Cancer and psychological conditions

Recognizing cancer: red flags

Physical therapists and physical therapy assistants must recognize potential signs of cancer to ensure timely referral for medical evaluation.

PTA role: Within an established plan of care, the PTA’s job is to collect data, recognize red flags or a change in patient status, and communicate findings to the supervising PT - not to independently evaluate, diagnose, or modify the plan of care. Any suspected sign of cancer, a psychological crisis, or an adverse response to treatment gets reported to the supervising PT for follow-up.

General red flags for cancer (CAUTION acronym)

• Change in bowel or bladder habits (colorectal, bladder cancer)
• A sore that does not heal (skin cancer)
• Unusual bleeding or discharge (gynecologic, gastrointestinal cancers)
• Thickening or lump in the breast or elsewhere
• Indigestion or difficulty swallowing (esophageal, stomach cancer)
• Obvious change in a wart or mole (skin cancer)
• Nagging cough or hoarseness (lung, throat cancer)

Other red flags

• Unexplained weight loss (>10% body weight in 6 months)
• Persistent pain (especially at night)
• Fatigue unrelieved by rest
• Recurrent infections
• Bone pain without a known cause
• Neurologic symptoms (e.g., sudden weakness, changes in coordination)

The 5 most common cancers

• Breast cancer PT considerations: mastectomy (surgical removal of the breast and surrounding tissue) will require restoration of shoulder function. Mastectomy and follow-up radiation will affect the axillary lymph nodes and require lymphedema management.

• Prostate cancer PT considerations: prostatectomy (surgical removal of the prostate) causes disruption of the pelvic floor with urinary incontinence and will require strengthening of the pelvic floor.

• Lung cancer PT considerations: lobectomy (removal of affected lung tissue) will require pulmonary interventions including segmental breathing, secretion management, and low-intensity exercise training.

• Colorectal cancer PT considerations: managing treatment side effects like pelvic floor dysfunction (incontinence, urgency) and lymphedema, and improving functional limitations such as balance and endurance.

• Melanoma, excluding non-melanoma skin cancers, PT considerations: managing side effects from treatments like surgery and radiation, and preventing skin scarring and contractures over surgical or radiation sites.

Universal PT considerations for patients with cancer

• Fatigue management: Prescribe low- to moderate-intensity exercise (aerobic + resistance training).
• Bone metastases: Avoid high-impact exercises to prevent fractures.
• Neuropathy (chemotherapy-induced): Balance training, fall prevention, and desensitization techniques.
• Lymphedema management: Compression garments, manual lymphatic drainage, and exercise.

Mole changes (ABCDE rule)

Early detection of melanoma and other skin cancers is critical.

The ABCDE rule helps in identifying suspicious moles

• Asymmetry: One half does not match the other.
• Border irregularity: Edges are ragged, notched, or blurred
• Color variation: Different shades of brown, black, or red
• Diameter: >6 mm (size of a pencil eraser)
• Evolution: Changes in size, shape, or color over time.

PT considerations

• If a suspicious mole is noticed, refer the patient for dermatological evaluation.
• Avoid excessive pressure or friction over areas with skin abnormalities.
• Educate on sun protection and regular skin self-exams.

Common tumors

Benign tumors

• Osteochondroma: most common benign bone tumor, often in long bones (femur, tibia). PT considerations: monitor for joint impingement or mechanical symptoms.
• Osteoid osteoma: small, painful bone tumor (common in young males); night pain relieved by NSAIDs. PT considerations: differentiate from stress fractures and infection.
• Enchondroma: benign cartilage tumor inside bones (hands, feet); can cause fractures due to bone weakening. PT considerations: avoid excessive loading on affected areas.

Malignant tumors

• Osteosarcoma: most common primary bone cancer (often in teenagers); occurs in the metaphysis of long bones (e.g., distal femur, proximal tibia). PT considerations: post-surgical limb salvage or amputation rehabilitation.
• Ewing’s sarcoma: aggressive tumor in children/adolescents; affects long bones, pelvis, ribs. PT considerations: manage chemo/radiation side effects, functional mobility training.
• Chondrosarcoma: malignant cartilage tumor in adults (40-70 years); common in the pelvis, ribs, and femur. PT considerations: post-surgical rehab, pain management.
• Multiple myeloma: cancer of plasma cells in bone marrow, leading to bone pain, fractures, and hypercalcemia. PT considerations: avoid high-impact activities due to fracture risk.

