cancer diagnosis and reflect a proximal or distal femur, proximal cute tasks, such as walking or bath-
disease-associated loss of bony mate- humerus, jaw, and metatarsals.126,127 ing (activity), and the ability to
rial (lytic tumor) or invasion of bone New-onset pain and decreased participate in life situations, such as
(sclerotic tumor) by a primary or sec- weight-bearing ability should alert regularly attending work or school
ondary tumor. Communication with therapists to the possibility of osteo- and conducting interpersonal rela-
the medical team can help thera- necrosis; however, this condition is tionships (participation). The subdo-
pists navigate through the many risks not always symptomatic.128 Pharma- mains for activity and participation
associated with tumor invasion of ceutical therapies (eg, corticoste- (such as mobility and domestic life)
skeletal structures. It is advantageous roids, hormonal therapies, androgen are given in a single list in the Figure,
for therapists to be familiar with therapy) and radiation are associated with each component being able to
common patterns of cancer-related with reduced bone mineral densi- denote activity, participation, or
skeletal system involvement (eg, ty.68 –70 Therefore, dual-energy x-ray both.24 This flexibility allows for in-
prostate, breast, lung, and colon absorptiometry or computed tomog- dividual tailoring and operational dif-
cancer often metastasize to the raphy test results can alert therapists ferentiation of activity and participa-
spine; sarcomas commonly present to this problem and allow for appro- tion.28,131,132 The ICF beginners
in the femur). As the tumor invades priate intervention planning. guide suggests that clinicians, re-
the normal structure of bone, there searchers, and policymakers may
is reduced bone strength and in- Tests such as a complete blood use this single list for their needs
creased risk of pathological frac- count can help physical therapists and purposes to “A) designate some
ture.124 Although there are no defin- determine safe exercise guidelines, domains as Activities and others as
itive guidelines to predict pathologic particularly for patients who are un- Participation and not allow over-
fracture risk, it is helpful to monitor dergoing or have just completed che- lap; B) make this designation but al-
the amount of cortex that has been motherapy, radiation therapy, or low overlap in particular cases; C)
disrupted by tumor growth in long bone marrow transplant.129,130 Each designate detailed (third- or fourth-
bones used for functional tasks (eg, medical center or rehabilitation de- level) categories within a domain as
the femur for gait, the humerus if partment has its own criteria for ex- Activities and broad (second-level)
an assistive device is being used). ercise prescription. These values of- categories in the domain as Partici-
This can be calculated by a radiolo- ten are the same as those used for pation; or D) designate all domains

as potentially both Activity and evaluation or by patient self-report. ring between surfaces. Because the
Participation.”24(p127) Impairments in For example, the Functional Mobility balance deficits discussed in the body
body function and structure dis- Assessment requires patients to function and structure section lead to
cussed in the previous sections can physically perform specific tasks and impaired ability to change and main-
result in changes at both the activity to answer questions, quantifying tain body positions, this is a critical
and participation levels. Therefore, their level of function.133 In contrast, area to explore in this population. Sev-
assessing change in these constructs the Toronto Extremity Salvage Score, eral appropriate activity-based mea-
is important. lower-extremity version, is a self- sures of maintaining and changing
administered questionnaire that asks body positions, including those that
Physical therapists typically select patients to indicate the level of dif- relate to balance impairments, are
primary outcome measures at the ac- ficulty they experience in dressing, described in Table 3.

