387

Radiation Therapy
Guidelines for physiotherapists
Claire Brooks instrumentation provides a direct pathway for
the spread of cancer cells. Contamination of
normal tissue can occur during the course of a
Key Words surgical procedure (eg biopsy or paracentesis), or
Radiation, physiotherapy, cancer. when a tumour is manipulated during surgery.
This is known as iatrogenic spread.
Summary
As the number of people with cancer is increasing and their Medical treatment is usually a combination of
mean survival is lengthening, physiotherapists will see more interventions. Cytotoxic chemotherapy, radia-
and more people who have or have had the disease. These
patients present for physiotherapy in any clinical setting and a tion therapy (RT), immunotherapy and surgery
significant number will have undergone a course of radiation all play a part, with the goal of all treatment
therapy. being to remove or destroy the cancer or its
This paper discusses how radiation therapy works and how it is effects. Perez and Brady reported in 1992 that
administered, as well as the effects on normal body tissues.
The information presented should help physiotherapists to
70% of patients with invasive cancer present
determine goals of treatment emphasising quality of life as the with the disease limited to a local region, and
primary focus, and to advise upon safe, effective treatment 30% have metastases at initial presentation.
plans for patients who have had radiation therapy. They suggested that 56% would be cured and
The paper stresses that therapists must be mindful to the pos- 44% would develop recurrent disease. The same
sibility of recurrent disease in patients who have previously had authors estimated that 60% of all cancer
cancer, and indicates warning signs to which therapists should
be alert.
patients received RT at some point.

Introduction Mechanism
If patients are having or have had RT, how do
The National Cancer Institute of Canada (NCIC)
we as physiotherapists modify or restrict our
estimates that 130,800 patients in Canada were
intervention while still maximising our physio-
diagnosed with cancer in 1997 and that there
therapeutic input?
has been a 30% increase in new cancer cases
from 1987 to 1997. It attributes this rise to the Radiation therapy is defined by Perez and Brady
increase in population numbers and age. Cancer (1992) as ‘a clinical specialty dealing with the
mortality for all sites other than the lung use of ionising radiations in the treatment of
dropped by 12% between 1971 and 1997. This patients with malignant neoplasms (and occa-
lower mortality despite stable or increased inci- sionally benign conditions). The aim of RT is to
dence rates indicates improved survival (NCIC, deliver a precisely measured dose of radiation to
1997). These statistics suggest that physiothera- a defined target volume, with as minimal dam-
pists will see more and more people who have or age as possible to surrounding healthy tissue,
have had the disease. resulting in eradication of the tumour, a high
quality of life and prolongation of survival at
Cancer is a disease characterised by an abnor- reasonable cost.’
mal unrestricted growth of body cells that com-
press, invade, and destroy body tissues. Pfeifer Tumours can be irradiated using X-rays, gamma
(1997) describes the metastatic process. When rays, electrons and, rarely, protons and neu-
malignant cells break away from the original trons. Ionising radiation can have a direct and
mass, they are carried by the blood or lymph an indirect effect on the target cells. Direct dam-
t o distant sites and they set up secondary age refers to the actual ionizing events damag-
or metastatic colonies at the new sites. Direct ing or destroying the cell DNA. There is also a
spread of tumour cells also occurs by serosal complex chain of chemical reactions that is trig-
seeding. After tumour cells spread into local gered by the radiation. This results in signifi-
tissues and then penetrate body cavities they cant toxic changes which include the formation
can attach t o the serosal surfaces of organs of free radicals. These free radicals are ulti-
within the cavity (eg pleural, peritoneal and mately responsible for reducing or eliminating
pericardial cavities) and form tumours there. the cells’ ability to reproduce and repair.
Seeding can also occur via the cerebrospinal The exact sensitivity of a cell to radiation
fluid with the malignant cells being spread depends on the position of the cell in its cycle;
through the central nervous system. Surgical the most efficient kill period is during early syn-

