Role of physiotherapy

Physiotherapeutic procedures have an important role in the healthcare of people of all ages and with different types of clinical status. These procedures are relevant in the treatment, in the prevention of diseases or complications and in the management or treatment of undesirable pathological conditions to thus minimize the impact these may have in the quality of life of the patient [7].

Physiotherapy is a profession defined by great diversity in areas of clinical practice with the purpose of developing, maintaining and restoring the maximum movement and functional ability of each person, considering the specific limitations of the individual. The role of the physiotherapist within the interdisciplinary group (physician, nurse, nutritionist, occupational therapy, social worker, psychologist, speech therapist) is well defined in various clinical conditions, as with the patient with cancer [5, 7].

The pressing need arises for the existence of a differentiated care system with the purpose to cater for the particular needs of the patients and their families. It is desirable that the physiotherapist working in oncology has a broad knowledge of other clinical areas, such as neurology, the musculoskeletal and cardiopulmonary systems and in rehabilitation and kinesiotherapy in general, as well as in services along the entire spectrum of patient care. There is also a considerable role for the physiotherapists in the evaluation of the clinical conditions and management of the patients, as well as in assisting people's return to work and normal life following treatment [6, 14].

It is often the fatigue and weakness caused by the disease and/or its treatment that delay this return to normal functions and limit the quality of life of a specific individual. An important aspect related to cancer and its treatment is the typically induced muscle atrophy. Probably this clinical condition is due to perturbations in different pathways of the muscle protein metabolism, including decreased muscle protein synthesis, increased muscle protein degradation, or a combination of both [5, 12, 15].

The most prevalent symptom in cancer is fatigue, which has now overtaken pain as the most common distressing symptom of the disease. The intensity of the fatigue varies from patient to patient and it is a complex and subjective phenomenon. Non-pharmacological fatigue cares are desirable. There is much evidence to suggest that appropriately prescribed physical exercises (kinesiotherapy) play an important role in the decrease of cancer fatigue and the improvement of the quality of life of the patient. The reduction of fatigue is highly relevant and desirable for the patient to (i) have the ability to continue or return to work; (ii) develop daily activities at home; and (iii) participate in social activities, all of which are clear parts of the overall quality of life of the patient [2-4, 15, 16]

It is thus essential that physiotherapists working with cancer patients have a clear and comprehensive understanding of the individual cancers and their staging and development, as well as the techniques that are being used in the diagnosis and treatment of the patient. The physiotherapist must have knowledge of the consequences and complications of clinical procedures, such as surgery, chemotherapy and radiotherapy, and their potential side effects such as neuropathies and cardiomyopathies. Moreover, the physiotherapist must be informed about the specific procedures that were used in the patient during medical intervention. A discussion about these procedures and the possible complications and occurrences are relevant to the management of the patient before and after the surgery. In addition, the physiotherapist must also know how these medical procedures can affect the physiotherapeutic interventions and thus select the best and convenient procedure for each patient [5, 7, 14]

The physiotherapist also needs to know more about individual medications as patients can survive longer using new cancer treatments, but often with severe side effects, which leave them weaker and often feeling quite unwell during the process. Hormonal therapy, for example, has an important effect on the muscle mass. The decrease in muscle mass, leading to muscle weakness and general debility, can be minimized by specific kinesiotherapyprog-rammes. These appropriated exercises are established and implemented by physiotherapists considering the anatomical area of the disease and specific capabilities and limitations of each patient [5, 6, 7, 14].

Whole body vibration exercises (WBV) performed in oscillating platform could be a good option to aid the patient with cancer. The vibrations generated in these platforms can be transmitted to body of the patient, and, it is suggested that, in appropriated conditions, these vibrations could improve walking function, muscle strength, bone mineral density, cardiovascular fitness and body balance. Moreover, the health-related quality of life is increased and the fall risk is decreased. The frequency and the amplitude of the vibration can be totally controlled by the physiotherapist that is supervising the clinical procedure. The duration of the work, as well as, the time to rest, the number of sets in a session and the number of sessions are also controlled. All these conditions depend on, mainly, the clinical and physical conditions of the patient. The mechanisms responsible for the WBV benefits are not fully understood, however it is hypothesized that these effects are probably related to direct and indirect actions. The direct effects would be related with the transmission of energy of the vibration, for example, to a muscle that would be stimulated. The indirect effects might to be associated with the neuroendocrine system. Whole body mechanical vibration on the muscle performance would be due to the induction of a myotatic reflex contraction referred as the tonic vibration reflex [17, 18, 19].

Normally, the person is standing on the platform, but other positions are possible, as it is shown in the Figure 1. It is possible to see in the Figure 1.c that the man has bent knees.

Figure 1. Some of the positions of the person in the oscillating platform. (a) sitting, (b) sitting in a chaise and the feet in the platform, (c) standing.

Physiotherapists utilize physical agents, such as therapeutic exercises (kinesiotherapy), electrotherapy and manipulative therapy to provide a holistic approach to the prevention, diagnosis and therapeutic management of clinical disorders, as well as possible future complications [5, 7]. Involving the movements of the body and the optimization of the functions of the tissues, they aim to enhance the health, welfare and quality of life and thus they can play an important role in the management and rehabilitation of patients with prostate cancer (PCa). In patients with PCa, the physiotherapist will also guide the patient in relation to the knowledge and understanding of the anatomic structures related directly with the pelvic floor, the correct breathing and the perception of the muscles of the pelvic floor, as other muscles of the pelvis. Specific attention is given to the comprehension of the functions of these muscles, especially to the levatorani muscle [20-26]

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexuality is considered as a personal and human dimension that is characterized as a strong aspect of the human personality and it is an aspect of the emotional and physical intimacy that men and women experience through their lives. Moreover, sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships [27, 28, 29]

Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors. Sexuality is present from the conception up to the dead and it consists of three interrelated and inseparable aspects, that are biological, psychological and social. In consequence, particular attention must be done to the relevance and hole of the organs related to the biological components involved in the sexuality [29, 30]. The importance of the comprehension of the possible undesirable consequences of the clinical procedures used to treat the PCa must be discussed with the patient and/or with the partner. The physiotherapist must have also knowledge about the sexuality to define specific exercises and techniques available to aid the patient with PCa in different steps of his life, as well as the limitations of these and other procedures. [6, 14]

Figure 2 shows some tools used to explain the patient about the anatomic structures directly and indirectly involved with the prostate and the structures that can be damaged in the surgery for the treatment of the PCa.

During the final stages of cancer treatment, the palliative care becomes paramount and the participation of the physiotherapist is also desirable in the interdisciplinary team. The care with the patient with cancer will contribute to minimize the progression of secondary symptoms [5, 6, 26].

The correct and appropriated mobilization of the scars to avoid adherence and important alterations in the posture of the patient is also highly relevant. This procedure contributes to the improvement of the quality of life of the patient immediatly and in the future [5].

Procedures of the physiotherapy in palliative care is also used for pain, lymphoedema, dyspnoea and other symptom assessment and treatment, as well as for the education on safe transfer and mobility management of the patient. Constipation, nausea, sleep disturbance (insomnia), anxiety, fatigue, dyspnoea, pain scores and appetite are all improved by physio-therapeutic intervention. Some of these clinical complications can be also prevented or minimized. Along the time, the lymphoedema management in the terminally diseases has developed more effectively, with evidence supporting the complex physiotherapy treatment and the integration with other professionals [5, 7, 16].

Figure 2. Tools used to explain to the patient about the anatomic structures of the pelvic floor

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