Review Series: Palliative Care for Lung Disease

Chronic Respiratory Disease

10(4) 223–232
Impact of physiotherapy on patients ª The Author(s) 2013
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with advanced lung cancer DOI: 10.1177/1479972313508965
crd.sagepub.com

Sevgi Ozalevli

Abstract
Patients with lung cancer have high mortality and high morbidity. Lung cancer-related symptoms and problems
such as dyspnea, fatigue, pain, and cachexia that begin in the early phase later result in poor physical functioning,
psychosocial, and quality of life status. In addition, advancing age is associated with significant comorbidity.
These patients may benefit from multidisciplinary therapy to reduce the perceived severity of dyspnea and fati-
gue and increase physical functioning and quality of life. Based on management of symptoms and problems such
as dyspnea, physical inactivity, cancer-related fatigue, respiratory secretions, pain, and anxiety–depression of
these patients, it is thought that physiotherapy techniques can be used on advanced lung cancer patients fol-
lowing a comprehensive evaluation. However, well-designed, prospective, and randomized-controlled trials
are needed to prove the efficacy of physiotherapy and pulmonary rehabilitation in general for patients with
advanced lung cancer.

Keywords
Advanced lung cancer, physiotherapy, exercise, dyspnea, fatigue, anxiety

Introduction 73% of male and 53% of female patients with lung can-
cer.6 It is obvious that when COPD accompanies the dis-
Lung cancer is the most common type of cancer. It is
ease, the systemic effects of COPD (peripheral muscle
responsible for more cancer-related deaths than the total
dysfunction, osteoporosis, loss of nonfat body mass,
of the other common cancers such as breast, prostate,
anxiety, and depression) will intensify the symptoms
and colorectal cancer.1 Patients with lung cancer have
and problems of lung cancer.7
a high mortality as well as high morbidity. In most of
The value of rehabilitation has been described in
the patients, cancer-related symptoms are seen. These
the context of thoracic surgery including lung resec-
patients confront problems such as dyspnea, fatigue,
tions, volume reduction surgery, and lung transplanta-
pain, and cachexia especially in the late phase. These
tion.5,8 However, in relation to patients with advanced
symptoms and problems that begin in the early
lung cancer, there have been only a limited number of
phase compromise compliance with treatment causing
studies that explore the effectiveness of pulmonary
poor physical functional condition accompanied by
rehabilitation. The adaptation and implementation of
psychosocial disorders and briefly negatively affect the
pulmonary rehabilitation is thought to be possible and
quality of life of patients with advanced lung cancer who
effective.2,6,7,9–12 In this article, only the physiother-
have limited life expectancy.2,3
apy aspects of pulmonary rehabilitation applied to
Pharmacological and nonpharmacological therapies
lung cancer will be discussed.
focus on increasing physical function and improving
quality of life.4 Pulmonary rehabilitation decreases
respiratory symptoms and improves functional exercise
capacity and increases quality of life, especially in chro- Dokuz Eylul University, School of Physical Therapy and Re-
nic obstructive pulmonary disease (COPD).5 Patients habilitation, Izmir, Turkey
with lung cancer, like COPD, frequently suffer from
Corresponding author:
symptoms such as dyspnea, fatigue, deconditioning, Sevgi Ozalevli, Dokuz Eylul University, School of Physical Therapy
exercise intolerance, malnutrition, impaired life status, and Rehabilitation, Izmir 35340, Turkey.