Physiotherapy, August 1998, vol 84, no 8

388

thesis and mitosis. Fractionating the dose of Administration Techniques

radiation given allows more cells to be exposed RT administered with the goal of cure is known
to the radiation during this phase of their cycle, as radical or curative radiation. Alternatively,
and thus maximises the effects of RT. The palliative radiation is designed to prevent or
successive doses of radiation also disrupt minimise the symptoms of the disease; for exam-
the tumour cell cycle causing division delay. ple, pain can be alleviated, lumen patency
Redistribution of tumour cells in their cycle restored, skeletal integrity preserved, bleeding
enhances the effectiveness of each successive stopped, neurological compromise slowed or
radiation dose, as more cells are likely in mitosis stopped and organ function re-established - all
at the same time. Healthy cells are less likely with minimal side-effects.
to be subject to redistribution.
Radiation oncologists, together with a highly
Cells deep within a tumour are usually hypoxic skilled group of professionals (radiation physi-
as they are distant to the capillary blood flow. cists, radiobiologists, computer scientists, radi-
These regions or masses of cells are resistant to ographers, radiation therapists, dosimetrists),
most forms of RT. Conversely, well oxygenated design the radiation prescription for each
cells are more radiosensitive. When RT is admin- individual patient. The decision to use RT is
istered in fractions, each dose kills a number made after consideration of a number of factors.
of cells. This then reduces the number of cells Histological confirmation of the diagnosis and
competing for oxygen, allowing more cells to staging of the adisease by appropriate clinical,
revert from a hypoxic to a well oxygenated state. surgical and laboratory procedures are neces-
sary before a treatment decision is made. Other
Successive doses of RT will kill these newly oxy- factors such as the patient’s age and general
genated cells and the cancer mass will decrease. condition, site of tumour, radio-responsiveness
Repair of sublethal injury caused by the radia- of the tumour, risk versus benefit, and the goal
tion generally occurs within 24 hours (Hilderley, of treatment also need to be considered.
1992).Normal cells therefore can repair between
daily doses of radiation. Repopulation or regen- Before, during or after receiving radiation ther-
eration of healthy cells continues after repair apy patients see many health care professionals.
The team may include nurses, physiotherapists,
of sublethal injury and allows mitosis to take
occupational therapists, social workers, dieti-
place.
cians and chaplains, all dedicated t o providing
The different fractionation schedules and their the most holistic care possible for these people at
impact for physiotherapy treatment are dis- such a difficult time. Hospital staff must have
cussed later in the paper. excellent links to community care providers so
the follow-up within the community is max-

Physiotherapy, August 1998, vol 84, no 8

 389

Brachytherapy is the temporary or permanent

placement of a radioactive source either on
or within a tumour. Brachytherapy may be
used for intracavity malignancies (eg oral and
gynaecological tumours), and intraluminal
treatment (eg oesophageal cancers). Radiation
can be administered interstitially with the
radioactive source being placed within the tissue
using wires, ribbons, grains or seeds which are
selected by the radiation oncologist according
to the size and site of lesion and whether the
implant is temporary or permanent. Unsealed
radio-isotopes using iodine 131 can be used
in carcinoma of the thyroid.
Fig 2: Radiation therapist making a plaster cast. This is
The chosen technique is tested using a radiation then used to fabricate a plastic shell to immobilise the
simulator. This device mimics the treatment patient when radiation therapy is administered. This
ensures exact reproducibility of each treatment
machine but produces superficial radiation
that can be used for direct imaging with an Different machines are used to deliver the RT,
image intensifier and for producing radiographs depending on the depth of the structure to be
that delineate exactly the beam location. This targeted. Orthovoltage machines deliver lower
information can be fed into a computer which energy X-ray beams that affect the skin maxi-
produces an isodose plot to guide the radiation mally with lower penetration beneath it, ie 200-
oncologist and physicist, allowing modifications 300 kV. Megavoltage machines (linear accelera-
to be made in the treatment plan. The goal tors) may range from 4-20 MV (1.25 MV for
of simulation is to spare normal tissues as cobalt units) and deliver their maximum dose to
much as possible (Hellman, 1997). Dedicated CT internal tumours. Some linear accelerators also
machines in which the patient can be studied in produce electron beams with energies ranging
the treatment position are linked to the simula- from 5-20 MeV.
tor t o provide additional information to allow
alterations in treatment to be made. Once the Recurrent Malignancy
precise location of the tumour is imaged and In the course of their clinical practice, physio-
exact field for delivery of the radiation deter- therapists are likely to encounter people who
mined, the skin is marked or tattooed to ensure have had RT in the past or who are currently
exact replication of the field at each treatment. receiving RT. It is vital that during the physio-
Immobilisation and positioning devices, eg casts, therapy assessment any history of malignancy
plastic masks, bite blocks and other devices, as well as the treatment received be determined.
may be necessary to ensure reproducibility of Specifically related to RT, physiotherapists must
exact treatment portal (fig 2). establish what was irradiated, for how long,
with what effect, and when this took place. This
The dose given is measured in centigray (cGy).
information, together with the material in this
The total dose is given to the patient in frac-
article, should enable them to plan their inter-
tions. Different centres administer fractions
vention safely and effectively and determine
according to various schedules - usually one per
goals of treatment.
day, five days a week. The use of several treat-
ments per day, either to reduce the overall time The metastatic nature of this disease must
(accelerated treatment) or to increase the total always be considered. Metastases can occur
dose (hyperfractionation), offers a range of many years after the initial presentation and
possibilities for improving the results (Thames treatment (eg breast cancer metastases have
et al, 1983). The benefits of fractionating the been known to present 20 years after initial
dose have been discussed above. Physiother- diagnosis). Therapists should always be alert
apists treating patients undergoing radiation to the possibility that a patient’s complaint of
therapy need to work around the radiation treat- pain could be the first sign of recurrent disease.
ment timetable. For example, when more than Consequently, it is advisable that metastatic
one treatment is administered each day, strict disease be ruled out before starting any physio-
schedules must be kept. Additionally patients therapy.
may not wish or be able to tolerate physiothera- Metastatic cancer is the most common cause of
py immediately following RT. spinal cord compression (SCC). Tumours that

