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CENTENNIAL TOPICS
Systematic Review of Occupational Therapy and Adult
Cancer Rehabilitation: Part 1. Impact of Physical Activity
and Symptom Management Interventions
Elizabeth G. Hunter, Robert W. Gibson, Marian Arbesman,
Mariana D’Amico
Elizabeth G. Hunter, PhD, OTR/L, is Assistant
Professor, Graduate Center for Gerontology, University of
Kentucky, Lexington; eghunt2@uky.edu
Robert W. Gibson, PhD, MS, OTR/L, FAOTA, is
Professor and Director of Research, Department of
Emergency Medicine, Medical College of Georgia,
Augusta University, Augusta, GA.
Marian Arbesman, PhD, OTR/L, FAOTA, is
Consultant, Evidence-Based Practice Project, American
Occupational Therapy Association, Bethesda, MD;
President, ArbesIdeas, Inc., Williamsville, NY; and Adjunct
Associate Professor, Department of Clinical Research and
Leadership, School of Medicine and Health Sciences,
George Washington University, Washington, DC.
Mariana D’Amico, EdD, OTR/L, BCP, FAOTA, is
Associate Professor, Department of Occupational Therapy,
Nova Southeastern University, Fort Lauderdale, FL.
This article is the first part of a systematic review of evidence for the effectiveness of cancer rehabilitation
interventions within the scope of occupational therapy that address the activity and participation needs of
adult cancer survivors. This article focuses on the importance of physical activity and symptom management.
Strong evidence supports the use of exercise for cancer-related fatigue and indicates that lymphedema is not
exacerbated by exercise. Moderate evidence supports the use of yoga to relieve anxiety and depression and
indicates that exercise as a whole may contribute to a return to precancer levels of sexual activity. The results
of this review support inclusion of occupational therapy in cancer rehabilitation and reveal a significant need
for more research to explore ways occupational therapy can positively influence the outcomes of cancer
survivors. Part 2 of the review also appears in this issue.
Hunter, E. G., Gibson, R. W., Arbesman, M., & D’Amico, M. (2017). Centennial Topics—Systematic review of occupational
therapy and adult cancer rehabilitation: Part 1. Impact of physical activity and symptom management interventions.
American Journal of Occupational Therapy, 71, 7102100030. https://doi.org/10.5014/ajot.2017.023564
Cancer may result in impairments, activity limitations, and participation
restrictions (Fialka-Moser, Crevenna, Korpan, & Quittan, 2003; Grov, Fossa
˚,
& Dahl, 2010; Hewitt, Rowland, & Yancik, 2003; Hwang, Lokietz, Lozano, &
Parke, 2015). Cancer survivorship covers the time from diagnosis until the end of life
(National Cancer Institute, 2015). Cancer survivors may have declines in func-
tioning and participation in areas ranging from mobility to return to work (Hwang
et al., 2015; Kroenke et al., 2004; Nomori, Watanabe, Ohtsuka, Naruke, &
Suemasu, 2004). Adults with cancer experience decreased levels of physical func-
tioning and participation in social, work, and leisure activities compared with before
diagnosis regardless of the kind of cancer or type of treatment received (Ganz et al.,
2004; Grov et al., 2010). The lowest function is experienced after treatment, with
function increasing over time, although functional recovery is moderated by pain
and co-occurring diseases (Hwang et al., 2015; Ko, Maggard, & Livingston, 2003).
The Institute of Medicine and National Research Council have strongly
suggested that cancer survivor research should include expanded exploration of
alternative models of survivorship care, such as supportive care and rehabilitation
Note. Each issue of the 2017 volume of the American Journal of Occupational Therapy features a special Centennial
Topics section containing several articles related to a specific theme; for this issue, the theme is occupational
therapy’s role in cancer treatment and recovery. The goal is to help occupational therapy professionals take stock
of how far the profession has come and spark interest in the many exciting paths for the future. For more information,
see the editorial in the January/February issue, https://doi.org/10.1054/ajot.2017.711004.
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programs (Hewitt, Greenfield, & Stovall, 2006; Institute of
Medicine, 2013). However, a major problem in the U.S.
health care system is that cancer survivors are frequently not
referred for and do not receive specialized rehabilitation care
appropriate for their diagnosis (Cheville, Troxel, Basford, &
Kornblith, 2008; Pergolotti, Cutchin, Weinberger, & Meyer,
2014). Rehabilitation is the standard of care for conditions
such as heart disease or stroke but, unfortunately, not for
cancer and cancer survivorship (Cheville et al., 2008; Segal
et al., 1999).
