Cancer and psychological conditions

Recognizing cancer: red flags

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. Axillary lymph node removal and radiation raise lymphedema risk and may 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 a lobe of the lung) will require pulmonary interventions including segmental breathing, secretion management, and low-intensity exercise training.

• Lung cancer symptoms can include a persistent or worsening cough, chest pain, trouble breathing, wheezing, blood in the phlegm, hoarseness, fatigue, and unexplained weight loss or reduced appetite.

• 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 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: Carry out the PT-prescribed 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.
• Low blood counts: chemotherapy can lower white blood cells (neutropenia: high infection risk), platelets (easy bleeding and bruising), and red blood cells (anemia, also caused by radiation: fatigue, shortness of breath, lightheadedness). Check the latest counts before each session; hold the activity and report to the supervising PT when one crosses the lab values thresholds.

Mole changes (ABCDE rule)

The ABCDE rule helps identify 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, report it to the supervising PT so a dermatology referral can be considered.
• Avoid excessive pressure or friction over areas with skin abnormalities.
• Educate on sun protection and regular skin self-exams.

Common tumors

Benign and soft tissue tumors

• Osteoid osteoma: small, painful bone tumor (common in young males); night pain relieved by NSAIDs. PT considerations: report findings that could instead suggest a stress fracture or infection.
• Infantile hemangioma: benign vascular tumor formed when immature blood-vessel cells form a tumor instead.
• Other benign tumors (osteochondroma, enchondroma, lipoma) rarely limit function, but lesions that weaken bone (like enchondroma) raise fracture risk - report new or worsening bone pain, especially at night, to the supervising PT.

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.
• Rhabdomyosarcoma: malignant soft-tissue cancer of skeletal muscle in 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 primary cancers that most often metastasize to bone are breast, prostate, lung, kidney, and thyroid.

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.

Other multi-system conditions

A few other conditions call for the same kind of multi-system vigilance as cancer:

• Pregnancy: the hormone relaxin increases ligamentous laxity, raising injury risk during exercise. Avoid prolonged supine positioning after the first trimester (risk of supine hypotensive syndrome). Stop exercise and report vaginal bleeding, amniotic fluid leakage, regular painful contractions, dizziness, or calf pain/swelling.
• Multitrauma: monitor vitals, skin integrity, and signs of DVT across all affected systems; track weight-bearing restrictions separately for each fracture site, prioritize safety around lines and drains during mobility, and watch for hemodynamic instability (e.g., tachycardia, hypotension). Report any changes to the supervising PT.
• Sarcoidosis: granulomas form most often in the lungs, causing dyspnea and fatigue. It is treated mainly with corticosteroids. Monitor SpO2 and exertional tolerance during activity.

Autoimmune disorders (e.g., lupus, rheumatoid arthritis) are covered in the infectious disease, immune disorders, and hematological disorders chapter; as a general rule, reduce activity intensity during a flare and progress exercise as tolerated during remission.

Comorbidities

• Diabetes and hypertension: complications are more likely when both are present. Check blood pressure and glucose before exercise; beta-blockers blunt the heart rate response (use RPE) and the rapid heartbeat that signals hypoglycemia.
• Obesity and arthritis: each pound lost takes about 4 pounds of load off the knee per step. Pair weight loss with exercise; aquatic exercise is low-impact.
• Dementia and hip fracture: dementia raises fall and hip fracture risk two- to threefold, and after surgery it raises delirium risk and makes pain harder to assess and precautions harder to learn. Keep instructions simple and repeated, teach caregivers fall prevention, and report new confusion to the supervising PT; dementia is no reason to withhold rehabilitation.

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.
• Recognize signs of suicidal ideation and report them to the supervising PT immediately; do not leave a patient at imminent risk alone.

Medications

• SSRIs (selective serotonin reuptake inhibitors) - first-line for depression and anxiety because of a milder side-effect profile
  • 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, improving mood and energy.
  • Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta)
  • Side effects: increased BP, nausea, dizziness, dry mouth
• Tricyclic antidepressants (TCAs)
  • Action: Increase serotonin and norepinephrine, with broad receptor effects.
  • Examples: Amitriptyline, Nortriptyline
  • Side effects: sedation, dizziness, weight gain, dry mouth, arrhythmias

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.

Key distinction: grief typically comes in waves tied to reminders of the loss, and the person’s sense of self-worth stays intact. Depression is more persistent and pervasive, with feelings of worthlessness and a loss of pleasure (anhedonia) in nearly everything.

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.

Panic disorder involves frequent, unexpected panic attacks, which are sudden waves of fear or discomfort or a sense of losing control. Obsessive-compulsive disorder involves uncontrollable, recurring thoughts (obsessions) and repetitive behaviors (compulsions), or both.

PT considerations

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

Medications

• SSRIs (e.g., sertraline, paroxetine): see Depression above for action and side effects.
• 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: Non-sedating, non-habit-forming anxiolytic.
  • 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

Dimensions of pain

Acute pain is protective, tied directly to tissue damage, and resolves as healing progresses. Persistent (chronic) pain continues beyond the normal healing time and often involves central sensitization, where the nervous system keeps amplifying pain signals even after tissue healing is complete. A full picture of a patient’s pain includes:

• Physiological/mechanical: tissue status, movement patterns, and mechanical load.
• Neurological: central sensitization, hypersensitivity, and altered pain processing.
• Psychological: fear-avoidance beliefs, catastrophizing, and comorbid depression or anxiety.
• Social: work demands, family support, and other environmental factors.

As a PTA, your role is to collect and report data across these dimensions so the supervising PT can adjust the plan of care.

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.

Medications

• SNRIs:
  • See above
• Gabapentinoids:
  • Action: Calms overactive nerve signaling to reduce neuropathic pain.
  • 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.

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).
• Stop activity and report to the supervising PT if you see bradycardia, orthostatic hypotension, an irregular heart rhythm, dizziness, or fainting - electrolyte imbalance from purging or starvation can trigger dangerous arrhythmias during exercise.

Medications

• SSRIs
  • See above
• Atypical antipsychotics (e.g., olanzapine, sometimes used for weight restoration): see Schizophrenia above.