Physiotherapy,August 1998, vol 84, no 8

390

metastasise to bone, such as lung, breast and and the disruption of delicate tumour vessels’.
prostate carcinomas, are common causes of Once free, the metastatic cells can spread as
spinal cord compression (Schafer, 1997). The previously described. Maxwell states that
tumours are usually epidural, extending from physiotherapists should use ‘constant vigilance’
the vertebral bodies and compressing the cord t o avoid mismanagement of these patients.
anteriorly. Siegal and Siegal (1989) state that Any physiotherapist who suspects possible
nearly 20% of patients with neoplastic involve- recurrence should immediately refer the patient
ment of the vertebral column develop SCC and in back to a physician.
8% this is the initial manifestation of cancer.
Back pain is usually the first presenting symp-
tom, as well as being the most common - Side Effects of RT
Maranzano et al (1991) claimed 96%. These All tissues within the radiation field will under-
patients may well be referred to physiotherapy go changes - some permanent, others temp-
for pain management without metastatic dis- orary. The gross manifestations depend upon the
ease being eliminated as a potential cause. kinetic properties of the cells - ie the rate of
Patients describe constant, unrelenting pain renewal of these cells. Some tissues are much
which may be local or radicular, worse with more radiosensitive than others. The changes
movement and worse at night (Baldwin, 1983). tissues undergo are classified into acute, suba-
Physiotherapists should always be vigilant cute or late. Acute changes occur during treat-
to history and signs and immediately refer ment and the first two months from treatment,
patients with any suspicious symptoms back subacute from two to six months after treat-
to a physician so that recurrent disease can be ment, and late changes at any time after that.
ruled out. Pain may precede any other signs
It is known that some effects of radiation can
of deterioration, eg in neurological function
occur years after the administration of the dose
(weakness, sensory loss, autonomic dysfunction),
by days or up to two years (Knight-Morse, 1992). (table 1).The following side effects of RT may
Early detection of spinal cord compression, even occur and intervention may need to be adapted
when symptoms are subtle, is vital and the most as a result (table 2).
important prognostic factor (Maranzano et al,
1991). Early compressions respond well to RT, Table 1: Recovery phase and time frame of RT induced
tissue changes
allowing patients t o attain optimal function
and quality of life (Knight-Morse, 1992). Recovery phase Time frame
Physiotherapists, especially in the out-patient Acute During RT and the following two months
setting, should be aware that the clinical behav-
Subacute From two to six months following RT
iour of the majority of musculoskeletal tumours
Late From six months to years following RT
is such that the symptoms are shared with a
wide range of non-tumorous orthopaedic disor-
ders (Maxwell, 1995). Pain, swelling, and local Table 2: Physiotherapy contra-indications and
warmth are also common to inflammatory precautions in FITtreatment settings
conditions. Maxwell states that the most likely
Contra-indications
sites for musculoskeletal tumours are regions
Heat on irradiated skin.
frequently involved in sports injuries, and
the patients are usually adolescents and young Massage, rubbing, frictions, pressure or manual therapy
techniques on irradiated skin.
adults. Tumours may elude early accurate diag-
nosis and become referred for physiotherapy. Application of any substances to irradiated skin during RT
This delay can often have dire consequences. Forceful stretching of irradiated joints and muscles.
Resisted testing and movement of bones at risk of
Ziskin et al (1990) and Maxwell (1995) discuss pathological fracture.
how therapeutic ultrasound does have the
Exercise when blood laboratory values are low:
potential to augment metastasis. Ziskin et al platelets < 50,000/mm3
(1990) state that research done in vitro suggests haemaglobin < 10 d/dl
that ultrasonic irradiation to malignant tissue white blood cells i3,000 mm3
may increase cellular detachment. Maxwell
Precautions
(1995) concurs with this but adds the actual
movement of the transducer on the tissue caus- Previously irradiated skin may be hypaesthetic, use electrical
modalities with caution.
es a superficial massage. Because the stroma of
Wounds will heal more slowly, handle with caution.
a tumour is fragile, with little tissue supporting
the tumour cells, ‘therapeutic ultrasound could Neutropenic patients are at increased risk of infection,
treat in a private room.
cause separation of weakly bound tumour cells

