Cancer Rehabilitation and the Importance of Balance Training

Effects of chemotherapy on balance and sensation of cancer patients

In the past decades, chemotherapy has helped improve the diagnosis and treatment of cancer and led to an increase in the number of cancer survivors.[1] However, the most common side effect from of the use of chemotherapy is chemotherapy-induced peripheral neuropathy (CIPN), which impacts both on a patient's physiological and psychological health.

CIPN can lead to a change in their quality of life (QoL) due to influences in their neuromuscular system2,3**. Patients with CIPN experience pain, muscle weakness, decrease balance control, gait unsteadiness and reduced or absent reflexes.[2] Additionally, it is common to have altered sensation such as numbness, burning and tingling, along with dysaesthesias and paraesthesias that follow a stocking and glove pattern in the lower and upper extremities.[1] These symptoms may improve to a certain extent but complete resolution is rare1. Motor deficits such as balance impairment, decreased gait speed and lower limb strength can persist, with increases in fall rates.[1] The clinically meaningful physical impairments of CIPN can lead to a vicious circle, impacting a patient's ability to independently complete activities of daily living (ADLs).

In contrast, promoting a healthy, active lifestyle could increase physical function and postural control, which can decrease fall risks and increase QoL.[1]


Figure 1: ‘Vicious circle’ of clinical meaningful impairments due to CIPN (image created from information (Duregon et al., 2018))[1]


Physiological changes of CIPN leading to postural instability

There are various underlying mechanisms that cause CIPN, which can lead to postural instability in cancer survivors.[1]


Figure 2: Physiological impact of CIPN leading to postural instability (image created based on (Duregon et al., 2018))[1]

Differences between Chemotherapy-induced peripheral neuropathy (CIPN) vs Radiation-induced peripheral neuropathy (RIPN)

Figure 3: Summary comparison of CIPN vs RIPN (image created based on (Delanian et al., 2012; Streckmann et al., 2014b)[3] [4]

Cancer survivors exhibit less postural steadiness than age-matched controls

There are two major differences between cancer survivors and age-matched controls:

1) Removal of visual input leads to a significant decrease in postural stability

Cancer survivors are much less steady compared to a control group when they are prevented from using vision to maintain balance, or are asked to stand on unstable surfaces.[2] While there may be various factors that lead to differences between cancer survivors and the control group, the groups were closely matched for age and body mass index, which rules out these factors as causes for major differences in balance.[2] In fact, cancer survivors require more proprioceptive and vestibular inputs to maintain postural stability compared to healthy counterparts similar in age.[2]

2) Effects of cancer treatments may have similar effects to aging

Interestingly, the balance of elderly adult cancer survivors (55 years) was similar to the balance of individuals without cancer who were about 15 years older,[2] thus cancer survivors demonstrate postural stability characteristics reflective of a more elderly population.[2] A possible explanation would be that the effects of cancer treatments are similar to the effects of aging, both leading to a decrease in postural control.[2]

Multifaceted benefits of balance training for cancer survivors

Figure 4: Benefits of cancer rehab such as improvements in aspects of balance, functional performance, and guidelines for future treatments (image created from (Duregon et al., 2018))[1]

The most significant improvements to postural control were combined exercise protocols which involved endurance, strength and sensorimotor training.[1] As well, exercise sessions led to an increase in patient QoL and independence.[1]

Benefit I: Static balance control

Significant improvements in static balance have been found to occur when programs include three major components in each exercise session;[4] [5] [6] [7]

  1. Sensorimotor training and postural exercises, such as tasks that required stabilization
  2. Closed kinematic chain exercises
  3. Stability training focused on engaging the core during balance exercises

Clinical recommendations for improving static balance control:

Sensorimotor training focuses on postural control using balance boards, foam pads and elastic bands to challenge balance.[8] It progressively challenges proprioception to regain normal motor patterns.[8] An example of an exercise program found to be effective at improving static balance is to progress through four different postural exercises, three sets of each.[4] Hold each position for 20 seconds, rest of 20 seconds and 1 minute between exercises to prevent fatigue. In fact, sensorimotor training has the potential to improve neuromuscular mechanisms that affect balance for various patient populations.[9] Interestingly, diabetic patients who have diabetic peripheral neuropathy (DPN), a type of nerve damage similar to CIPN, demonstrate an increase in balance control and trunk proprioception following a program of balance exercises.

Static balance can be measured using a single-leg balance test. After 12 weeks of exercise training consisting of aerobic, resistance, core stability and balance exercise sessions led to improvements which were maintained by a follow-up assessment after 24 weeks.[6]

Table 1: Sample Cancer Rehab for CIPN Routine[7]

Exercise Instructions
(1) Open chain active ankle range of motion exercises

(including warm up)

Draw alphabet in the air by moving the ankle.
(2) Bipedal toe raises and heel raises Try to do this as quickly as possible, with support if needed.

Start with one set of 10, and increase by one set every 5 exercise sessions. The goal is 3 sets. Progress depending on their tolerance.

(3) Bipedal inversion and eversion This challenges the participant to control their center of mass, as they will tend to shift laterally using their ankle invertors and evertors.

Start without support from upper extremities. The goal is to do it independently. The key is to move toes in and out. Begin with 10 reps in both directions. Increase by adding another set after 5 sessions, or progress depending on their tolerance.

(4) Unipedal toe raises and heel raises Try to do this as quickly as possible, with support if needed.

Lift the non-weightbearing limb, with the knee bent at about 45°. Start with five repetitions in each direction, and increase to 10 repetitions each set. Then increase to two sets after 10 exercise sessions, or progress depending on their tolerance.