and quality. It has been found that COPD is present in Email: sevgi.ozalevli@gmail.com
224
Dyspnea
Dyspnea is one of the most distressing symptoms in
advanced lung cancer, and treatment of this symptom
may be difficult and complex.3 Although the severity
of dyspnea in lung cancer varies according to the dis-
ease’s stage and progress, it has been suggested that
78% of the patients with advanced lung cancer have
dyspnea.13 Once diagnosed with lung cancer fatigue,
pain, anorexia, coughing, and insomnia are the most
frequent problems. In the later phase, dyspnea, pain,
noisy breathing, and psychological stress frequently
cause problems.14,15 It has been determined that dys-
pnea is seen in every stage of lung cancer and is asso-
ciated with patients’ quality of life.16–18 Dyspnea in
cancer patients is caused by associated conditions and
diseases such as the cancer itself, the treatment, COPD,
cardiac failure, anxiety, and the patient’s behavioral
responses to other symptoms of the disease.19
Nonpharmacological approaches are preferred to
pharmacological ones such as opioids or anxiolytic
medication, which is used to reduce dyspnea caused
by respiratory depression.20 There are a variety of
methods and strategies to reduce dyspnea among
COPD patients that are proved to be effective.14,21
Educating the patient and his or her family about arran-
ging the humidity and temperature of the patient’s
room, preventing noise, and creating a relaxing envi-
ronment with music are useful suggestions.14,21,22
Anxiety, depression, and other psychological fac-
tors occur frequently in patients with advanced lung
disease and influence breathlessness.22 Therefore,
breathing control and relaxation therapy may be ben-
eficial for both the individual and the family.23,24 It
has been shown that a forward leaning position is a
particularly effective strategy to reduce dyspnea. For-
ward leaning is associated with a significant reduction
in electromyographic activity of the scalenes and
sternomastoid muscle, an increase in transdiaphrag-
matic pressure and inspiratory mouth pressure, and
significant improvement in thoracoabdominal move-
ments. This position has been shown to improve dia-
phragmatic function and hence improves all chest
movements and decreases accessory muscle recruit-
ment and dyspnea.25
It has been shown that fanning cold air on the nose,
mouth, and chin reduces dyspnea perception. It has
been thought that cold air circulation changes
patients’ dyspnea perception by stimulating extrathor-
acic mechanoreceptors on the face or within the nasal
passages.26 The usage of a small, portable, and cheap
Chronic Respiratory Disease 10(4)
fan may decreasing dyspnea even among advanced
lung cancer patients.26–28
Acupuncture may be an alternative approach to
reduce breathlessness, but the data are limited and
mixed.28,29
A number of studies have shown that the pursed lip
breathing technique is particularly helpful in reducing
or settling dyspnea.20,25,30,31 Other studies on breath-
ing training has observed that when breathing training
is applied to patients (panic management, pursed lip
breathing, and diaphragmatic breathing), their
respiratory rate dyspnea decreases dramatically and
their functional capacities improve.21,28,31,32
At present there is no information about the appli-
cation and effects of inspiratory muscle training on
lung cancer patients with chronic pulmonary disease.
When the advantages and benefits of this technique
are considered, it is assumed that it can be used with
an exercise program on advanced lung cancer
patients.33 Inspiratory resistive training was used only
in one study on a pulmonary rehabilitation program
for nonsmall cell lung cancer (NSCLC) patients who
had undergone lung resection, but the effects of the
application alone are not stated.34
It has been stated that lung cancer patients employ
an avoidance of activity strategy so as to prevent dys-
pnea and this situation causes a sedentary lifestyle and
deconditioning.35 Therefore, it would be useful to
inform the patients about energy conservation tech-
niques in order to increase their physical condi-
tion.20,36 Recommending portable oxygen support
and/or assistive tools for walking (walkers, wheel-
chairs, rollators, etc.) when necessary and giving the
patients breathing control training during activities are
other assistive strategies for reducing dyspnea.23,37 It
has been found that pursed lip breathing taught during
walking activity reduces the severity of dyspnea in
COPD patients and increases the walking distance.38
Physical inactivity
Particularly in the advanced stage, the lung cancer
patients’ physical abilities reduce due to the symp-
toms of the illness and problems caused by the treat-
ment.39 It has been determined before that the
physical activity level is relevant to the quality of
life.4,15,17,39
It is thought that in these patients skeletal muscle
dysfunction arises from skeletal myopathy (due to use
of oral corticosteroids), deconditioning (from physical
Ozalevli
inactivity), and high levels of systemic inflammation
(from underlying disease and therapy).40 For these rea-
sons, exercise training should be applied in every stage
