_____ Fialka-Moser / Rehabilitacija - letn. VIL supl. 2 (2008) __________ _ 
AUSTRIAN EXPERIENCE IN 
REHABILITA TION CANCER 
REHABILITATION 
Prof. dr. Veronika Fialka-Moser 
Oepartment of Physical Medicine and Rehabilitation, Medical University Vienna, Austria 
In 2004, 36.923 people were diagnosed with malignant 
neoplasms in Austria. There were 9.5% more than ten years 
ago (33.706 new cases). New cases in men increased by 
1.1 % from 2003 to 2004, and growth of 18.9% was recorded 
for the period f
r
om 1994 to 2004. For women, there was 
an increase of 1.0% over 2003 and an increase of 0.6% 
over 1994. 
Since 1994, the most common cancer for men has been 
prostate cancer, with 91.1 cases per 100.000 (5.416 cases in 
absolute terms) in 2004. The most common cancer site in 
women continues to be the breast. 
The stage at diagnosis of cancer is an important factor in 
the prognosis of a cancer and is therefore recorded as far as 
possible for ali cancer incidences. In 2004, approximately 
a third of ali cancers were diagnosed while the cancer was 
stili limited to the particular organ (localised cancer stage: 
32.4%). A fifth of diagnoses were only made after the can­
cer had spread to other parts of the body (regional lymph 
node metastases, regionalised cancer stage: 19.9%). Distant 
metastases were discovered in a further 10.8% of diagnoses 
(disseminated cancer stage). 
A total of 74.295 people died in Austria in 2006. Malignant 
neoplasms are responsible for more than a quarter of ali 
deaths (28.5%). 
Once cancer is diagnosed and treated, the patient's life is 
necessarily and permanently altered. 
Many cancer su rvivors will experience physical and 
psychological sequelaes that affect their everyday li ves. 
Studies demonstrate the important findings that treatments 
of localised cancer have consequences that continue to 
wield or impact patients even for years after therapy is 
completed. 
Some types of cancer can cause multiple impairments. 
Common functional impairments include loss of motor 
control, cranial nerve deficits, cognitive and speech prob­
lems, swallowing and feeding problems, and sensory loss. 
Similarly, spinal cord tumors, primary or metastatic, can 
cause neurological dysfunction including motor, sensory, 
and bowel and bladder impairment similar to traumatic 
spinal cord injury. Other cancers are more localized in their 
impact, for instance, head and neck cancers, which can cause 
difficulties with speech or swallowing. 
Rehabilitation problems can be identified by the organ 
system involved which is skeleta!, vascular, lymphatic, 
respiratory, neuromuscular, skin, head and neck. Within 
each system specific problems can be isolated. Problems 
can be viewed f
r
om functional perspectives as impaired 
communication, impaired respiratory function, pain prob­
lems, cosmesis, restricted activity of daily life, ambulation, 
mobility and transfer. 
Rehabilitation for patients with cancer is not different f
r
om 
that in other areas of rehabilitation except that the rehabilita­
tion team must be familiar with the various types of tumors 
and their behaviour. Important information about malignan­
cies includes their appearance, their ways of spread, and 
available methods of treatment, such as surgery, radiation 
therapy, chemotherapy. hormone treatment and immuno­
therapy. Also, a rehabilitation specialist must know the 
disabilities and complications these treatments can produce, 
how to avoid them, and how to treat them. 
Tissue loss from the tumor and its treatment is not the cancer 
patient's only problem. Many of the chemotherapeutic treat­
ments res uit in loss of appetite, loss of a sense of well-being. 
nausea, vomiting, loss of libido, and partial or complete 
loss of hair. Among the many other long-term side effects 
of chemotherapy is sometimes the development of a second 
and different type of malignancy. Because these side effects 
are foreseeable, every effort should be made to lessen the 
patient's anxiety about them and to reassure the patient 
concerning their temporary nature (when this is the case). 
Because of the different types of problems that can result 
f
r
om cancer, rehabilitation efforts are now evolving along 
multiple f
r
onts including not only multidisciplinary institu­
tional rehabilitation settings, but also acute care, subacute 
rehabilitation, outpatient rehabilitation and home care. 