Cancer rehabilitation can benefit people with cancer
from diagnosis to end-of-life care. The goals of cancer
rehabilitation might focus on symptom management or
helping a survivor return to work or community partic-
ipation (Gamble, Gerber, Spill, & Paul, 2011). The role
of occupational therapy practitioners is well suited to
helping cancer survivors at all stages of illness.
Objective of the Systematic Review
The objective of the cancer rehabilitation review was to
systematically search for and assess interventions within the
scope of occupational therapy practice to improve occupa-
tional engagement. The focused question guiding selection
of research studies for review was “What is the effectiveness
of cancer rehabilitation interventions within the scope of
occupational therapy practice to address the activity and
participation needs of adult cancer survivors in activities of
daily living, instrumental activities of daily living, work,
leisure, social participation, and rest and sleep?”
This systematic review was supported by the American
Occupational Therapy Association (AOTA) as part of the
Evidence-Based Practice (EBP) Project (Lieberman & Scheer,
2002). Because of the breadth of the systematic review, the
results were divided into two parts. In this article, we report
on Part 1 of the systematic review, which is focused on the
importance of physical activity and symptom management
for cancer survivors. Part 2, also in this issue, is focused on
multidisciplinary rehabilitation and interventions that address
psychosocial outcomes, sexuality, and return to work.
Method
Process
The research question and search terms for the reviews
were developed by the methodology consultant, AOTA staff,
and the advisory group in consultation with the review au-
thors. The search terms were related to population (adult
cancer survivors), types of intervention, outcomes, sequelae,
and types of study design to be included in the systematic
review. A medical research librarian with experience in
completing systematic review searches conducted all
searches and confirmed and improved the search strategies.
Databases and sites searched included Medline, PsycINFO,
CINAHL, and OTseeker. In addition, consolidated in-
formation sources, such as the Cochrane Database of Systematic
Reviews, were included in the search. Reference lists from
articles included in the systematic reviews were examined for
potential articles, and selected journals were hand searched to
ensure that all appropriate articles were included.
Inclusion Criteria
Included in the review were peer-reviewed scientific ar-
ticles on adults with cancer published in English between
1995 and 2014 and within the scope of practice of occu-
pational therapy. The review excluded data from presenta-
tions, conference proceedings, non–peer-reviewed research
literature, dissertations, and theses. The review also excluded
studies focusing on caregivers, family members, or friends
rather than cancer survivors; studies of childhood cancer; and
interventions that required an academic degree other than
occupational therapy (e.g., music therapy, neuropsychology).
AOTA uses standards of evidence modeled on those devel-
oped in evidence-based medicine (Lieberman & Scheer, 2002;
Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996):
•Level I: Systematic reviews, meta-analyses, randomized
controlled trials (RCTs)
•Level II: Two-group, nonrandomized studies (e.g., co-
hort, case control)
•Level III: One-group, nonrandomized studies (e.g.,
pretest and posttest)
•Level IV: Descriptive studies that include analysis of
outcomes (e.g., single-subject design, case series)
•Level V: Case reports and expert opinion that include
narrative literature reviews and consensus statements.
Studies included in the review provide Level I, II, and III
evidence. Level IV and V evidence was excluded from this
part of the review.
Data Extraction
The team of three reviewers (Hunter, Gibson, D’Amico)
worked together to evaluate all articles at all stages of the
review. Eligibility assessment was performed independently
in an unblended, standardized manner by the three
reviewers. Disagreements among reviewers were resolved
by consensus. The synthesis entailed a detailed reading of
the studies and completion of an evidence table describing
each study specifically. Figure 1 depicts the flow of abstracts
and articles through the process, and the evidence table
is provided in Supplemental Table 1 (available online at
http://ajot.aotapress.net; navigate to this article, and click on
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“Supplemental Materials”). The articles were grouped into
themes and analyzed and reported by theme.
Analysis
AOTA staff and the EBP Project consultant reviewed the
evidence tables to ensure quality control. Analysis of study
design, outcomes, and risk of bias determined which studies
were assessed as strong or moderate evidence. Strong evi-
dence typically includes 2 or more well-designed RCTs.