of the disease. It has been proved that exercise training
frequently applied in pre- and postoperative periods
decreases the symptoms of lung cancer patients and
improves exercise capacity and quality of life.41,42 But,
generally there is no clear information about the content
of exercise programs that should be applied in advanced
lung cancer patients. When skeletal muscle influence on
patients is suggested, resistance exercises should also be
applied. It is thought that the combination of aerobic and
resistance training may be the most effective form of
exercise training to optimally augment peak oxygen
consumption in patients with lung cancer. It is believed
that the suggested comprehensive program will improve
oxidative capacity, additionally increase muscle
strength and endurance, reduce fatigue, and improve
exercise tolerance.43,44 It is determined that aerobic and
resistance exercise with exercise training frequently
used with breast cancer patients increase their cardio-
pulmonary capacity and quality of life, reduce fatigue,
improve physical functional levels, and cure psycholo-
gical problems (resulting in regular sleep patterns, gen-
eral well-being, self-confidence, energy, and so on).45
Although there are differences in intensity and fre-
quency in exercise training studies, it should be noted
that exercise applied in cancer patients should not cause
over fatigue and should be programmed individually
according to patients’ tolerance.10,11,43–47 In accordance
with this purpose, it is thought that interval exercise
programs may be more suitable and beneficial for lung
cancer patients instead of continuous exercise.47 It has
been identified that interval exercise programs that can
be applied even in severe COPD patients improve the
quality of life and are safe and beneficial.48 Moreover,
it has been found that one-legged exercise training,
which is a new exercise strategy used in severe
COPD patients, causes lower ventilatory stress than
conventional bipedal cycling and also increases aerobic
capacity much more.49 Also, this exercise strategy is
appropriate especially for advanced lung cancer
patients. There is a need for more research into this
subject.
Although some research shows that multidimen-
sional exercise programs are suitable for patients with
lung cancer, exercise adherence is considerably low
(19–44%).50,51 Even though supervised outpatient
exercise programs are preferred for patients with
comorbid disease and poor health, community-based
programs are thought to be more acceptable and more
225
feasible for patients undergoing chemotherapy. For
this reason, improving low intensity and more
appropriate programs, especially for patients with
advanced lung cancer who are undergoing chemother-
apy, is necessary. There is no information about
home-based exercise training for these patients. How-
ever, it has been proved that home-based exercise
programs are feasible and improve functional status
and quality of life in patients with breast cancer and
reduce cardiac dysfunction.2,52,53
A few studies have described the effectiveness of
exercise in patients with advanced lung cancer.8
Spruit et al.54 researched the multidisciplinary inpati-
ent rehabilitation program’s effects in NSCLC
patients with comorbidity such as COPD, arterial
hypertension, and transient ischemic attack. Exercise
training consisted of daily cycle ergometry, treadmill
walking, weight training, and gymnastics. The
impairment of pulmonary function was unchanged,
while significant improvements were found in the
6-minute walking distance and peak cycling power
output.54 Jones et al.55 applied an aerobic exercise
program to 19 lung cancer patients (I–III B NSCLC).
Significant improvements in quality of life, exercise
performance, and fatigue severity of patients were
reported.55 Cesario et al.34 applied a multidisciplinary
inpatient pulmonary rehabilitation program to 25
NSCLC patients who had undergone lung resection.
It was found that walking distance was significantly
improved despite there being no change in pulmonary
function.34 Ozalevli et al.11 enrolled 18 patients with
stage IIIA–B and IV advanced lung cancer who did
not have surgical indications and received intense
chemotherapy and radiotherapy in an inpatient chest
physiotherapy program. Although there was no
change in pulmonary function at the end of the pro-
gram, a significant decrease in severity of fatigue and
dyspnea was perceived by patients, and a significant
increase in their quality of life and exercise capacity
was determined.11 Riesenberg and Lübbe56 applied
an aerobic exercise program to 45 multimorbid lung
cancer patients who had undergone surgery and/or
radiotherapy and/or chemotherapy. It determined that
after increased work performance by bicycle ergome-
try and a 6-minute walk test (functional status), heart
rate at rest was reduced, quality of life was improved,
and fatigue was reduced.56 Temel et al.50 enrolled 25
patients with advanced lung cancer (advanced
NSCLC, stage IIIB with pleural or pericardial effu-
sions or stage IV), who were receiving chemotherapy,
in an aerobic and strength-training exercise program.