Again, due to the potential for disease progression, success­
ful outcomes depend upon timely recognition of functional 
problems and prompt referral for rehabilitation. 
lil 

Fialka-Moser / Rehabilitacija - letn. VIT, supl. 2 (2008) __________ _ 
In Austria the Medica! University Vienna is one of the 
leading hospitals in cancer research, teaching and taking 
care of the patient. Rehabilitation plays an important role 
in improving activity, participation and quality of life of 
these patients. The Department of Physical Medicine and 
Rehabilitation in the General Hospital Yienna is consultant 
for ali patients requiring physical medicine and rehabilitation 
(about 2.000 beds). It is organised in specialiscd teams of 
physiatrists, physiotherapists, occupational therapists and 
massage therapists. 
Cancer rehabilitation starts in the hospital and is continued in 
the Deparlment of Physical Medicine and Rehabilitation for 
outpatients after discharge. The physiatrists are responsible 
for the whole rehabilitation proccss which is adapted to the 
individual needs of the patients and includes ali diagnostic 
and therapeutic possibilities of the departmenl. 
GENERAL SYMPTOMS 
Deconditioning 
Because patients with cancer will of'ten undergo multiple 
medica! interventions and prolonged or repeated hospitaliza­
tions, thcy are vulnerable to an overall decrease in activity. 
Also referred to as the inactivity/disuse syndrome or the 
immobility syndrome, deconditioning is the term used to 
describe the reduced functional capacity of bodily systems 
and it is considered a separate entity from the condition 
that led to the inactivity in the first place. For example, the 
earliest and most f
r
equent result of immobility/inactivity 
usually occurs in the musculoskeletal system. Contractures 
and limitations in range of moti on can res uit in joints that are 
immobilized in a faulty position. Since muscles at complete 
rest lose strength rapidly, generalizcd weakness has been 
identified as the second most common functional problem 
in patients with cancer. Early intervention can prevent prob­
lems, as it is much easier to maintain strength and range of' 
motion than to regain it. 
Fatigue 
Most cancer patients experience a loss of energy, fatigue 
and an impairment of physical performance. This problem 
affects up to 70% of cancer patients during adjuvant chemo­
and radiotherapy or after surgery. For many patients fatigue 
is a severe and activity-limiting symptom that reduces their 
quality of life. 
Low physical performancc imposes limitations on basic 
activities of daily life. For patients with incurable advanced 
malignancy, the prognosis and clinical course is profoundly 
influenced by the site of the primary tumour and the availa­
bility of palliative treatment strategies. Nevertheless patients 
■ 
suffering from advanced cancer urgently need treatment 
strategies that wi II increase their physical performance and 
health-related quality of life for the rest of their lives. 
Aerobic exercise improves a wide range of biopsychosocial 
outcomes in 11011-metastatic cancer patients. It has proven 
beneficial effects on physical performance quality of life and 
moods of cancer patients receiving adjuvant treatment, and 
is also postulated to have positive effects on immunological 
parameters. 
SPECIFIC PROBLEMS 
Breast cancer 
Breast cancer is the most common female malignancy. The 
vasi majority of patients presenting with breast cancer will 
undergo surgical resection (whether this is mastectomy or 
breast conservation surgery), with this procedure, usually, 
combined with at least axillary node biopsy or a format 
axillary lymph node dissection. 
The restricted arm motion is one of' the most common com­
plications in the breast cancer patients. Early rehabilitation 
plays an important role in preserving function and return­
ing the patient to her previous level of activity. Specifically 
designed exercise programs aim to preserve function of the 
shoulder. 
One of thc complications of breast cancer treatment is 
lymphedema of the ipsilateral arm. Lymphedema is defined 
as a swelling of the arm caused by insufficient lymph drain­
age. It may result in cosmetic deformity, loss of functional 
ability, physical discomfort, recurrent episodes of erysipelas 
and psychological distress. The incidence of lymphedema 
after treatment for breast cancer ranges between 6 % and 38 
o/c, depending on the extcnt of axi llary surgery and the use 
of radiotherap y. Lymphedema can be divided into 3 stages. 
During the first "reversible" stage a protein-rich edema is 
present. Stage 2, designated as "spontaneously irreversible", 
presents fibrosclcrotic alterations and an increase in the 
number of ceratinocytes and connective tissue cells. Stage 3, 
"elephantiasis", is characterized by massive hyperkeratosis 
and by a tremendous increase in the volume of the limb. 
Lymphedema may arise immediately after treatment or show 
up after severa! years. 