Physiotherapy, August 1998, vol 84, no 8

 391

Wound Healing Some patients exhibit chronic skin changes that

The rate of healing in all tissues within the can develop days or weeks after completion of
treatment field will never return to normal. The RT. For example, fibrosclerotic changes in the
decrease in the speed of wound healing is an subcutaneous structures may occur so that
important consideration for physiotherapists. patients present with smooth, taut and shiny
Davis (1992, unpublished) states that it is not skin. Telangiectasia may also be evident. The
uncommon to see wounds open during a physio- skin may exhibit a permanent tanned effect.
therapy session. Irradiation usually does not Factors that contribute to the severity of the
begin until at least three weeks post-operatively effects are dose, fractionation and volume.
in patients who have had surgery for limb When mega voltage machines are used, there is
sarcoma, to allow the tissues a chance to heal. a lesser skin effect and skin reaction is reduced.
Skin Skin that has been irradiated will always be
With any external beam RT, the skin will be irra- more sensitive to heat and to the sun’s rays. The
diated. As a result patients are given strict area should be protected from direct sunlight.
instructions on what to do during the course All physiotherapy heat modalities are contra-
of radiation treatment as well as longer-term indicated (Ragnarsson, 1992; Dietz, 1981). While
precautions (London Regional Cancer Centre, patients are undergoing their RT, no metallic
1994). While undergoing radiation treatment, powder (although some physicians allow non-
patients may complain of redness, itching, sore- metallic powders), lotions, oils or soaps, etc,
ness or peeling. If there is severe damage within should be allowed on the skin in the treatment
the basal cell layer, the keratin layer will not be field. The skin should not be damaged in any
replaced, and the integrity of the epithelial bar- way, so rubbing, application of pressure,
rier will be lost. The irradiated area becomes frictions, etc, should be avoided. Washing
moist from leakage of serum - known as moist the skin may be permitted in some patients
desquamation. Skin in naturally warm and so long as the area is patted dry Massage is
moist areas, eg groin, perineum, buttocks, contra-indicated directly over and in the vicinity
axillae and inframammary folds, has a lesser of a tumour site (Ragnarsson, 1992) as well as
tolerance to radiation. Severe reactions will stop to any skin that has been radiated (Dietz, 1981).
shortly after completion of treatment or when Consequently, all manual physiotherapy tech-
the daily dose is lowered and repopulation of the niques o r any intervention that involves
normal tissue is allowed to progress unimpeded application of substances to the skin are also
(Griffiths et al, 1984). Figure 3 shows a severe contra-indicated.
skin reaction. Once a course of RT is complete, therapists have
to use their professional judgement concerning
what techniques can be used. The application of
heat remains contra-indicated. All electrical
modalities (eg TENS, FES) should be used with
caution, and electrodes must be not be placed in
areas of skin erosion or in hypaesthetic areas.
Transcutaneous nerve stimulation is used
extensively to treat cancer pain. In preparation
of this article no literature could be traced that
stated what could or could not be used or how
long after RT is complete, it is safe to apply
electrical modalities. Precautions for the use of
manual therapy techniques once RT is complete
are the same as described above. Therapists
must constantly be aware that radiation
is given to treat cancer and that undetected
malignant cells can remain in treated areas.
This is a particular risk with palliative RT - the
disease remains even if the symptoms subside.
Bone Marrow
Bone marrow is highly radiosensitive. When
large areas of bone marrow (ilia, vertebrae, ribs,
skull, sternum and long bones) are irradiated,
Fig 3: Severe skin radiation reaction there is a gradual destruction of the primitive

