I was hoping for some guidance with using manual therapy in the presence of prostrate cancer. I have a patient referred with low back pain with recent history of prostate cancer and was wondering how most of you handle this type of patient. My typical approach is hands off and exercise only. However I am starting to see more physicians refferring patients with mechanical pain and history of CA in that area and they feel manual therapy is okay.
I always thought this was a contraindication - any advice.
Joined: August 25, 2000
I would be weary about where the cancer is located or where it spread to, especially if it was in the lower extremities and perfoming heavy activities. Yes, I too would also be concerned about a pathological fracture.
I should have clarified that CA is recent in the past 2 months but according to patient it so far under control. I realize MT would not be contraindicated if a past history but I am speaking more of those currently in the initial year of treatment.
Joined: May 11, 2004
If the cancer hasn't metastasized and the primary tumor is "under control," there is nothing that contraindicates any manual treatment. Maybe in some of the cases the pain IS mechanical in nature because of the positioning and the time in position for cancer treatments OR evaluation of the cancer tumor itself OR some of the positions the patient maintains during the day as a result of cancer treatments or pain. I have zero concerns about a pathological fracture if 1) the original tumor isn't within bone and 2) if the tumor hasn't metastasized.
There are other cases where the person has tumors metastasized to the bone - even lower extremity bones. You know what? We can be concerned about pathological fractures... but the choices always rest on the patient. It is our role to educate. I had a lady whom I was treating who had cancer metastasize to her hip joint. She wanted to go horseback riding with her daughter. Quite a risky activity, especially considering she was also on coumadin. You know what - I did mention the risks of riding the horse... internal bleeding from a fall or a toss IF an accident occurred which could lead to death... sure, a pathological hip fracture from riding... but you know, she wanted to ride and she wanted to be able to spend some time with her daughter before she died. So, we discussed the choices of horses and we discussed saddles and we discussed forms of riding. Yep, she rode. Sure, it was a major risk she took. You know what though, I know I would have done the same thing. She wasn't going to live the life she had left in a world of "what if's" and fear - she made her decision and rode as safely as she could to achieve her greater goal - more bonding and a closer relationship with her daughter.
I am curious about your take on an "under control" cancer that hasn't metastisized doens't contraindicate manual therapy. I was always under the impression that manual therapy was contraindicated in any active cancer due to the risk of mestastisis.
The experience of massage during chemotherapy treatment in breast cancer patients. Billhult A, Stener-Victorin E, Bergbom I.Department of Physiotherapy, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden.
This study aimed to describe the experience of massage for breast cancer patients during chemotherapy treatment. Ten patients received massage at five occasions. They were interviewed and analysis was conducted using Giorgi's ideas of phenomenological research. The essential meaning of getting massage during chemotherapy was described as a retreat from the feeling of uneasiness toward chemotherapy. Results revealed five themes: the patients experienced distraction from the frightening experience, a turn from negative to positive, a sense of relaxation, a confirmation of caring, and finally they just felt good. In conclusion, the findings of this study show that massage offered a retreat from uneasy, unwanted, negative feelings connected with chemotherapy treatment. It is a treatment that can be added to the arsenal of treatment choices available to the oncological staff.
Safety and efficacy of massage therapy for patients with cancer. Corbin L.Department of Rehabilitation Medicine, University of Colorado Health Sciences Center, The Center for Integrative Medicine at the University of Colorado Hospital, Aurora 80045, USA. email@example.com BACKGROUND: As the popularity of complementary/alternative medicine (CAM) grows, patients are incorporating more CAM therapies into their conventional cancer care. Massage therapy, a CAM therapy known primarily for its use in relaxation, may also benefit patients with cancer in other ways. Massage can also be associated with risks in the oncology population. Risks can be minimized and benefits maximized when the clinician feels comfortable discussing CAM with his or her patients. This article reviews and summarizes the literature on massage and cancer to help provide the clinician with information to help facilitate discussions with patients. METHODS: MEDLINE and CINAHL databases were searched to identify relevant articles. These were reviewed for content and other pertinent references. RESULTS: Significant information was extracted from these resources to provide this overview of the use of massage for patients with cancer. CONCLUSIONS: Conventional care for patients with cancer can safely incorporate massage therapy, although cancer patients may be at higher risk of rare adverse events. The strongest evidence for benefits of massage is for stress and anxiety reduction, although research for pain control and management of other symptoms common to patients with cancer, including pain, is promising. The oncologist should feel comfortable discussing massage therapy with patients and be able to refer patients to a qualified massage therapist as appropriate.