Decongestive lymphatic therapy (DLT) can be effective in 
reducing lymphedema. DLT is a combination of intensive 
treatment using compression by bandages, manual lymphatic 
drainage (MLD), exercises enhancing the lymphatic flow, 
and skin care. This usually is followed by daily use of com­
pression garment exercises, and skin carc. Intensive treat­
ment is mainly used for severely swollen or misshapen limbs, 
where an elastic garment cannot be fitted. MLD is a gentle 
massage technique, which stimulates the lymphangiomo-

___________ Fialka-Moser / Rehabilitacija -letn . VII. supl. 2 (2008) __________ _ 
toric activity. This directs the lymphatic flow away f
r
om the 
edematous part of the trunk and arm and thereby decreases 
the edema and fibrous changes in the arm. MLD is a part 
of DLT and should be adjusted to the individual patient, but 
MLD alone has been found inadequate. The main constituent 
of DLT is compression by elastic sleeves. The patient's own 
contribution includes skin care, exercises and if necessary 
in combination with MLD. The intensity of application of 
the individual components of DLT depends on the stage of 
lymphedema at the tirne of treatment starts. 
Uncomplicated cases of lymphedema can be treated in an 
outpatient setting. In studies using DLT it was found that 
the most important reduction of the edema was obtained in 
the first week. During the second week, the results obtained 
were stabilized. In our experience, women treated for breast 
cancer with an uncomplicated edema in stage 1 or 2 have a 
notable reduction effect with a standard therapy consisting 
of daily use of compression sleeves, exercises, skin care 
and precautions. Compliance is essential in maintaining 
subsequent lymphedema reduction following conservative 
therapy. 
A significant proportion of women suffer disturbances in 
body image and self concept. Social isolation and disrup­
tions in family and sexual relationships are related to fears 
of recurrence and death. Attention to these psychological 
issues in rehabilitation promote the quality of life, but also 
improve compliance to treatment and reduce utilisation of 
health care in the long term. 
Prostate cancer 
Prostate cancer is one of the most common forms of cancer 
diagnosed in older men. Impaired physical performance, 
psychological distress, fatigue, weight gain, urinary inconti­
nence, sexual dysfunction, and changes in male body image 
are long-term consequences of prostate cancer. To improve 
participation in the activities of daily living strengthening 
and endurance exercise should be performed. In cases of 
bladder or bowel involvement special training and informa­
tion programs help the patients. Pelvic-floor re-education 
should be considered as a first-line option in curing incon­
tinence after radical prostatect omy. 
Although cancer control is always of primary importance, 
potency is often a consideration of great concern to patients 
when deciding between the various treatment options for 
clinically localized prostate cancer. Preoperative coun­
seling informs the patient that erectile dysfunction can be 
successfully managed in most cases with therapy tailored 
to the goals and expectations of both the patient and the 
partner. Sexual rehabilitation should be addressed by the 
primary care team. Ejaculatory dysfunction is difficult 
to handle with. The management of erectile dysfunction 
includes the application of topical intraurethral therapies, 
oral medication, vacuum-assisted devices, intracavernosal 
injection therapy and penile prosthesis. In conclusion sexual 
rehabilitation is a vi tal component of the overall care of the 
prostate cancer patient and contributes significantly to the 
subsequent quality of life. 
The detailed listing of problems in cancer rehabilitation may 
be helpful to clinicians in their interactions with patients. 
The need for further studies has to be underscored. 
Recommended readings: 
l. Andersen L, Hojris I, Erlandsen M, Ande rsen J.
Treatment of breast-cancer-related lymphedema with or
without manual lymphatic drainage: a randomized study.
Acta Oncol 2000; 39(3): 399-405.
2. Badger C, Preston N, Seers K, Mortimer P. Physical
therapies for reducing and controlling lymphedema of
the limbs. Cochrane Database Syst Rev 2004 Oct 18; (4):
CD003141 [Review].
3. Crevenna R, Schmidinger M, Keilani M, Nuhr M, Nur
H, Zoch C, et al. Aerobic exercise as additive palliative
treatment for a patient with advanced hepatocellular
cancer. Wien Med Wochenschr 2003; 153(9-10): 237-
240.
4. Fialka-Moser V, Crevenna R, Korpan M, Quittan M.
Cancer rehabilitation: particularly with aspects on
physical impairments. J Rehabil Med 2003; 35(4): 153-
162.
5. Markes M, Brockow T, Resch KL. Exercises for women
receiving adjuvant therapy for breast cancer. Cochrane
Database Syst Rev 2006 Oct 18; (4): CD00500I
[Review].
6. Taylor K. Morbidity associated with axillary surgery for
breast cancer: ANZ J Surg 2004; 74(5): 314-317.
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