Physiotherapy,August 1998, vol 84, no 8

392

blood precursor cells. As a result patients are at that frequently accompany this treatment can
risk of becoming neutropenic and therefore high- develop into a chronic problem.
ly likely to develop infections andlor neutropenic
When patients’ nutrition is severely compro-
fever, usually a week or so after completing RT
mised, either in the short term or as an ongoing
(Perez and Brady, 1992).
problem, their energy will be limited (Terrill
Many patients receiving RT have concurrent Ross, 1990) and their tolerance for any form of
cytotoxic chemotherapy and this has an even physiotherapy will be reduced. Malnourished
greater effect on reducing the blood counts and individuals lose muscle mass quickly. As a result
altering the immune response. The myeloblasts their muscle power and endurance decrease so
recover rapidly (Hilderley, 1993) and the white that their functional capacity is compromised, as
blood cell count returns to normal. Two to three is their tolerance for therapy and exercise. The
weeks after exposure, thrombocytopenia com- situation is further compounded by the fact that
monly develops with the platelets taking two to the body is in a hypermetabolic state due to the
six weeks to recover. Anaemia is slower to pre- tumour. Tumour cells compete for nutrients,
sent and will last much longer. Clinically these which results in further decreased weight and
patients present with decreased energy due to appetite (Hunter, 1996), and consequently more
the anaemia and a high risk of haemorrhage due fatigue and a reduced ability to participate in
to the decreased platelet count. Physiotherapists therapy.
are therefore encouraged to monitor the blood
laboratory values and modify their treatment
plans accordingly. Winningham (1991) suggest- Bone, Muscle and Joints
ed that if the levels drop below those listed Normal bone can tolerate high doses of radia-
below, exercise is contra-indicated: tion. However, with radical doses, demineralis-
platelets < 50,000/mm3 ation can occur for up to three months after
haemoglobin < 10 g/dl treatment as the osteoblasts are killed. The risk
white blood cell count < 3,000 mm3 of fracture goes up proportionally to the amount
of bone radiated in the treatment field. Bone
Recovery is related to the degree of initial growth can be arrested in extreme instances.
response and begins with regeneration of the Patients with soft tissue sarcoma are treated
depleted stem cells. Winningham et al (1986) with radical doses of RT following their surgery.
cautions clinicians that all patients who have This surgery is usually extensive and involves
had chemotherapy or RT may never respond limb reconstruction. A prolonged course of phys-
normally to exercise training. iotherapy and rehabilitation will follow to max-
imise function of the affected limb and of the
individual. Given the nature of the surgery and
Digestive System associated RT, the surgeon must provide guide-
Some patients undergoing RT are subject to lines and precautions to the patient and thera-
anorexia and eating problems (Ontario Dietetic pist to allow appropriate, individualised goals to
Association, 1989). Many already have nutrition be set. A physiotherapist treating this type of
concerns before receiving RT - which may be due patient should always bear in mind the reduced
rate of healing, changes in skin sensation, and
to the disease itself, psychological distress that
possibility of metastatic spread of the disease,
accompanies the diagnosis, or the effects of other
treatment (chemotherapy and surgery). When as well as the patients’ own goals and quality
the head and neck are irradiated, adequate
of life decisions. Optimal mobility is usually
the patients’ desired outcome and they may
nutrition is especially challenging for patients.
prefer t o compromise their gait pattern in
The tumour itself, as well as the treatment, will
return for independence.
impact on the ability to chew, swallow, taste and
produce saliva. Severe mucositis can occur any- The other joints in the affected limb are at high
where along the gastro-intestinal tract, and will risk of dysfunction due to the tissues within the
be very distressing for patients. This mucositis treatment field becoming fibrotic, and thus any
causes nausea and vomiting, diarrhoea, part of the limb may become painful (O’Sullivan,
anorexia and pain. When the thorax is radiated, 1988). When treating this type of patient, the
in treatment of lung, breast, or oesophagus, physiotherapists are encouraged to screen all
dysphagia and oesophagitis may present. joints in the affected limb repeatedly and insti-
The gastro-intestinal tract will be in the field tute an independent daily stretching programme
for RT to the pelvic, spine or intra-abdominal prophylactically. Forceful stretching of joints
masses and the enteritis, colitis and anorexia and muscles should be avoided (Dietz, 1981).

~ ~~

Physiotherapy, August 1998, vol 84, no 8

 393

Palliative radiation is given to bone in much intervention. Ongoing reassessment of patients’

