Cipla Palliative Care and Training Centre in Pune, in the state of Maharashtra in India, has provided free inpatient and home care for cancer patients and their families since 1997. Dr Mugdha Vaidya, the physiotherapist at Cipla, describes one of the weekly case presentations.
Mr M.S. aged 40, was diagnosed with squamous cell carcinoma of the tongue and admitted to our centre in February 2016. Earlier, in 2014, he was operated on for hemiglossectomy with primary reconstruction of the tongue, followed by chemotherapy and radiation. In January 2016, he received further surgery for external carotid artery ligation and marginal mandibulectomy. On being admitted to our centre, Mr M.S. complained of breathlessness, generalised weakness and right upper limb weakness.
On examination, we found that the patient had a flexed neck, slightly rounded shoulder and forward flexion of the upper back. During the first few days of his admission, the patient was dysphonic, that is breathless on minimal exertion, and thus able to walk only for a short distance. His range of movement was normal for a lower limb whereas his right upper limb was fully compromised. There was right upper limb monoparesis that was probably due to brachial plexus involvement (either resulting from the disease process or from surgery). He could only move his fingers. As per the activities of daily living assessment (ADL), much of the patient’s ADLs were affected. He was not able to feed himself, brush his teeth or comb his hair due to restricted right arm functioning.
As there was no significant complaint of pain, we started physiotherapy exercises soon after the patient’s admission. As finger movements were intact and forearm muscles were functional, we introduced therapeutic sponge balls to strengthen the forearm muscles and also gave passive wrist, elbow and shoulder exercises, a small amount of weight-bearing exercises along with postural correction. Due to this sustained introduction of physiotherapy, the patient’s shoulder complex muscles and bicep muscles started responding. Slowly, along with his earlier exercises, we replaced his passive range of motion (ROM) with active assisted ROM exercises. Quadriceps strengthening exercises were added for lower limb strengthening. Mr M.S. started to practise writing the alphabet holding a pen. The next four days saw him completing full ROM of shoulder and elbow. Gradually, we introduced strengthening exercises to manage his daily activities.
By the end of his stay at our centre, Mr M.S. was able to feed himself, brush his teeth and comb his hair using the same right arm, and we observed him practising his signature with a wide smile on his face.
- Patient cooperation and adherence increase the impact of intervention
- The intervention needs to be paced according to the patient’s comfort.
We feel confident that in this case, a physiotherapy intervention achieved an improved quality of life for our patient, which is one of the main goals of palliative care. But it was equally due to the patient’s own motivation, and perseverance with the prescribed exercises, that enabled him to get back what he thought was lost forever.
Links and resources
- Read more posts relating to physiotherapy in palliative care on the EAPC Blog.
- Potential and Possibility: Rehabilitation at End of Life: Physiotherapy in Palliative Care, Taylor, R. Simader and P. Nieland (Eds.), Elsevier (Urban & Fischer, München), 2013. (Published in English and German).
- You can read another case study from the team at Cipla Palliative Care Centre on the EAPC Blog.