Moderate evidence includes 1 RCT, 2 or more studies
providing lower level evidence, or inconsistent findings from
well-designed projects. Only selected articles from the sys-
tematic review are mentioned in this article.
Results
The review team identified 138 articles for inclusion in the
final qualitative synthesis; 86 articles are included in this
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of physical activity and symptom
management studies included in the systematic review.
Note. PAMs 5physical agent modalities. Format from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by
D. Moher, A. Liberati, J. Tetzlaff, and D. G. Altman; The PRISMA Group, 2009, PloS Medicine, 6(6): e1000097. https://doi.org/10.1371/journal.pmed.1000097
The American Journal of Occupational Therapy 7102100030p3
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article (Part 1). The remainder are discussed in Part 2. The
articles provide Level I evidence, with the exception of 1 Level
III article. Articles were organized into two broad intervention
areas: (1) physical activity interventions, including exercise (25
articles) and complementary and alternative medicine
(CAM; 26 articles), and (2) symptom management in-
terventions, including pain, fatigue, and breathlessness (19
articles); lymphedema (12 articles); and physical agent
modalities (PAMs; 4 articles). Details about each article are
giveninSupplementalTable1(online).
Risk of Bias
The risk of bias of individual studies was assessed using
the Cochrane risk-of-bias guidelines described by Higgins,
Altman, and Sterne (2011; see Supplemental Table 2,
online). The method for assessing the risk of bias of
systematic reviews was based on the Assessment of Mul-
tiple Systematic Reviews (AMSTAR) system developed
by Shea et al. (2007; see Supplemental Table 3, online).
Physical Activity Interventions
Twenty-five Level I articles related to exercise met the
criteria for the review; 11 were systematic reviews and 14
were RCTs. Twenty-six Level I articles related to com-
plementary and alternative medicine met the criteria and
were included in the review; 21 were systematic reviews
and 5 were RCTs. CAM physical activity interventions
included yoga, Qigong, Tai Chi, and dance.
Strong Evidence. Strong evidence was found that ex-
ercise is safe and beneficial for the majority of cancer types,
at all stages including end of life, and regardless of age
(Adamsen et al., 2009; Albrecht & Taylor, 2012; Baumann,
Zopf, & Bloch, 2012; Beaton et al., 2009; Daley et al.,
2007; Henke et al., 2014; Hwang et al., 2008; Spence,
Heesch, & Brown, 2010). Exercise, particularly aerobic
exercise, reduced cancer-related fatigue (CRF; Andersen
et al., 2013; Kuchinski, Reading, & Lash, 2009; McMillan
& Newhouse, 2011; McNeely et al., 2006). Exercise
also increased muscle tone and strength and lung capacity
(Granger, McDonald, Berney, Chao, & Denehy, 2011;
Keogh & MacLeod, 2012). Exercise was found not to
cause lymphedema or to make existing lymphedema
worse (Cormie et al., 2013; McClure, McClure, Day, &
Brufsky, 2010).
Moderate Evidence. Moderate evidence was found that
exercise improves health-related quality of life (HRQOL)
for some survivors. Rehabilitation using physical training
(strength, interval, and home-based activities) was signifi-
cantly better than usual care in terms of HRQOL (Basen-
Engquist et al., 2006; Beaton et al., 2009; Korstjens et al.,
2008). Supervised exercise was better than nonsupervised
exercise (Knols, de Bruin, Shirato, Uebelhart, & Aaronson,
2010), and counseling and telephone support were helpful
in keeping people exercising (Knols et al., 2010). Diet and
exercise interventions reduced the rate of self-reported
functional decline (Morey et al., 2009; Rogers et al., 2009).
Exercise improved sleep quality for people undergoing
cancer treatment (Sprod et al., 2010; Tang, Liou, & Lin,
2010).
Moderate evidence was found that yoga, regardless
of type, benefits mental health, quality of life, sleep, and
sense of well-being and decreases stress (Cramer, Lange,
Klose, Paul, & Dobos, 2012; Harder, Parlour, & Jenkins,
2012; Mustian et al., 2013; Shneerson, Taskila, Gale,
Greenfield, & Chen, 2013). Qigong improved quality of
life, mood, fatigue, and immune response and reduced
inflammation (Chan et al., 2012; Oh et al., 2012; Zeng,
Luo, Xie, Huang, & Cheng, 2014).
Symptom Management Interventions
Nineteen articles addressing pain, fatigue, and breath-
lessness in cancer patients and survivors met the criteria for
the review; 5 were systematic reviews, and 14 were RCTs.