tivity and participation levels when grooming, mobility, work, sports,
their intervention plan as a whole is and leisure.134,135 Both methods of The concepts of transferring be-
directed toward improving a per- measurement have different positive tween surfaces and walking and
son’s physical capacity or perfor- attributes. In using quantitative mea- moving often are combined in re-
mance. Individually tailored rehabil- surement of limitations or restric- habilitation outcome measures, al-
itation goals, commonly seen in tions, a therapist removes some of though they are separate categories
physical therapy, take into account the potential influences of symptom in the ICF model. A few examples of
personal and environmental factors distress or cognitive changes.136 combined transfer and mobility sta-
unique to the patient; however, the However, the therapist must take tus measures include the Timed “Up
use of standardized measures allows into account that performance-based & Go” Test and the L Test of Func-
for the comparison of individual ac- measures are effort dependent and tional Mobility (Tab. 3).
tivity and participation performance require that the activity be done in a
to what might be expected from standard way. Severe cognitive prob- Self-care
control or population-specific val- lems may make a performance-based The ability to care for one’s self is a
ues. The ability to make such com- measure difficult or impossible to construct often measured in rehabil-
parisons may assist the therapist in do. Qualitative measures also are itation settings. A few commonly re-
gauging patient progress during the important, as patient-reported out- ported measures are listed in Table 3
course of rehabilitation. comes reflect the patient’s own per- (Self-care). The Karnofsky Perfor-
spective on his or her limitations mance Scale138 has been a “gold stan-
Important activity and participation and restrictions. Additionally, some dard” measure of overall performance
domains typically addressed by phys- symptoms, such as pain, can be mea- status in cancer treatment trials. In its
ical therapy interventions include: sured only by self-report. By adding mid-range values, scores indicate the
(1) mobility, for example changing the patient’s perspective, we can ability of a person to perform self-care.
and maintaining a body position, better document the perceived bur- Because of its limited scope, some
carrying objects, or walking and den of cancer and meaningful impact authors139,140 have reported that it is
moving around; (2) self-care, such of interventions.137 potentially limited in its responsive-
as dressing, bathing, and toileting; ness, a factor that may make it less
(3) domestic life (eg, carrying a Mobility useful for measuring rehabilitation
child, doing dishes); and (4) major The mobility subdomain includes outcomes. Other measures, such as
life areas such as the ability of a child the following constructs: changing the Barthel Index,141 have multiple
to access a classroom or the ability of and maintaining body positions; car- components, including large represen-
an adult to perform specific tasks re- rying, moving, and handling objects; tations of self-care activities in their
lated to paid employment (Tab. 3). walking and moving; and moving content, and are likely to be more re-
Currently available measures of activ- around using transportation. We will sponsive to changes seen with rehabil-
ity and participation are rarely lim- discuss the changing and maintain- itation. Although these scales are used
ited to a specific subdomain, and ing body positions and walking and often in inpatient rehabilitation re-
most instruments include portions of moving constructs, as they are as- search, they have relevance for oncol-
multiple constructs (eg, mobility and sessed most commonly by physical ogy populations that may or may not
self-care).131 therapists. be seen in such a setting.
Measuring activity limitations and Changing and maintaining body posi-

participation restrictions can be tions incorporates both the concepts
done by timed or clinician-observed of maintaining balance and transfer-

Table 3.
Measurement of Activity and Participation, With International Classification of Functioning, Disability and Health (ICF) Code
(Alphabetic Chapter and Numeric Second-Level Domains) in Parentheses
in Populations of
a
Construct Measurement Tool Measurement Characteristics Patients With Cancer
Mobility—changing and maintaining 5-time sit-to-stand Performance-based assessment of None

body positions (d410–d429) transitional movement ability224
Functional reach Performance-based measure of balance Palliative care226

during voluntary movement in
standing225
Berg Balance Scale Performance-based, standardized None

measure of static and dynamic
balance227,228
Dynamic Gait Index Standardized performance-based Vestibular schwannoma102

assessment of gait characteristics229,230
Standard Romberg Test and Standardized performance-based Breast cancer104

Tandem Romberg Test assessment of static balance in various
positions229
Mobility—walking and moving Tinetti Balance and Gait Simple and easily administered Lymphoma185
(d450–d469) Scale performance test that quantifies gait
and balance characteristics. Scored on
patient performance of gait- and
balance-specific tasks.231
Timed “Up & Go” Test A timed measure of balance and Leukemia,178,182,233
mobility232 lymphoma,185
sarcoma,207,234
breast cancer79
L Test of Functional A performance-based assessment of basic Lower-extremity solid

Mobility mobility skills, including walking, tumor234
transferring, and turning234
Functional Mobility An instrument that combines assessment Lower-extremity

Assessment of a patient’s physical performance sarcoma133
with self-report assessment of pain,
function, supports, satisfaction,
participation, and endurance133
Toronto Extremity Salvage A questionnaire that measures the level of Sarcoma134,235,236

Scale difficulty experienced by patients with
upper- and lower-extremity sarcoma in
performing everyday activities135
Fullerton Advanced Balance Standardized performance-based clinical Breast cancer104

Scale test of gait and balance
characteristics237
Mobility—developmental Bruininks-Oseretsky Test of A performance-based measure of gross Leukemia239

(d410–d469) Motor Proficiency and fine motor skills in children
41⁄2–14 years of age (second edition:
41⁄2–21 years of age)238
Gross Motor Function Performance/observation-based measure Leukemia239

Measure of movement in children240
Peabody Developmental Performance-based measure of motor Leukemia,242 children with

Motor Scale development in children aged 0–38 cancer243
months with gross and fine motor
scales241
(Continued)

Table 3.
Continued
in Populations of
Construct Measurement Toola Measurement Characteristics Patients With Cancer
Self-care (d510–d599) Barthel Index Performance or self-report measure of Prostate cancer,244

independence in basic activities of daily hospice,245,246
living141 brain tumor247
Physical Performance Test A 9-item timed test that simulates daily None
activities248
Functional Independence Provides estimate of burden of care based Solid tumor,249