Soft tissue tumors

• Lipoma (benign): fatty tumor under the skin, soft and movable. PT considerations: no functional impact unless compressing nerves.
• Rhabdomyosarcoma (malignant): cancer of skeletal muscle (children), common in the head, neck, and extremities. PT considerations: strength and mobility training post-treatment.

Metastatic cancer

• When cancer cells break away from the original tumor and spread to other parts of the body
• The most common types of metastatic cancers are breast, prostate, lung, colorectal, and bladder cancers.

Stop and report: Certain findings mean you pause the intervention and notify the supervising PT right away rather than continuing per protocol - new or worsening bone pain (possible pathologic fracture), a significant drop in blood pressure or an abnormal heart rate response, sudden dyspnea, or any expressed suicidal ideation.

Common psychological conditions, physical therapy interventions, and medications

Depression

Symptoms: Persistent sadness, loss of interest, fatigue, sleep disturbances, suicidal thoughts.

PT considerations

• Encourage physical activity (moderate-intensity aerobic exercise is effective).
• Provide structured, goal-oriented therapy.
• Be aware of signs of suicidal ideation and refer if necessary.

Medications

• SSRIs (selective serotonin reuptake inhibitors)
  • Action: Block the reuptake of serotonin in the brain, increasing serotonin levels and improving mood.
  • Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Escitalopram (Lexapro)
  • Side effects: nausea, headache, insomnia, sexual dysfunction, weight gain
• SNRIs (serotonin-norepinephrine reuptake inhibitors)
  • Action: Block the reuptake of both serotonin and norepinephrine, increasing their availability in the brain and improving mood and energy.
  • Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta)
  • Side effects: increased BP, nausea, dizziness, dry mouth
• Tricyclic antidepressants (TCAs)
  • Action: Inhibit the reuptake of serotonin and norepinephrine, but also block muscarinic, histamine, and alpha-1 adrenergic receptors, which accounts for many of their side effects (dry mouth, sedation, and dizziness).
  • Examples: Amitriptyline, Nortriptyline
  • Side effects: sedation, dizziness, weight gain, dry mouth, arrhythmias
• MAOIs (monoamine oxidase inhibitors) (less common)
  • Action: Inhibit the monoamine oxidase enzyme, preventing the breakdown of serotonin, norepinephrine, and dopamine, thereby increasing their levels.
  • Examples: Phenelzine (Nardil)
  • Side effects: hypertensive crisis with certain foods (aged cheese, wine), dizziness

Grief

Symptoms: Sadness, tearfulness, sleep and appetite changes, fatigue, difficulty concentrating, and reduced motivation following a loss. Grief is a normal response, but prolonged or complicated grief can overlap with depression and reduce engagement in therapy.

PT considerations

• Acknowledge the loss and allow flexibility - reduced motivation, low energy, and inconsistent attendance are common; adjust pacing within the established plan of care rather than pushing through.
• Watch for signs that grief has progressed to depression (persistent hopelessness, withdrawal, or suicidal ideation) and report these to the supervising PT.
• Use structure and clear short-term goals to support re-engagement in activity.

Schizophrenia

Symptoms: Positive symptoms (hallucinations, delusions, disorganized thought) and negative symptoms (flat affect, low motivation, social withdrawal). Cognitive impairment and reduced initiation can make following multi-step instructions difficult.

PT considerations

• Give simple, concrete, one-step instructions in a calm, low-stimulation environment, and be consistent to build trust and predictability.
• Monitor for antipsychotic side effects that affect safe mobility: sedation, extrapyramidal symptoms (drug-induced parkinsonism, akathisia, dystonia), tardive dyskinesia, and orthostatic hypotension all raise fall risk. Screen for orthostatic changes with position changes and guard accordingly.
• Report significant behavioral changes or safety concerns to the supervising PT.