SJ is right. The only real risk, assuming no mets to bone is the risk of not helping these folks with real neuromusculoskeletal problems and pain. We certainly don't want to be associated in discovering mets (that weren't previously known) to bone by causing a fracture, but it would be discovered at some point anyway.
I tend to aggree with those who say that unless there is evidence of mets to the bone (and thus risk of fracture with mobs) then it would make sense to proceed with caution.
However, it is typically taught in school and MT courses that manual therapy in the area of a malignancy is contraindicated do to the risk of actually causing mets with a mobilzation technique.
I know many people will argue, and I aggree, that joint mobilizations of the cervical spine should not have enough physiological impact on the system to cause a malignancy to metastisize. But the real issue here is that there is no evidence to prove that this is not a possibility and thus I have always had the stance that I don't want to be the last person who has done something manually assocaited to that area and then later find out the cancer had spread. Who will the patient look at.
It is the same reason MT - joint mobs and manips, is often taught as a contraindication during pregnancy. Even though there is a lot of joint and ligament laxity - careful joint mobs when needed have there place. However, spontaneous abortion is highest in the first trimester when many of these individuals are first seeking help. The question again is do you want to be the person who did an SI mob to that individual and then they have a spontaneous abortion the next day. There is no evidence to support that mobs would have caused this but do you want to put yourself in that situation.
Joined: February 14, 2003
From: Madison WI USA
Kaden, You are teetering on the edge of reasonable caution, and outright paranoia.
There is no evidence that a forceful sneeze doesnt cause metastasis because of the resultant head and neck movement. In addition, CA mets and pregnancy is not an apples to apples comparison, but rather an apples to basketballs. Sure, both are round, but you really cant eat one of them. With pregnancy, this desire to avoid manipulation is a reasonable precaution because you are affecting the tissues close to the child. With cancer, who is to say that walking around wont increase circulation enough to cause mets? Yet, folks with CA are not told to move as little as possible. Lying in sidelying on the trochanter doesnt cause mets, so what makes you think manual pressure on a vertebra it is even in the spectrum of possibility? Your desire to not make the patient look your way if mets were to be found is understandable, but there is no way, I repeat, no way that this could be connected with your mobilizing forces.
How can you make the claim that it is a reasonable precaution in pregnancy b/c you are affecting the tissues close to the child but the same not hold true with affecting the tissues close to a malignancy.
Don't get me wrong Shill, I aggree with you take on the issue. I am just playing devils advocate b/c these questions will be asked to us by patients, doctors, etc.
Does anyone know if malignancy (in the are of treatment of couse) is still being taught in shcools as a contraindication to therapy?
I bring up these points b/c if what is being taught in schools and manual therapy programs is that it is a contraindication then this is the standard we will be held to.
Joined: February 14, 2003
From: Madison WI USA
Kaden, WAIT. I messed up. You are talking about lumbar pain. For some reason, I was thinking you said cervical pain, which would be a fair distance from the prostate in most people. You did not say this, so I understand your confusion with my prior response. Nevertheless, my answer is the same, there is really no reason for extreme concern, as manual therapy isnt going to do anything different to the tissues that regular daily movements would. The proximity issue is an issue in pregnancy, but not CA, again reasonable caution versus avoiding what could be helpful therapy out of irrational fear. Thats how I feel, and I am sticking to it. Look for a study that shows that mets can occur with manual therapy, and I doubt you find a controlled study that compares rates of problems to those who didnt have manual therapy. This person is already sick, and mets can occur without the patient doing anything other than living. If it were to occur in an area treated, there is no way to differentiate that it occurred from what someone did.
Mobilization and manipulation are not key factors in causing a tumor to metastasize. Often times, when someone has cancer, that person is monitored quite frequently. Blood tests can give an indication as to whether cancer numbers are increasing, decreasing or maintaining. Tumors metastasize all on their own and don't require manual intervention to jump start the process. The probability of metastasizing depends on the type of cancer. Gene expression also plays a significant role.
