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Physiotherapy Management: Complex Oncology Case

70-Year-Old with Laryngeal Tumor, D9 Vertebral Metastasis, Canal Stenosis, Permanent Paraplegia & Permanent Tracheostomy

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Case Summary & Framework

• Prevent secondary complications (pressure injuries, contractures, DVT, pneumonia)
• Maximize residual function and upper limb independence
• Optimize respiratory status through the permanent tracheostomy
• Maintain quality of life and dignity in a 70-year-old with advanced cancer

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1. INITIAL ASSESSMENT (within 24–48 hours)

Mandatory Assessments

Critical principle: No physiotherapy should begin without spinal stability clearance from the treating surgeon or oncologist. Unstable SINS score (≥13) requires spinal precautions.

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2. RESPIRATORY PHYSIOTHERAPY (Highest Priority Given Tracheostomy)

2A. Tracheostomy Management (Permanent)

• Intercostal muscle weakness (T9 level — partial preservation of intercostals above)
• Potential laryngeal/tracheal compromise from primary tumor
• Age-related reduced mucociliary clearance

• Sterile/aseptic technique, sterile gloves at all times
• Maximum 2 passes per procedure
• Suctioning pressure: 100–200 mmHg in adults
• Apply suction only as catheter is withdrawn (not on insertion) — prevents mucosal damage
• Catheter insertion limited to ~15 cm into tracheostomy tube
• Suction catheter diameter = half the tracheostomy tube diameter
• Hyperoxygenate for 1 minute before and after suctioning

• Active Cycle of Breathing Techniques (ACBT): breathing control → thoracic expansion exercises → forced expiration technique (FET/"huff")
• Autogenic Drainage (AD): tidal volume manipulation at low, mid, and high lung volumes
• Manual Assisted Cough (MAC): therapist applies anterior-superior abdominal thrust synchronized with patient's expiratory effort — critical since intercostals are partially compromised
• Mechanical Insufflation-Exsufflation (MI-E / "CoughAssist"): strongly recommended for high thoracic SCI — applies positive pressure then rapid negative pressure to simulate cough; evidence supports use in SCI-related respiratory dysfunction
• Postural drainage: Modified positions considering spinal precautions
• Humidification: essential with permanent tracheostomy to prevent mucus plugging — heated humidifier or heat-moisture exchanger (HME)

• Inspiratory Muscle Training (IMT) with a threshold device — systematic review (Tamplin & Berlowitz, Spinal Cord 2014) confirms significant improvement in inspiratory muscle strength in SCI patients
• Upper limb breathing exercises to recruit accessory muscles (scalenes, sternocleidomastoid, pectoralis — preserved above T9)

• Upright sitting (45–90°) improves diaphragmatic excursion
• Abdominal binder when upright — supports diaphragm and improves expiratory pressure in thoracic SCI

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3. NEUROLOGICAL PHYSIOTHERAPY — PARAPLEGIA MANAGEMENT

3A. Spinal Precautions

• Confirm with surgeon: spinal orthosis requirements (rigid TLSO vs. soft brace vs. log-roll precautions)
• Logroll technique for all position changes until stability confirmed
• No unsupported sitting until spine is cleared

3B. Passive Range of Motion (PROM)

• All lower limb joints: hip (flexion/extension/abduction), knee, ankle (especially ankle dorsiflexion to prevent equinus contracture/drop foot)
• Frequency: twice daily
• Rationale: prevents contractures, maintains joint integrity, maintains circulation (GAIN MSCC guidelines, evidence level B)

3C. Upper Limb Function (Critical for Independence)

• Strengthening: progressive resistance training for shoulder depressors (triceps, latissimus dorsi, pectorals) — essential for wheelchair propulsion and transfers
• Systematic review (Santos et al., J Bodyw Mov Ther 2022, PMID 35248264): resistance training significantly improves muscle strength in SCI — should be incorporated
• Functional task training: reaching, gripping, ADL skills
• Wheelchair prescription: appropriate manual or power wheelchair with pressure-relieving cushion

3D. Positioning & Pressure Injury Prevention

• Pressure relief lifts: every 15–30 minutes when sitting — weight shifts/push-ups
• Turning schedule: every 2 hours in bed — document on a turning chart
• Pressure-relieving mattress: alternating pressure or high-specification foam (NICE CG179)
• Heel protection: foam boots/pillows under calves to float heels
• Skin inspection: twice daily — bony prominences (sacrum, ischials, trochanters, heels, ankles)