Twelve articles related to lymphedema treatment; 6 were
systematic reviews, 5 were RCTs, and 1 was a Level III
study. Finally, 4 articles related to the use of PAMs to treat
lymphedema met the criteria for the review; 1 was a
systematic review, and 3 were RCTs.
Strong Evidence. Strong evidence was found that ex-
ercise reduces CRF and increases quality of life (Kuchinski
et al., 2009; Wanchai, Armer, & Stewart, 2011). Non-
pharmacological interventions, such as problem solving,
energy conservation, and education, reduced the symptom
of breathlessness (Corner, Plant, A’Hern, & Bailey, 1996;
Zhao & Yates, 2008). The use of neuromuscular electrical
stimulation in conjunction with traditional swallowing
training facilitated greater recovery than swallowing training
alone for adults after head and neck cancer treatment (Ryu
et al., 2009).
Regarding lymphedema management, compression
bandages worn on a daily basis were found to be important
for volume control (Devoogdt, Van Kampen, Geraerts,
Coremans, & Christiaens, 2010; Kim & Park, 2008;
King, Deveaux, White, & Rayson, 2012; Preston, Seers,
& Mortimer, 2004). Exercise was found not to make
lymphedema worse and to improve mood, quality of life,
range of motion, and weight loss (Kim, Sim, Jeong, &
Kim, 2010; McClure et al., 2010).
Moderate Evidence. Moderate evidence was found sup-
porting sleep therapy modifications, education and problem
solving for pain management, and cognitive–behavioral ther-
apy in CRF management (Armes, Chalder, Addington-Hall,
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Richardson, & Hotopf, 2007; Berger et al., 2009; Gielissen,
Verhagen, Witjes, & Bleijenberg, 2006; Jacobsen, Donovan,
Vadaparampil, & Small, 2007; Ling, Lui, & So, 2012;
Oldenmenger, Sillevis Smitt, van Montfort, de Raaf, &
van der Rijt, 2011). Moderate evidence also supports the
use of PAMs, including low-frequency, low-intensity
electrotherapy to reduce feelings of pain, heaviness, and
tightness when treating lymphedema of the arm (Belmonte
et al., 2012).
Discussion
Part 1 of the systematic review provides evidence that
physical activity is helpful for people diagnosed with
cancer. The type of physical activity in these studies
was varied and included aerobic, light and heavy re-
sistance, walking activities, aquatic exercise, yoga, Qigong,
and Tai Chi, among others. Occupational therapy prac-
titioners can help clients incorporate physical activity into
their daily routines to enhance health, wellness, and
quality of life. Physical activity can help reduce CRF,
improve the quality of sleep, increase physical function,
and increase HRQOL regardless of type or stage of cancer.
It is beneficial for some clients pretreatment and for most
clients during and after treatment (Spence et al., 2010).
Strong evidence indicates that exercise, including
resistance, aerobic, or a combination of the two, does not
exacerbate lymphedema and provides other physical and
mental health benefits. Moderate evidence exists for the
use of CAM; the strength of this evidence is negatively
affected by the quality of the studies and high risk of bias.
Moderate evidence supports the use of the CAM interventions
of yoga, Qigong, and mindfulness-based interventions to
improve quality of life and mental health outcomes.
Symptom management is another area in which oc-
cupational therapy intervention is useful. The most com-
mon symptoms assessed in the literature were pain, fatigue,
and breathlessness. Occupational therapy practitioners
should include exercise and other physical activity and
occupation-based interventions such as problem solving,
energy conservation, and education to address these symp-
toms. Cognitive–behavioral therapy and psychoeducational
programming also can be useful in treating CRF. Ad-
ditionally, occupational therapy practitioners can feel
confident in suggesting physical activity to clients with
lymphedema.
Many studies were found that addressed treatment of
lymphedema, but the majority did not qualify for this
review because they addressed only arm volume and not
functional outcomes. The studies included in the review
show strong support for the use of compression bandages
to improve functional outcomes, particularly when com-
bined with therapy that includes skin care, range of motion,
and strengthening.
Overall, the evidence indicates that use of PAMs can
be beneficial in treating lymphedema for some people
diagnosed with cancer. PAMs can improve the pain
that accompanies lymphedema, along with the feelings
of heaviness and tightness. Currently, no evidence indicates
that transcutaneous electrical nerve stimulation improves
chronic pain among cancer survivors.