(5) Unipedal inversion and eversion Try to do this as quickly as possible, with support if needed.

Lift the non-weightbearing limb, with the knee bent at about 45°. Start with five repetitions in each direction, and increase to 10 repetitions each set. Then increase to two sets after 10 exercise sessions, or progress depending on their tolerance.

(6) Wall slides Lie facing ceiling, with both legs up against a wall. Slide heels along wall to a maximum of where the knee bends to 45.°

Do 3 sets of 10 repetitions. Progress depending on their tolerance.

(7) Unipedal balance for time Stand on one leg and try to maintain balance without losing control over posture for as long as they can. Try wth eyes open, then eyes closed. Choose a time target appropriate to participants’ level. Progress depending on their tolerance.

Completing these CKC exercises at least 15 times over 3 weeks can increase a participant's subjective understanding of the severity of CIPN as well as his/her static and dynamic balance.[7] Thus, these exercises can improve postural control over a short amount of time and are tolerated well by participants.[7]

The improvement in balance may be due to increasing the challenge of the exercises.[7] The exercises were first completed with support, then after a few sessions, the subjects were tasked with using minimal support, working their way up to performing the exercises without any support. Furthermore, there was an increase in proprioception and strength of muscles around the ankle joint which may have led to an increase in their balance and decreased incidents of falls.[7]

Benefit II: Dynamic balance control

Exercise training for cancer survivors can improve dynamic balance or postural control during movement.

Clinical recommendations for improving static balance control:

i) Using obstacle courses (interactive game-based balance training)

Obstacle courses that involved repetitive weight shifting and crossing-over obstacles led to significant (43-74%) improvements of dynamic balance.[5] After the exercises, the sway of the hip, ankle and center of mass had significantly decreased while standing in feet-closed position with eyes open among older cancer patients with CIPN. Significant increases in postural balance may be due to the nature of obstacle courses so that the participant has many opportunities to continuously weight shift.[4] The most significant improvements to dynamic balance were observed in the monopedal (single leg) stance.[4] Individuals without access to game-based balance exercises can include obstacle courses in balance training programs so they can still utilize dynamic control repetitively for prolonged periods of time.

ii) Gait training

Furthermore, dynamic control for people with CIPN can be improved by using gait training.[4] Those with CIPN can exhibit gait patterns similar to diabetic patients with DPN who have prolonged time in stance phase, slower speeds, and reduced step length as a strategy to maintain stability in walking.[10] Walking tasks (e.g. tandem walk, or different types of gait patterns), functional exercises (sit to stands from a chair, climbing stairs, walking up and down an incline, or small hops) and walking with progressive task complexity (e.g. concurrent head rotations or verbal tasks like counting by 10’s) have been shown to be effective for patients with DPN.[11]

iii) Mechanical perturbations

An effective way to challenge the participant’s dynamic balance when they have gained back more postural control is to add in mechanical perturbations.[4] Mechanical perturbations involve tasks that suddenly change the participant’s center of mass so she learns to adjust her balance according to unexpected changes. For example, with a patient standing on one leg, an exercise band can be tied around the stance knee and then pulled in different directions at random intervals by a physiotherapist or friend/family member, thus challenging the patient to regain postural control after each external force.

Benefit III: Quality of life and physical function

Although a balance rehab program with a combination of aerobic, strength and sensorimotor training did not significantly improve the fear of falling, the lack of change may be due to the short-term, 4-week intervention period of the program. In fact, balance programs that lasted from 10-36 weeks improved quality of life and the benefits remained at the follow up period.[6] Thus, longer balance rehab programs may be more effective at QoL and long-term changes for people with CIPN.

Interestingly, balance rehab programs help patients with the adverse effects of chemotherapy by introducing breathing techniques and stretches.[7] Thus, alternatives to exercise-based balance rehab programs, such as yoga, which focus on breathing techniques and stretches may be beneficial to improve aspects of QoL for patients with CIPN.[7]

In addition, exercise-based balance rehab programs improve upper and lower body strength and lower body functional abilities over a long-period of time, which can then lead the adoption of a healthy, active lifestyle.[6] Exercise helps to prevent the effects of physical inactivity during chemotherapy, such as muscle atrophy, osteopenia, decreased cardiorespiratory fitness, decreased insulin sensitivity, decreased immune function and increased risk of chronic illness.[13]

Balance training and impact on sensation

Balance and exercise training can help people with sensory neuropathy which is common to CIPN.[14] After 15 sessions of CKC exercise, patients state they have a decrease in tingling sensation and pain and return to having normal sensation for a pin prick and vibration in the lower limbs.[14]

Outcome measures for patients recovering from cancer treatment

Clinicians can use the BESTest and its short versions (Mini-BESTest, and Brief-BESTest) (https://www.physio-pedia.com/Balance_Evaluation_Systems_Test_(BESTest), http://www.bestest.us/test_copies) to assess and identify balance problems among older cancer survivors (over age of 55) who lived in the community (Huang et al., 2016).[15] The BESTest and its short versions has high interrater and test-retest reliability, and exceptional concurrent validity with the ABC Scale for this patient population. The minimal detectable change MDC is 2.39-6.86 points, which can be used detect significant and relevant changes to balance.[15]

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  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Schmitt AC, Repka CP, Heise GD, Challis JH, Smith JD. Comparison of posture and balance in cancer survivors and age-matched controls. Clinical Biomechanics. 2017 Dec 1;50:1-6.
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