lower doses and fewer side effects are seen. status and goals is necessary.
When cancer metastasises to bone, whether to For patients receiving cranial RT, fatigue is
long bones, ribs or the spine, patients frequently especially challenging. Faithful (1991) found
require physiotherapy. All too often they present that 100% of patients reported somnolence.
with severe pain, especially associated with These patients, who often have neurological and
movement. As a result their mobility and func- mobility deficits, require intensive therapy but
tional independence decrease. Palliative RT can they are unable to tolerate it. All patients with
drastically reduce the pain, enabling patients to neurological dysfunction could benefit from
begin some physical rehabilitation. Bone is at physiotherapy, but the expected outcomes and
risk of developing a pathological fracture as the goals should be considered in light of their dis-
disease remains, but this should not normally
ease as well as the treatment they have received
prevent patients from mobilising within their
o r are receiving.
tolerance. Resisted manual muscle testing or
isolated strengthening techniques involving Lhermitte’s sign (electric sensations in the
resistance are not encouraged, but functional, hands and/or feet on flexing the neck) can occur
active exercises are preferred. several months after radiation to the spinal
cord. This gradually disappears in the following
These patients often benefit from education on three to four months but while it lasts can be
back care, positioning and posture. Their goals uncomfortable for patients and interfere with
are paramount in planning a treatment pro- physiotherapy.
gramme and their quality of life must be the pri-
mary concern. This is true when treating all can- Loescher et al(1989) have documented a delayed
cer patients but especially so when metastatic radiation myelopathy that developed months to
disease is present, and they have only a limited years after therapy to the spinal cord. Radiation
life expectancy. Their wishes are therefore not to myelopathy is rare and characterised by sensory
be ignored, and frequently therapists will have changes in the lower extremities that may grad-
to make decisions that would not be ideal in ually involve the trunk and upper extremities.
other situations. Muscle weakness, which in extreme cases could
lead to para- or tetraplegia, may follow.
The use of walking aids is encouraged as they
can minimise the risk of falling, decrease the Fibrosis of the connective tissue surrounding the
load through a lower limb (when the bone is brachial plexus can occur 16 months to 20 years
at increased risk of fracture), as well as save after RT to this area (Loescher et al, 1989).
energy in a fatigued individual. These patients may have difficulty maintaining
their upper extremity function and will often
be referred for physiotherapy.
Neurological System
Complications as a result of radiation exposure
are not common in the neurosensory system, due Cardio-pulmonary System
to the ability of neural tissue to resist damage Dyspnoea is a frequent complaint for patients
(Griffiths et al, 1984). Griffiths and colleagues receiving RT to the chest area. Pulmonary
suggest that neural changes occur if there is a changes commonly present as diffuse alveolar
disruption of the fine vasculature of the brain or damage, pneumonitis, and interstitial fibrosis.
spinal cord caused by RT, and that this leads to These changes may be temporary or permanent,
damage that presents clinically six months and the severity depends upon the dose of radia-
after’ completion of RT. Loescher et al (1989) tion as well as the individual’s tolerance.
described a delayed radiation necrosis that Angina, pericarditis, cardiac myelopathy and
could occur three months to several years after cardiac failure have been described by Loescher
direct radiation to the brain. Speech and visual et al (1989). If changes occur, they could happen
changes may accompany the motor and sensory at any time from six months t o 30 years after
changes. administration of RT to the heart. Radiation to
Cerebral oedema as a side effect of cranial RT left sided breast cancers can lead to fibrosis of
is more common and may be seen during the the coronary vessels. Not all patients who have
course of treatment. It may lead to a deteriora- had their hearts irradiated develop problems,
tion in neurological function and/or an increase but those who do experience cardio-pulmonary
in intra-cranial pressure. This in turn may cause changes secondary t o RT show a marked
nausea and vomiting, anorexia and fatigue as decrease in their capacity for exercise, and
well as neurological changes, all of which force as a result their tolerance for therapy will be
physiotherapists t o modify and adapt their compromised.