3E. Spasticity Management

• Passive stretching: 20–30 minutes sustained stretch, daily
• Positioning splints: resting foot splints in neutral to prevent equinus
• Neurodynamic mobilisation: carefully
• Input to medical team regarding pharmacological management (baclofen, tizanidine) if spasticity impairs function or causes pain

3F. Sitting Balance & Transfers

• Progressed carefully once spine is cleared as stable
• Supported sitting → unsupported sitting → assisted pivot/sliding board transfers
• Transfer training: bed ↔ wheelchair ↔ commode
• Sliding board (banana board) transfers are standard for T9 paraplegia
• Hoist assessment if transfers unsafe

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4. PAIN MANAGEMENT (Integrated Throughout)

• Optimise analgesia before physiotherapy (GAIN MSCC guideline — mandatory)
• TENS (Transcutaneous Electrical Nerve Stimulation): useful for neuropathic/cancer-related pain, avoid over tumor sites and insensate areas
• Positioning and support: careful pillow positioning to reduce mechanical pain
• Heat/cold therapy: avoid over insensate skin (risk of burns)
• Collaborate with palliative care team for opioid optimization
• NCCN Cancer Pain Guidelines (v1.2023) recommend structured analgesic protocols before any therapeutic activity

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5. BLADDER & BOWEL (Physiotherapy Contribution)

• Intermittent Catheterization (IC) program: educate patient/caregivers — standard for T9 SCI; timing typically every 4–6 hours
• Bowel program: upright positioning post-meals to use gravity; digital rectal stimulation protocol; prevent constipation (opioids worsen this)
• Physiotherapy teaches Valsalva manoeuvre modifications (modified due to tracheostomy — no glottic closure possible)

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6. CARDIOVASCULAR & THROMBOEMBOLIC PREVENTION

• Deep Vein Thrombosis risk is very high (immobility + cancer + age + paraplegia)
• Lower limb compression: TED stockings or compression bandaging (unless contraindicated by tumor involvement)
• Passive leg exercises: ankle pumps, knee/hip passive cycling
• Ensure medical team has initiated pharmacological VTE prophylaxis (LMWH)
• Graduated mobilization program as tolerated

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7. FUNCTIONAL REHABILITATION GOALS (Realistic for This Patient)

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8. PALLIATIVE REHABILITATION FRAMEWORK (Dietz Model)

• Preventative: prevent complications in a patient who may have reasonable function (before deterioration)
• Supportive: maximize independence with permanent deficits
• Palliative: comfort, dignity, symptom control when disease progresses

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9. MULTIDISCIPLINARY TEAM (MDT) — Essential

• Oncologist: disease trajectory, further treatment options (radiotherapy to D9 may reduce tumor burden)
• Surgeon: spinal stability status
• Palliative care: symptom control, goals of care discussion
• Speech & Language Therapist: tracheostomy speaking valve (Passy-Muir) assessment if appropriate — important for communication and QoL in laryngeal tumor patient
• Occupational Therapist: upper limb ADLs, home adaptations, wheelchair seating
• Dietitian: nutritional support (tracheostomy/laryngeal tumor may affect swallowing)
• Psychologist/Social Worker: coping, family support, discharge planning
• Specialist nurse: tracheostomy and stoma care

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10. SPECIAL CONSIDERATIONS FOR AGE (70 years)

• Reduced physiological reserve — shorter, more frequent sessions (20–30 min, 2× daily > 1× long session)
• Polypharmacy risk — check for drugs impairing balance/cognition (opioids, steroids)
• Frailty assessment (Clinical Frailty Scale) — modify intensity accordingly
• Systematic review (Ni et al., Cancer Invest 2026, PMID 41606818): exercise management in frail elderly cancer patients improves chemotherapy tolerance and reduces complications — supports structured physiotherapy even in this group

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Key Evidence Sources

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Summary Priorities (Ranked)