226
Authors have stated that this program is applicable in
patients with advanced lung cancer.50
Interestingly, it is observed in the studies that cycle
ergometer is preferred over treadmill walking. Exer-
cise intensity can be arranged more accurately and
monitoring of patients is easier. Besides, the cycle
ergometer is a more appropriate exercise device than
the treadmill because most of the patients with lung
cancer are old and probably suffer from balance prob-
lems.43 There is not enough information about exer-
cise and physiotherapy approaches for patients with
advanced lung cancer, especially during chemother-
apy. But it has been said that to protect physical per-
formance, despite chemotherapy-related over fatigue
and exhaustion, aerobic exercises can be appropriate
and effective in this period.57,58 It has been stated
through research that aerobic exercise, massage,
relaxation, and body awareness training in advanced
lung cancer patients undergoing chemotherapy espe-
cially decrease fatigue symptoms and help to cope
with symptoms.2,57 Generally in this period, doing
exercises in rhythmic contraction without increasing
fatigue and low rhythm with relaxation in the applied
aerobic exercise programs is suggested.58
In patients with advanced lung cancer, mobiliza-
tion, with or without oxygen, of patients who suffer
particularly from severe deconditioning is useful. It
is stated that applied passive or active assistive exer-
cises used for preventing muscular atrophy can be
beneficial for severe lung cancer patients who cannot
do active muscle contraction effectively. In these
cases, it has been shown that neuromuscular electrical
stimulation (NMES) is also effective.59 Several inves-
tigators have shown that NMES intervention is well
tolerated and effective alone or in combination with
exercise, results in improvements in strength, muscle
mass, exercise capacity, and sense of dyspnea during
daily living activities in patients with very severe
COPD, chronic heart failure, and mechanically venti-
lated intensive care unit patients who experience intol-
erable symptoms during or after active training due to
the progression of their underlying disease.12,22,60,61
It has been suggested that applying the NMES as a
home-based NMES program maintains and improves
quadriceps femoris muscle strength in patients with
lung cancer.62,63 Randomized-controlled trials are
needed to study the efficacy and safety of NMES for
severely disabled lung cancer patients.
A small number of studies have shown that pul-
monary rehabilitation reduces perioperative risks and
improves functional capacity in patients with lung
Chronic Respiratory Disease 10(4)
cancer. Pulmonary rehabilitation is suggested as a fea-
sible and safe therapeutic treatment in patients with
lung cancer.8 However, there is not much literature
about the effectiveness and content of pulmonary
rehabilitation in patients with advanced lung cancer.
Well-designed, further research is needed to expand
the role of pulmonary rehabilitation and special exer-
cise programs in patients with advanced lung cancer.
Cancer-related fatigue
One of the most common and distressing effects of
cancer is fatigue. Cancer-related fatigue is defined
as ‘‘an unusual persistent subjective sense of tired-
ness’’ arising directly and/or indirectly from cancer
or its treatment.53 This symptom occurs from the ear-
liest stages of the disease and affects patients nega-
tively.64 A study defined that 57% of the patients
with stage 1A-1B NSCLC have fatigue according to
Brief Fatigue Inventory. It has been stated that the
high level of fatigue despite the early stage of disease
causes the impaired functional status of the patients.65
It has been found that physical functioning of
patients with advanced lung carcinoma decreased due
to fatigue. The fatigue was not caused by weight loss
and anemia but was related to psychological factors.66
In a study conducted in ambulatory patients with
advanced lung cancer, stage lllA–B, IV suffered from
81.5% fatigue and accompanying 74.5% dyspnea and
65% pain symptoms. It was found that approximately
one-third of patients with fatigue had limited daily life
activities such as walking due to fatigue, which also
affected the emotional state of the patients in a nega-
tive way.15
As well as resulting from the cancer itself, there
can be many reasons for cancer-related fatigue such
as anemia, medications, changes in metabolism,
infection, dehydration, loss of strength and muscle
coordination, decline in physical condition, emotional
distress, trouble sleeping, inactivity, pain, poor nutri-
tion, and other comorbidities or medical conditions in
addition to cancer.67 Cancer-related fatigue is a com-
plex problem with physical and psychosocial influ-
ences. Thus, the therapies and strategies to be used
to reduce fatigue must be considered in a multidirec-
tional and comprehensive manner.