Physiotherapy, August 1998, vol 84, no 8

394

Fatigue Faithful, S (1 991). ‘Patients’ experience following cranial

radiation: A study of the somnolence syndrome’, Journal of
Fatigue is common in people undergoing RT Advanced Nursing, 16, 939-946.
(Piper et al, 1987). Various theories have been Griffiths, M, Murry, K and Russo, P (1984). Oncology Nursing:
proposed to suggest why this is so, but the actual Pathophysiology, assessment and intervention, Macmillan,
New York, chap 10.
mechanism is unknown. Fatigue was studied
Hassey Dow, K and Hilderley, L (eds) (1992). Nursing Care in
in 1985 by King and colleagues, who observed Radiation Oncology, W B Saunders, Philadelphia.
that fatigue started in the first week, gradually Hellman, S (1997). ‘Principles of cancer management:
increased throughout the course of RT, and took Radiation therapy’ in: Devita, V, Hellman, S and Rosenberg, S
up to three months following completion of (eds) Cancer Principles and Practice in Oncology, Lippincott-
Raven, Philadelphia, pages 307-332.
RT to subside. Winningham et al (1994) identi-
Hilderley, L (1992). ‘Radiation oncology: Historical background
fied some patients who never regained their pre- and principles of teletherapy’ in: Hassey Dow, K and Hilderley,
treatment energy levels. Physiotherapy often L (eds) op cif, pages 3-16.
has to be postponed or modified to allow for Hilderley, L (1993). ‘Radiotherapy’ in: Groenwald, S, Hansen
fatigue, and patients may need to adapt or mod- Frogge, M, Goodman, M and Henke Yarbro, C (eds), Cancer
Nursing, Principles and Practice, Jones and Bartlet, Boston,
ify their goals and desired outcomes. Because pages 235-267.
fatigue can increase after RT and therefore after Hunter, A M (1996). ‘Nutrition management of patients with neo-
discharge from hospital (Piper, 19961, these plastic disease of the head and neck treated with radiation
patients should be followed up within the therapy’, Nutrition in Clinical Practice, 11, 4, 157-169.
community. King, K B, Nail, L M, Kreamer, K, Strohl, R A and Johnson, J E
(1985). ‘Patients’ descriptions of the experience of receiving
radiation therapy’, Oncology Nursing Forum, 12, 4, 55-61.
Conclusion Knight-Morse, L (1992). ‘Spinal cord compression’ in: Hassey
Dow, K and Hilderley, L (eds) op cit, pages 237-251.
Cancer is a devastating disease with far-reach- Loescher, L, Welsh-McCaffrey, D, Leigh, S, Hoffman, B and
ing effects for patients as well as their families. Meyskens, F (1989). ‘Surviving adult cancers. Part 1:
Physiological effects’, Annals of lnternal Medicine, 111, 5 , 411 -
As has been demonstrated, RT - a common 432
treatment for cancer - also has significant London Regional Cancer Centre (1994). ‘Caring For Your Skin
effects on the body of which physiotherapists After Radiation Therapy’, LRCC, London.
should be aware. It is hoped that the informa- Maranzano, E, Latini, P, Checcaglini, F, Ricci, S, Panizza, B,
tion presented here, with the subjective and Aristei, C, Perrucci, E, Beneventi, S, Corgna, E and Tonato, M
(1991). ‘Radiation therapy in metastatic spinal cord compres-
objective data gained in assessment, will help sion’, Cancer, 67, 1311-17.
physiotherapists develop appropriate, individu- Maxwell, L (1995). ‘Therapeutic ultrasound and tumour metas-
alised treatment plans and goals of treatment tasis’, Physiotherapy, 81, 5, 272-275.
for each patient. This in turn will help maximise National Cancer Institute of Canada, (1 997). Canadian Cancer
each patient’s function and quality of life. Statistics, NCIC, Toronto.
Ontario Dietetic Association (1989). ‘Nutritional support of
Acknowledgments patients with cancer’ in: Nutritional Care Manual, published by
Ontario Hospital Association, Don Mills, pages 545-547.
I am grateful for help in preparing this article to friends and
colleagues, and in particular to B Chesworth, Dr A Hammond, OSullivan, B (1988). ‘Limb-sparing management in extremity
Dr J Gilchrist and Professor N Brooks. soft-tissue sarcomas in the adult: The radiation oncologist‘s
viewpoint’, Canadian Journal of Surgery, 31, 6, 397-403.
Funding support was provided by the Physiotherapy Perez, C and Brady, L (eds) (1992). Principles and Practice of
Department, London Health Sciences Centre, Ontario. Radiation Oncology, J B Lippincott, Philadelphia.
Figures 1 and 2 are reproduced with permission from the Perez, C and Brady, L (1992). ‘Overview’ in: Perez, C and
Radiation Therapy Department, London Regional Cancer Brady, L (eds) op cit, pages 1-63.
Centre, and figure 3 with permission from Dr J Gilchrist, London
Regional Cancer Centre, Ontario. Pfeifer, K (1997). ‘Pathophysiology’ in: Otto, S (ed) Oncology
Nursing, Mosby, St Louis, chap 1.
Author and Address for Correspondence Piper, B F, Lindsey, A M and Dodd M J (1987). ‘Fatigue mecha-
nisms in cancer patients: Developing nursing theory’, Oncology
Claire Brooks MCSP is the physiotherapist in the Adult Nursing Forum, 14, 6, 17-23.
Oncology Unit, L7T2, WC, London Health Services Centre -
Victoria Campus, Box 5375, London, Ontario, Canada N6A Piper, B (1996). ‘Assessment and management of fatigue in the
4G5. cancer patient’, presented at Fatigue and Advanced Pain
Workshop, February 20, 1996, London, Ontario.
This article was received on February 12, 1997, and accepted
on April 27, 1998. Ragnarsson, K T (1992). ‘Rehabilitation of patients with
physical disabilities caused by tumors of the musculoskeletal
References system’ in: Lewis, M M (ed) Musculoskeletal Oncology, A multi-
disciplinary approach, W B Saunders, Philadelphia, pages 429-
Baldwin, P (1983). ‘Epidural spinal cord compression sec- 447.
ondary to metastatic disease: A review of the literature’, Cancer
Nursing, 6, 441-446. Schafer, S L (1997). ‘Oncologic complications’ in: Otto, S (ed)
Oncology Nursing, Mosby, St Louis, chap 19.
Davis, A (1989). ‘Physiotherapy management of extremity soft
tissue sarcoma patients following limb salvage procedures’, Siegal, T A and Siegal, T Z (1989). ‘Current considerations in
unpublished. management of neoplastic spinal cord compression’, Spine, 14,
2, 223-228.
Dietz, J H (1981). Rehabilitation Oncology, Wiley and Sons,
New York. Terrill Ross, B (1990). ‘The impact of radiation therapy on the