Medications

• Atypical antipsychotics
  • Action: Modulate dopamine and serotonin receptors to reduce hallucinations, delusions, and agitation.
  • Examples: Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel)
  • Side effects: sedation, weight gain, orthostatic hypotension, extrapyramidal symptoms, tardive dyskinesia

Anxiety disorders

Symptoms: Excessive worry, restlessness, increased heart rate, hyperventilation, muscle tension.

PT considerations

• Use relaxation techniques (deep breathing, guided imagery).
• Incorporate aerobic exercise to reduce anxiety.

Medications

• SSRI:
  • Action: Block the reuptake of serotonin in the brain, increasing serotonin levels and helping reduce anxiety symptoms.
  • Examples: Sertraline (Zoloft), Paroxetine (Paxil)
  • Side effects: same as for depression (nausea, insomnia, weight gain).
• Benzodiazepines:
  • Action: Enhance the effects of gamma-aminobutyric acid (GABA), a neurotransmitter that slows brain activity, producing rapid anxiolytic and sedative effects.
  • Examples: Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium)
  • Side effects: sedation, dizziness, dependency, respiratory depression
• Buspirone
  • Action: Acts as a serotonin (5-HT1A) receptor partial agonist, helping reduce anxiety without significant sedation or risk of dependence.
  • Example: Buspar
  • Side effects: dizziness, nausea, headaches

Post-traumatic stress disorder (PTSD)

Symptoms: Flashbacks, hypervigilance, avoidance behaviors, sleep disturbances.

PT considerations

• Maintain a calm, structured, and predictable environment with low stimulation.
• Use gradual exposure to movement and relaxation techniques.

Medications

• SSRIs: See above

Chronic pain syndromes

Symptoms: Widespread pain, fatigue, hypersensitivity.

PT considerations

• Use graded exercise and pacing strategies.
• Avoid overexertion.
• Consider comorbidities and polypharmacy: many patients take multiple psychotropic and analgesic medications together (e.g., an SSRI plus a gabapentinoid), which can have additive sedation and orthostatic hypotension effects and raise fall risk during treatment.
• Evaluate pain across its physiological, psychological, and mechanical/functional dimensions, since a patient’s pain report reflects more than tissue damage alone.

Medications

• SNRIs:
  • See above
• Gabapentinoids:
  • Action: Bind to voltage-gated calcium channels in the central nervous system, reducing the release of excitatory neurotransmitters and helping decrease anxiety, neuropathic pain, and seizure activity.
  • Example: Pregabalin (Lyrica), Gabapentin (Neurontin)
  • Side effects: drowsiness, dizziness, weight gain

Eating disorders: anorexia and bulimia

Definitions

Anorexia

Severe calorie restriction due to intense fear of gaining weight. May involve excessive exercise and malnutrition.

Bulimia

Cyclical binge eating followed by compensatory purging (vomiting, laxatives, or excessive exercise) to prevent weight gain; patients are often at or near normal body weight, which can mask the disorder.

Symptoms of anorexia

• Extreme weight loss
• Hair thinning, brittle nails
• Cold intolerance
• Severe malnutrition

Symptoms of bulimia

• Frequent episodes of binge eating followed by purging
• Dental erosion from stomach acid
• Electrolyte imbalances
• Swelling of salivary glands

Key distinction: patients with anorexia are typically markedly underweight, while patients with bulimia are often at or near normal body weight - a difference that can make bulimia harder to recognize from appearance alone, so watch for the physical signs above (dental erosion, electrolyte imbalance) rather than relying on body weight.

PT considerations for eating disorders

• Monitor for over-exercise and excessive fatigue.
• Work with a multidisciplinary team (nutritionist, psychologist, MD).
• Focus on safe, balanced movement rather than excessive exercise.

Medications

• SSRIs
  • See above
• Atypical antipsychotics
  • Action: Modulate dopamine and serotonin receptors in the brain, helping stabilize mood, reduce agitation, and manage symptoms of psychosis. Some are also used as adjunctive therapy for depression and bipolar disorder.
  • Example: Olanzapine (Zyprexa)
  • Side effects: weight gain, sedation