1. Respiratory/tracheostomy physiotherapy — secretion clearance, suctioning protocol, humidification, MAC, MI-E
2. Pressure injury prevention — turning schedule, positioning, skin inspection
3. Contracture prevention — passive ROM twice daily, foot splints
4. Upper limb strengthening — for independence in transfers and wheelchair
5. Pain control before every session — analgesic pre-medication
6. DVT prevention — compression, passive exercises, mobilization
7. Transfer training — sliding board, hoist safety
8. Patient/family education — tracheostomy care, pressure relief, bowel/bladder program
9. Psychological support — maintain dignity, realistic goal-setting, advance care planning discussion

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Home-Based Physiotherapy Exercise Program

Complete Paraplegia (D9) — No Sensory or Motor Function Below T9

1. Caregiver-assisted exercises — for the paralysed lower limbs (patient cannot do these alone)
2. Patient self-directed exercises — upper limbs and trunk (fully preserved at T9)

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⚠️ SAFETY RULES BEFORE ANY EXERCISE

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PART A: CAREGIVER-PERFORMED EXERCISES (Lower Limbs)

Passive Range of Motion (PROM) — 2× Daily, 10 repetitions each

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🦵 HIP EXERCISES (Patient lying flat on back)

• Caregiver supports leg at knee and ankle
• Gently bend the knee, bring it toward the chest
• Hold 3–5 seconds at end range, return slowly
• Normal range: 0–120°
• Prevents hip flexor shortening

• Patient lies on side; caregiver gently moves leg backward (hip extension)
• Hold 3 seconds, return
• Prevents hip flexion contracture — most common in bed-bound patients

• Caregiver supports at knee and ankle, leg straight
• Slide leg out to the side (away from midline), return
• Keep opposite leg still
• Normal range: 0–45°
• Prevents adductor tightness, improves perineal hygiene access

• From abducted position, bring leg back to midline
• Do not cross midline excessively

• Leg flat, knee straight; caregiver gently rolls leg inward and outward
• Small, slow movements — 10 each direction
• Reduces risk of hip contracture affecting seated posture

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🦵 KNEE EXERCISES

• Caregiver supports at thigh and heel
• Gently bend knee toward buttock (heel toward bottom), then straighten
• Normal range: 0–135°
• Critical — prevents knee flexion contracture which worsens sitting and transfers

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🦶 ANKLE EXERCISES (Most Critical)

• Caregiver cups heel in one hand, forearm along the sole of foot
• Gently push the foot upward (toes toward shin) — lean body weight forward
• Hold 30–60 seconds (sustained stretch is more effective than repetitions for contracture prevention)
• Do 3× per session, each ankle
• Target: 90° or neutral — loss of this range makes transfers and standing frames impossible

• Point the foot downward — full range
• Then cycle between dorsiflexion and plantarflexion slowly (10 reps) to promote circulation

• Rock the foot inward and outward slowly
• Maintains subtalar mobility, prevents ligament tightening

• Gently extend all toes upward, hold 5 seconds
• Then flex toes down, hold 5 seconds
• Prevents toe flexion contractures

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🩹 SKIN PROTECTION EXERCISES

• When lying, place a folded pillow/foam under the calf so heels are completely off the mattress
• Hold this position throughout rest periods
• Heels are the #1 pressure injury site in paraplegics — this is non-negotiable

• Every 2 hours — caregiver turns patient: back → right side → back → left side
• Maintain 30° tilt (not full lateral), using foam wedge
• Document on a turning chart on the wall

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PART B: PATIENT SELF-DIRECTED EXERCISES (Upper Limbs + Trunk)

T9 = Full upper limb function. This is where independence is built.

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💪 UPPER LIMB STRENGTHENING — 3 sets × 10 reps, 3×/week

• Set shoulder down and back before every exercise (scapular retraction)
• Do NOT shrug shoulders
• Hold each rep for 1 second, return slowly (eccentric phase is just as important)
• Use a chest strap or body brace for trunk support if needed in early phases

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• Arm at side, slowly raise straight arm forward to shoulder height (90°) or overhead
• Return slowly
• Builds deltoid anterior, serratus anterior — essential for overhead reaching

• Raise arm out to the side to shoulder height, elbow straight
• Avoid shrugging
• Builds middle deltoid — important for wheelchair propulsion and weight relief lifts

• Elbow bent at 90°, upper arm at side; rotate forearm outward
• Use resistance band fixed to wheelchair or bedframe
• Critical for rotator cuff health — prevents shoulder impingement, the #1 overuse injury in wheelchair users