Physiotherapy, August 1998, voi 84, no 8

 395

nutrition of the cancer patient: An overview’ in: Bloch, A (ed) Winningham, M L (1991). ‘Walking program for people with
Nutrition Management of the Cancer Patient, Aspen cancer, getting started’, Cancer Nursing, 14, 5, 270-276.
Publications, Rockville, pages 173-180. Winningham, M L, Nail, L M, Barton Burke, M, Brophy, L,
Thames, H, Peters, L, Withers, R and Fletcher, G (1983). Cimprich, B, Jones, L S, Pickard-Holley, S, Rhodes, V,
‘Acceleratedfractionation versus hyperfractionation:Rationales %Pierre, B, Beck, S, Glass, E G, Mock, V L, Mooney, K H and
for several treatments per day’, lnternational Journal of Piper, B (1994). ‘Fatigue and the cancer experience: The state
Radiation Oncology Biology Physics, 9, 127-138. of the knowledge’, Oncology Nursing Forum, 21, 1, 23-361.
Winningham, M L, MacVicar, M G and Burke, C A (1986). Ziskin, M C, McDiarmid, T, and Michlovitz, S L (1990).
‘Exercise for cancer patients: Guidelines and precautions’ ‘Therapeutic ultrasound’ in: Michlovitz, S L (ed) Thermal Agents
Physician arid Sports Medicine, 14, 10, 125-134. in Rehabilitation, FA Davis, Philadelphia, chap 7.

Professional Affairs Department

Information Papers
These publications are all available free of charge PA20: General Principles of Record Keeping
(though a stamped addressed envelope is apprec- PA21: Physiotherapists Working Outside the Scope
iated). If you would like any please photocopy this form of Physiotherapy Practice 0
and tick the appropriate boxes. Add your name and PA22: Accreditation
address and send it to the Professional Affairs Depart-
ment, CSP, 14 Bedford Row, London WClR 4ED. PA23: Specialisms and Specialists 0
PA24: Licensing of Acupuncture 0
PA1: Reports for Legal Purposes 0 PA25: Use of Lasers by Chartered Physiotherapists
PA2: Access to Health Records 0 in Private Practice - The legal position 0

PA3: Use of NHS Facilities for Private Practice n PA26: Standards of Business Conduct
PA28: Patterns of Health Care Delivery:
PA4: Equipment Safety and Product Liability
Managed care information for
(Consumer Protection Act 1987) 0
chartered physiotherapists
PA5: Patients Seeking Treatment in the Public aii d
PA29: Clinical Physiotherapy Specialist Posts in
Private Sectors 0
Out-patient clinics: Guidance for members
PA6: The Delegation of Tasks to Physiotherapy PA30: Rationing of Physiotherapy Services 0
Assistants and Other Support Workers 0
PA31: Use of Injections by Physiotherapists:
PA7: Thinking of Private Practice n Interim guide 0
-
PA8: Patient Handling Training 0 PA32: Chartered Physiotherapists and Insurance
PA9: Manual Handling of Inanimate Loads Training r i PA33: Medical Devices Agency 0
PAIO: Working in the United Kingdom PA34: New NHS Complaints Procedure
PA11: Facilitating Exchanges 0 PA35: Treatment Involving Manual Handling
PA12: Going Abroad - Questions to ask LI PA36: Clinical Guidelines - Reference list 0
PA13: Joint Statement of Working Together in PA37: The Protection and Use of Patient Information
Psychophysical Preparation for Childbirth PA38 An Introduction to Marketing 0
PA14: Quality Assurance in Health Care - PA39: Guidance on Good Practice in Hydrotherapy
A glossary of terms 0
PA40: Guidance for the Safe Teaching of
PA15: Quality Assurance - Conducting a consumer Manipulation to Undergraduates 0
satisfaction survey ri
PA41: Joint Statement on Manual Handling -
PA16: How to Set Standards 0
CSP, RGN, COT 0
PA17: The Patient’s Charter n PA42: Business Planning 0
PA18: Quality Assurance: References for audit 0
PA43: Recommended Salaries and Fees in
PA19: Pelvic Floor and Vaginal Assessment: Private Practice
Guidance for course tutors and postgraduate
physiotherapists n

Name ................................................................................................................................

Address ...............................................................................................................................

...................................................................................................... Post code .........................................

Physiotherapy, August 1998, vol 84, no 8