Measure on level of dependence in brain tumor250

performing basic activities of daily
living52
Karnofsky Performance A standard measure of the ability of adult Most drug clinical trials
Scale patients with cancer to perform for all types of cancers
ordinary tasks. The Karnofsky
Performance Scale scores range from 0
to 100. A higher score means the
patient is better able to carry out daily
activities.251
Domestic life, interpersonal relations, General Sickness Impact A 136-item questionnaire that measures General253
and major life areas (d710–d799) Profile the effect of sickness on everyday
activities and behaviors in adults252
Reintegration to Normal An 11-item questionnaire covering Sarcoma146,235

Living Index mobility, self-care, family roles, family
roles and personal relationships,
presentation of self, coping skills, work,
housework, and recreational and social
activities for adults145
a
Not intended to be an all inclusive list of measures, but as examples of measures that have been used in the oncology literature.
Domestic Life, Interpersonal the Reintegration to Normal Living restrict activities (grooming, dress-
Relations, and Major Life Areas Index.145 This tool measures adults’ ing, child care) and participation (at-
Few measures typically used by perception of their ability to resume tending community activities, re-
physical therapists attempt to quan- their life roles after a serious illness duced job expectations) provide a
tify the capacity of a person to live as or trauma. It has been used sparingly broader view of the patient’s abili-
a family member and as a member of in populations of people with can- ties. Therapists need to be adept at
society (Tab. 3). Restrictions in the cer.146,147 Because performance of understanding the intended focus of
ability of an individual to interact activities and participation in life their therapeutic interventions and
with the environment or participate roles often are the main goals of re- using the most appropriate tools to
fully in life situations increase the habilitation, measurement of perti- assess the effectiveness of those
disease burden on the individual, the nent activity and participation sub- interventions.
family, and society. Indeed, people domains provides useful information
with participation restrictions are regarding the need for and effective-
All authors provided concept/idea/project
more likely to report poor health142 ness of oncology rehabilitation. design and writing. Dr Gilchrist and Dr Ga-
and bouts of depression.143 It is gen- lantino provided project management. Dr
erally recognized that patients and Conclusion Ness provided consultation (including re-
survivors of cancer have restrictions This article uses the ICF model to view of manuscript before submission).
in these domains,144 yet there is a describe outcome measures that al- As the Research Committee of the Oncology
paucity of outcome measures tar- low for broad quantification of Section of the American Physical Therapy
geted here. global function and methods to doc- Association, the authors thank the Oncology
Section for their assistance and support in
ument progression in patients with
the development of the manuscript.
A measurement tool that is focused cancer and survivors of cancer. Un-
specifically on the return to lifes derstanding and documenting how
roles after a major health change is these structural or anatomic deficits

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Cancer Rehabilitation Assessment

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What are some of the long term effects of cancer and its treatment?

What are some of the long term effects of cancer and its treatment?

What framework is described for assessing patients with cancer?

What framework is described for assessing patients with cancer?

Perspective

LS Gilchrist, PT, PhD, is Associate A Framework for Assessment in

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GS Morris, PT, PhD, is Director of

KK Ness, PT, PhD, is Assistant

[Gilchrist LS, Galantino ML, Wam-

© 2009 American Physical Therapy

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Mini-Mental State Examination An 11-item questionnaire that is Brain tumor150

Functional Assessment of A 38-item questionnaire that All populations of patients with

Perceived Cognition A self-report scale that rates an Breast cancer152

Profile of Mood States Measures 6 mood or affective Prostate cancer,153

Sensory functions and pain

Computerized gaze stabilization/ A mechanical test that assesses Vestibular schwannoma161

Semmes-Weinstein Mechanical test that quantifies Breast cancer79

Biothesiometer Mechanical test that quantifies Breast cancer79

Numeric rating scale Unidimensional measure of pain Pediatric cancers168,169; mixed

Faces Pain Scale–Revised171 Intensity measure appropriate for Pediatric cancers168,169

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Pain Treatment Satisfaction Scale A 5-item questionnaire that None

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Muscle functions Manual muscle testing Standardized performance test Osteosarcoma101

Handheld dynamometry Mechanical measure of force Leukemia178,182

Grip strength Mechanical measure of force Osteosarcoma,101 breast

Involuntary movement Computerized posturography Computer-based, quantitative Breast cancer,104 vestibular

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Oxygen saturation Indirect measure of Lung cancer199

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2- or 6-minute walk test Performance-based assessment of Osteosarcoma,101 leukemia,182

Borg Rating Scale of Perceived Self-report of physical effort None

Piper Fatigue Scale A 26-item multidimensional Leukemia,212

Limb volume: infrared Direct, quantitative measure of Breast cancer120

Limb volume estimates: limb Indirect, quantitative measure of Breast cancer117,118

National Cancer Institute’s Numeric scales that use Survivors of cancer20

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Radiography or computed If 25%–50% of the cortex of bone is Multiple myeloma220

Cardiovascular system Echocardiograma Assesses ventricular function, Hodgkin disease,222 breast

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