• With resistance band in front: pull elbow backward toward hip (row motion)
• Squeeze shoulder blade back at end range
• Builds rhomboids, posterior deltoid, biceps — key for transfers and pressure relief lifts

• Arms straight, move both arms backward to form a "T" position
• Bands anchored in front
• Strengthens posterior shoulder girdle, reduces injury risk

• Elbow at side, bent; straighten arm backward
• Triceps are the primary muscle for wheelchair push-up pressure relief — must be strong

• Standard curl with bands or weights
• Transfer strength, ADL tasks

• Band overhead or at shoulder height; push forearm downward
• Strengthens triceps for wheelchair push-ups

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🏋️ PRESSURE RELIEF PUSH-UPS — Every 15–30 Minutes (in wheelchair)

• Both hands on wheelchair armrests or wheels
• Push down with both arms, lift buttocks completely off seat cushion
• Hold 30–60 seconds
• If unable to fully lift: lean side to side (lateral weight shift) for 30 sec each side
• Prevents ischial, sacral, and coccygeal pressure injuries — evidence-based frequency: every 15–30 min when seated

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🫁 RESPIRATORY EXERCISES (Via Tracheostomy) — 2–3× Daily

• Hand on upper abdomen; breathe deeply, feel the belly rise
• Breathe in slowly through tracheostomy for 4 counts, hold 2 counts, breathe out slowly for 6 counts
• 10 repetitions
• Maintains diaphragm strength and lung volumes

• Deep breath in, expanding the chest sideways and upward
• Hold at full inspiration for 3 seconds (air stacking)
• Release through tracheostomy
• Part of ACBT protocol — clears secretions, prevents atelectasis

• After deep breath: open mouth/tracheostomy and forcefully huff "ha-ha" (like steaming a mirror)
• NOT a cough — it is a controlled forced expiration
• Sequence: 2 huffs → breathing control → repeat
• Mobilises secretions without the airway closure of coughing — safe with tracheostomy

• Use a threshold IMT device (e.g., Threshold PEP/IMT — low cost, widely available)
• Set at 30–40% of Maximal Inspiratory Pressure (MIP)
• 30 breaths once daily
• Meta-analysis (Tamplin & Berlowitz 2014, Spinal Cord): significant improvement in inspiratory muscle strength in SCI patients

• Patient takes deep breath in
• Caregiver places hands on upper abdomen
• Patient attempts to cough/huff — caregiver simultaneously gives firm upward-inward abdominal thrust
• Synchronize timing
• Essential when secretions are visible or SpO₂ drops — D9 SCI significantly weakens expiratory force

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🧘 TRUNK EXERCISES (Partial trunk control at T9 — some intercostals preserved)

• With back support and safety strap: lean slowly forward, return upright using hands on thighs
• 10 reps
• Activates thoracic extensors, improves balance confidence

• Seated: reach one arm across the body to opposite side
• Caregiver stabilizes wheelchair
• 10 reps each side
• Activates obliques, serratus — improves seated stability for ADLs

• Hands behind head; lean forward from sitting, return to upright
• Only if spine is STABLE (confirmed by oncologist/surgeon)
• 10 reps

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🚿 ADL (Activities of Daily Living) Training as Exercise

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DAILY SCHEDULE (Sample)

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WHAT TO MONITOR AT HOME

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EQUIPMENT NEEDED AT HOME (Low Cost)

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Evidence Base

• Shepherd Centre Home Exercise Program (Spinal Cord Injury Clinical Guidelines) — passive ROM, UL strengthening protocol
• Paralyzed Veterans of America (PVA) T1–T9 SCI Outcomes Guide — expected independence goals, exercise frequency
• Santos et al. 2022 (PMID 35248264): Meta-analysis confirming resistance training significantly improves UL strength in SCI — 3 sets × 10 reps, 3×/week
• Tamplin & Berlowitz 2014 (Spinal Cord 52:175): IMT improves inspiratory muscle strength in thoracic SCI — supports daily IMT
• MSKTC Exercise after SCI Factsheet (Model Systems Knowledge Translation Centre): stretching 1–2× daily; strengthening 3×/week; cardiovascular 20–30 min, 3×/week
• Willig et al. 2022 (PMID 32644024): Community-based upper body exercise improves function in chronic paraplegia — home-based programs are effective