To combat cancer-related fatigue, the stage of the dis-
ease, treatment regimes, age factor, fatigue-aggravating
dyspnea, pain, vomiting and such problems, the severity
of these problems, and the quality of life of the individ-
ual must be assessed comprehensively. Based on this
Ozalevli
assessment, exercise training, diet therapy, sleep ther-
apy, cognitive therapy, and pharmacological therapy
can be individually adjusted and applied to reduce
cancer-related fatigue.68
Nonpharmacological interventions for fatigue con-
sist of education, counseling, and support groups for
stress reduction and energy conservation, nutrition,
and exercise. It is believed that exercise changes the
negative neuromuscular influence caused by the dis-
ease. Thus, fatigue can be reduced with regular exer-
cise. It has been shown in patients with COPD that
exercise training for at least 4 weeks, with or without
education and/or psychological support, leads to a
clinically significant reduction in fatigue, as well as
improving dyspnea, emotional function and patients’
sense of control.69 There is some evidence to support
the use of exercise for cancer-related fatigue, although
the role of exercise for patients with lung cancer specif-
ically has not been examined. Exercise would likely
provide a benefit to this patient population, although
additional data are needed to support this.12,57,67,70,71
Chemotherapy-induced fatigue leads to physical
discomfort and exhaustion, leading to reduced activ-
ity levels and avoidance of physical effort.2 Despite
this symptom, it has been found that aerobic exercise
training applied in the chemotherapy period reduces
psychological stress and perceived fatigue severity.57
Moreover, moderate walking training as a home pro-
gram decreases fatigue.53 Exercise programs to
reduce fatigue may not be appropriate for advanced
lung disease, but it is assumed that fatigue can be
reduced by addressing the symptoms of dyspnea,
depression, and insomnia related to fatigue.72,73 In
addition, understanding the underlying mechanisms
for energy loss and gain, as well as the relationship
between the right amount and type of activity and
sleep, are important and can lead to more effective
therapy programs. It is known that training in energy
conservation techniques reduces fatigue and improves
functional capacities, thereby maintaining symptom
control.9,28,68,74 Energy conservation strategies can
also be used for patients with advanced lung cancer.
Cough and respiratory secretions
Cough and excess secretions are a common and dis-
tressing symptom in patients with lung cancer. Both
symptoms are seen particularly in patients in the late
stages of lung cancer at an approximate rate of 40%.
Lung cancer patients with underlying COPD can
227
suffer from more severe cough with bronchial
secretion.75
Cough in patients with lung cancer results from pul-
monary pathology (upper and lower respiratory infec-
tion, COPD, asthma or pulmonary edema, etc.),
gastroesophageal reflux disease, aspiration, and some
drugs (angiotensin converting enzyme inhibitor and
nonsteroidal anti-inflammatory drugs, etc.).14 Chronic
and severe cough increases the cancer pain of patients
with lung cancer, causes sleep deficit, dyspnea, and
fatigue or increases their severity and causes anxi-
ety.14,75 Even though in lung cancer, cough is helped
with medication, it has been stated that hydration, gen-
tle suctioning, postural drainage, chest physiotherapy,
and external oscillation applications can be useful for
patients with lung cancer, underlying COPD and
bronchiectasis who have poor cough reflex to maintain
bronchial hygiene.5,7,9,14,23,25,61 Unfortunately, there
are no studies in this area. Since the risk of metastasis
is high in patients with advanced lung cancer, it is sen-
sible to avoid the percussive applications on the chest
wall (percussion, vibration, etc.).76 Although there is
no related evidence, interpretation can be made for
patients with lung cancer based on the application of
the techniques that maintain bronchial hygiene in risky
and complex diseases. For example, thoracic expan-
sion exercise and breathing control may be helpful to
assist in mobilizing secretions up the bronchial tree.