I have no idea what is being taught in schools. Just because something has been taught in school doesn't mean the information is/was accurate anyways. If I listened to everything I was taught is school, every patient would be discharged when they were completely 100% perfect (unrealistic). I'd never, ever manipulate anyone (manipulation requires intense training and is dangerous). I'd always be doing ultrasound because it is a form of deep heat and heals tissues.
And some evidence... generally speaking, physical therapists aren't going to be blamed for much. Why? Evidence indicates that we tend to listen and we tend to spend time with patients. I'd look into the area of risk management if you are as concerned as you are. I definitely wouldn't use what is taught in school as a standard - sometimes what is taught is behind the actual evidence out there. Let the evidence or the lack of evidence guide you - both clincally and legally.
Thanks for the info. And by the way I aggree with both of you on your take that there is no harm to manual therapy in this case. I simply wanted to post this issue b/c many references including MT books, peer reviewed journals, con ed courses and schools still teach that it is a contra-indication to manual therapy. It is good to see that others are starting to question things.
The only question I have for both of you is how you educate a patient regarding this subject. True we don't have evidence that show MT can cause mets but we also don't have evidence out there that says it can't cause mets. ....and thus are we leaving our selves open to the possibility of being blamed for mets.
Joined: February 14, 2003
From: Madison WI USA
Kaden, I tell them exactly what I told you. The only potential metabolic effect of manual therapy is increased circulation. I tell them that heat also increases circulation, as do hot tubs, exercise, and breathing deep. So, "the effect of my moving your joints would be the same as these other things that you do on a regular basis".
Joined: May 11, 2004
If I have a woman who just had breast cancer and is coming to physical therapy for shoulder pain and her cancer numbers are down in the normal range, I mobilize the shoulder if that's what needs to be done. I do not discuss a potential chance for metastasizing because there is no research out there that indicates that mobilizing the shoulder will cause a breast cancer tumor that has been removed/radiated to metastasize. The determining factors for metastasizing is the type of breast cancer and the gene expressions - neither of which I can control. And frankly, the oncologists discuss this with patients - the likelihood of metastasizing, especially after biopsy of lymph nodes combined with the pathology report on the type of cancer.
Now, if I have a patient beginning physical therapy 4 or 5 years post cancer diagnosis (or less time, I'm just tossing out numbers) and the patient has been referred for back pain... IF the patient hasn't had any diagnostic tests by the oncologist within the last 2-4 months, I contact the oncologist and communicate the current complaints. Now, I don't clinically do this because I'm afraid of being sued if I mobilize or manipulate the spine; I don't do this because I'm afraid that I might cause a pathological fracture; I simply do this because IF the person has back pain because of an unknown metastasized tumor, physical therapy is NOT the service required at that point in time to potentially resolve the issue. IF metastasis is the reason for the complaints, the oncologist has to be involved to determine the medical interventions to address the cancer. Generally speaking, the oncologist immediately orders a CT scan and bloodwork.... generally speaking someone in the oncologist's office provides diagnostic test results within 2 days to me.
Technically, I believe the cancer research isn't indicating that "heat" or "increase circulation" cause tumors to metastasize. Increased circulation just moves any metastasized tumor in the blood at a faster rate. Having tumor cells in the blood isn't the whole problem, it is whether the tumor cells will bind on another organ and whether once bound the cells can acquire some sort of blood supply. The cells don't break off into the bloodstream because of exercise or manual interventions, that aspect is depending on how cohesively bound the tumor cells are. Cancer research is actually indicating that resistance exercise and aerobic activities should become a part of life after cancer.
Anyone can sue for any reason. Yes, we ALL have the potential of being sued for anything - anything under the sun. The claims by those suing us would have to prove beyond a reasonable amount of doubt that we were factor that caused mets. The evidence isn't there. And then... even if the evidence isn't there, believe it or not, your employer may just settle out of court and pay fines/fees or whatever so that the company name is not ruined AND to reduce the financial costs of actually going to court. Are there any court cases out there in which a physical therapist was sued for causing a met? I doubt it...
I agree with SJBird55 in what he has stated thus far. There are no mets and manual therapy will not affect this. The best thing you can do for your patient is to listen to his complaints so that if he does report red flag symptoms (night sweats, fever, chills, etc.) one day then you can immediately send him to the doc.