Three major gaps exist in the research examining
cancer rehabilitation interventions. First, more high-
quality, rigorous study designs are needed to provide the
best, most reliable results. Second, most studies were not
specific about the use of or return to meaningful activities
and participation for either assessments or outcomes.
Third, only a handful of the studies examined occupation-
based interventions. As occupational therapy practitioners
develop and take part in high-quality studies in the area of
cancer rehabilitation, they should ensure that these studies
include outcomes that go beyond physical function to
address activity and participation.
Implications for Occupational
Therapy Practice
Most studies in this review are within the scope of
occupational therapy practice but lack a focus on im-
portant outcomes of function and participation. This
evidence should be viewed as indicating initial steps to-
ward achieving functional outcomes and not achievement
of the outcomes themselves. Occupational therapy prac-
titioners must interpret and apply this evidence within
their unique professional understanding of function, en-
gagement, and participation.
Occupational therapy practitioners can use a wellness
or health promotion approach to encourage meaningful
activity and exercise. AOTA (n.d.) has called on prac-
titioners to help people prevent and manage chronic
disease through a health and wellness model. Practi-
tioners can feel confident in incorporating physical ac-
tivity into their practice because strong evidence indicates
that exercise helps in multiple ways (e.g., mental health,
physical health, symptom management) and does not make
symptoms worse (i.e., lymphedema, fatigue). Exercise is
clearly beneficial, but it does not have to consist of lifting
weights at the gym; yoga and Qigong were found to be
beneficial as well. Physical activity is helpful for maintaining
weight, increasing muscle strength, improving sleep, and
reducing cancer-related fatigue (CRF), among other positive
outcomes.
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Occupational therapy practitioners are well suited to
conduct individual and group yoga, Qigong, and mind-
fulness interventions to improve symptom management,
mental health, quality of life, participation in daily living
occupations, and social engagement. These are important
factors for cancer survivors and are not always addressed as
fully as they could be. Practitioners need to keep in mind
that cancer survivorship symptom management is far more
than lymphedema care. Although this is the symptom
rehabilitation professionals have focused on most fully,
CRF, pain, sleep disorders, and breathlessness are more
common and less often addressed.
Implications for Research
More rigorous, better designed research is needed to provide
a greater understanding of which people need what type of
intervention at what point in their cancer care and survi-
vorship. Specifically, more research is needed that focuses on
participation outcomes and occupation-based interventions.
The area of exercise is the best researched and has the
most robust outcomes in terms of cancer survivorship and
cancer rehabilitation, but the occupational therapy focus
of participation and occupation is missing in this research.
Most of the exercise studies looked at the use of traditional
exercise as an intervention; the occupational therapy point
of view might provide a richer understanding of how to in-
corporate the broader idea of physical activity into a client’s life.
In terms of symptom management, most interventions
were not conducted by occupational therapy practitioners.
The vast majority were conducted by nurses, social workers,
or psychologists. Occupational therapy–specific studies are
needed that look at return to participation and occupation-
based interventions as they relate to managing symptoms in
cancer survivors. In general, few of the studies moved into
the realm of occupation, particularly in terms of outcomes.
Occupational therapy researchers could make strong con-
tributions toward filling this gap in research.
Limitations
Limitations of the systematic review result from limitations
in the individual studies’ designs and methods, including
small sample sizes, short intervention periods, limited use of
standardized assessment, and short follow-up periods. Many
studies included multiple interventions, so pinpointing the
effects of any single intervention may not be possible. Fi-
nally, the role of occupational therapy in the multidisci-
plinary interventions was seldom discussed. Many studies
focused on impairment interventions and the outcomes of
symptom management and quality of life rather than the
occupational therapy’s concern with function, occupational
engagement, performance, and social participation.
Conclusion
Occupational therapy practitioners working with survivors
of cancer of all types, stages, and points on the survivorship
continuum have a body of evidence to support current
and future practice. More research is needed to support
occupation-based interventions geared toward positive
activity and participation outcomes for this large and
continually growing population. s
Acknowledgments
We thank Deborah Lieberman, Program Director, AOTA
Evidence-Based Practice Project, for her guidance and
support during the process of this review. Marian Arbesman
is Methodology Consultant, AOTA Evidence-Based Practice
Project; no other potential conflicts of interest are reported.
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