The Academy of Oncologic Physical Therapy has a new Special Interest Group (SIG)—Balance and Falls! Let me guess—you immediately thought—“Cool!” or “Hmm, they thought it was necessary?” or “Gosh! Another thing on my social media to check?” This is a very “cool” initiative that will help enrich the understanding of fall prevention in cancer survivors.
If you are reading this commentary, you likely understand cancer and treatment-related side effects. You understand how those concerns may influence balance. Chemotherapy-induced peripheral neuropathy, brain metastasis, fatigue, and pain probably all come to mind. Factors such as age, polypharmacy, and opioid use, which are typically the major risk factors in healthy aging individuals, are not always the strongest predictors of falls in cancer survivors.1 Did you know that cancer survivors may or should be screened for diagnosis- or intervention-specific fall risk factors? Bear with me, I am alluding to patients who do not present with readily observable mobility and balance impairments, such as foot drop.
Emerging research is demonstrating that a skilled oncological physical therapist should understand that each cancer diagnosis and treatment plan may present with its own fall risk profile.2 A cancer survivor living with prostate cancer may have a higher risk of falling secondary to urinary incontinence.2 However, a survivor of breast cancer may be best served if screened for foot sensation impairment and concerns completing activities of daily living (ADL).2 Furthermore, not all survivors of breast cancer are treated similarly. If a woman has a history of adjuvant endocrine therapy, visual disturbances may be present. Specifically, examining slowness in contrast acuity may elucidate balance concerns.3 If the individual had doxorubicin or cisplatin, vestibular concerns may impair ADL.4,5 Therefore, once medical history is reviewed, it may be most effective and efficient to ask a survivor of breast cancer if there are changes in foot sensation and/or changes in the ability to perform ADL—in the context of visual, vestibular, or neuropathic concerns.
Research is parsing out relationships among mobility impairments, setting, age, and fall risk. For the elderly survivor of cancer, factors ranging from “frailty,” dementia, depression, and social support may all contribute and should be considered.6 Once fall risk factors are identified by screening, further examination is warranted. Cognition is a construct that frequently needs thoughtful examination—no pun intended. The assessment should go beyond orientation to person, place, or date. SIG member, Dr Jennifer Blackwood,7 alerted readers that the relationship between fall risk and cognition requires a physical therapist to understand various domains of cognition. Blackwood's7 study noted delayed word recall as a potentially useful domain to examine cognitive function when evaluating a fall risk. Examining executive function with a tool such as the Trail Making B is also a reasonable consideration. Understanding how cancer and its treatment effect balance secondary to cognitive impairment and the utility of relevant assessment tools remains an open door for future research, an interesting topic that the SIG will track.
The SIG strives to educate rehabilitation therapists, as well as other professionals, about the unique implications of treating cancer survivors. It is free to join for Academy members. Simply go to www.oncologypt.org/sigs and select the Balance and Falls SIG. You will gain easy access to consumer- and professional-oriented fact sheets. On the Web site, our members have collected the most recent relevant research articles. There is a link to our September 2018 Radiocast on PTMoveForward, titled “The Risk of Cancer-Related Falls,” presented by Dr Elizabeth Hile. The SIG manages a listserv to foster collaboration and discussion. If you are looking for an in-service topic or have a public speaking opportunity, contact us through the listserv or individually. We would love for you to serve as an advocate with us.
The SIG functions by disseminating periodic messages on social media and short informative videos. If you thought, “Gosh! Another thing on my social media to check?” Yes, social media sometimes goes awry. We get 231 e-mails, 45 Twitter notifications, and 50 Facebook posts—all before our morning coffee. How we use social media varies as much as the lattes you can order. It is up to us as professionals to stay current in the recent research. The “cost” of deleting a short text message (after you've read it) is low relative to the valuable insight offered.
As the SIG moves forward, we cannot stand alone to efficiently or significantly reduce the risk of balance and falls in cancer survivors. Many patients diagnosed with cancer are also geriatric patients or have neurological impairments. We are collaborating with the other APTA Balance and Falls SIGs in Neurology and Geriatric Academies to develop further education and opportunities.
We need Academy members to serve as advocates, so ... go ahead, visit oncologypt.org, and click on our SIG before you finish your next latte. It's free! (the SIG, not the latte)
1. Wildes Tm, Dua P, Fowler SA, Miller JP, et al Systematic review of falls in older adults with cancer. J Geriatr Oncol. 2010;6(1):70–83. doi:10.1016/j.jgo.2014.10.003.
2. Huang MH, Blackwood J, Godoshian M, Pfalzer L. Predictors of falls in older survivors of breast and prostate cancer: a retrospective cohort study of surveillance, epidemiology and end results—Medicare Health Outcomes Survey Linkage. J Geriatr Oncol. 2019;10(1):89–97. doi:10.1016/j.jgo.2018.04.009.
3. Winters-Stone KM, Torgrimson B, Horak F, et al Identifying factors associated with falls in postmenopausal breast cancer survivors: a multi-disciplinary approach. Arch Phys Med Rehabil. 2011;92(4):646–652. doi:10.1016/j.apmr.2010.10.039.
4. Black FO, Pesznecker SC. Vestibular ototoxicity (Clinical considerations). Otolaryngol Clin North Am. 1993;26:713–736.
5. Kros CJ, Steyger PS. Aminoglycoside and cisplatin-induced ototoxicity: mechanisms and otoprotective strategies. Cold Spring Harb Perspect Med. 2018. doi:10.1101/cshperspect.a033548.
6. Zhang X, Sun M, Liu S, et al Risk factors for falls in older patients with cancer. BMJ Support Palliat Care. 2018;8(1):34–37. doi:10.1136/bmjspcare-2017-001388.
7. Blackwood J. The influence of cognitive function on balance, mobility, and falls in older cancer survivors. Rehab Oncol. 2018. doi:10.1097/01.REO.0000000000000128.