Forced expiratory technique and coughing can be used
to help the patient mobilize secretions. Forced expira-
tory technique consists of one or two huffs combined
with breathing control. This technique can be used in
any position according to the individual’s require-
ments, and studies have shown that there is no effect
on hypoxemia. Besides, it has been stated that these
techniques were used and proved effective in the acute
exacerbation periods of patients with COPD.76,77 In
addition to this, flutter, a device that is simple, easy
to use, and self-applicable, increases sputum removal
during treatment and diminishes total and peripheral
airway resistance in hypersecretive patients.78
Pain
It has been observed that 56% of patients with
advanced COPD and cancer patients suffer from dis-
tressing pain.13 Moreover, it has been found that 28%
of lung cancer patients have severe pain.79 Causes of
pain in COPD include subcostal pain due to diaphrag-
matic and intercostal muscle fatigue, rib fractures
related to coughing and/or corticosteroid-induced
228
osteoporosis, and pleural inflammation caused by
infection.20 In patients with lung cancer, pain may
be caused by tumor invasion into soft tissues, nerves
or bone, either at primary site or from metastasis.12
What is more, it is obvious that pain related to inactiv-
ity that develops as a result of dyspnea and fatigue
will further reduce the quality of life of advanced lung
cancer patients, most of whom also have COPD.
Pain reduction strategies used on patients with
COPD can also be used on patients with lung cancer.
It has been stated that biofeedback and breathing tech-
niques can be effective in reducing the pain of cancer
patients generally.12 In particular, transcutaneous
electrical nerve stimulation (TENS) may be helpful.
It has been shown that TENS reduces the pain related
with lung resection.60,80 Ozalevli at al.11 reported that
77.8% of 18 advanced lung cancer patients who they
monitored with an inpatient physiotherapy program
suffered from pain, especially in the waist–hip and
thorax regions. It was found that with the application
of TENS (conventional TENS: 80 Hz, using square
wave 100 microseconds pulses), the pain and its
severity was reduced significantly, while the analge-
sic intake of the patients did not change. This study
has shown that TENS can be safely used for the reduc-
tion of pain and is effective on patients with advanced
lung cancer.11 Massage can be a safe and effective
application in palliation of symptoms and mood that
occur in patients with advanced cancer.81 It has been
found that massage therapy (6 therapies every 2
weeks) significantly reduces the severity of the pain
and improves the mood of patients with advanced
lung cancer.82
Anxiety and depression
It has been shown that, particularly in patients with
advanced COPD, depression and anxiety increase
the perceived dyspnea severity and associated with
the poor physical, social and quality of life of
patients.72,83 Similar to COPD, patients with lung
cancer can also experience psychological morbidities
like depression and anxiety. It has been stated that the
most frequently used methods to reduce anxiety and
depression are cognitive behavioral therapy and pro-
gressive muscular relaxation applications.20,53,66,84,85
Methods include progressive muscular relaxation
with systematic tensing and relaxing of all muscle
groups, visualization and guided imagery, self hypno-
sis, and distraction by music 20,28,86 It has been proved
that the progressive muscular relaxation technique
Chronic Respiratory Disease 10(4)
reduces anxiety, dyspnea, and heart and respiratory
rate, especially in patients with COPD.25,59,84 It is
acknowledged that this technique and teaching other
relaxation methods and positions are advantageous
and simple for COPD patients in that they require
no devices and allow the patients self-control of
symptoms.25 However, it has been found that these
applications are not effective in reducing anxiety and
depression in advanced lung cancer patients.87 They
must be taught to the patients, practised, and adapted
specifically to each individual at the earliest stage
possible when there are no respiratory problems
and/or the severity of the problem is at its lowest so
that these approaches used for reducing symptoms
and problems may prove effective.20,87
Besides, it has been shown that depression and
anxiety reduce the physical activity level of an indi-
vidual, and exercise cures these symptoms.88 Exercis-
ing reduces anxiety and depression, perceived
dyspnea severities and fatigue, and increases quality
of life, especially in older COPD patients.12,89,90 The
effect of exercise on depression and anxiety is, on the
other hand, unknown in advanced lung cancer
patients. Although the symptoms of fatigue, pain, and
dyspnea of 171 advanced lung cancer patients at an
age average of 63 were defined as low severity (1 to
3 on a 0–10 numerical scale), these symptoms proved
significantly effective in their daily life activities,
walking, working, and moods. Moreover, it has been
detected that the dyspnea perception of patients is
affected by their psychological state as well as by
symptoms such as pain and coughing. It has been
thought that, in these patients, reducing depression
and anxiety decreases the severity of dyspnea and the
negative effect of dyspnea on daily activities.15
Briefly, curing symptoms like dyspnea, pain, and
coughing that cause and are increased by psychologi-
cal stress, especially in advanced lung cancer patients,
will reduce the negative influence of the disease in its
early stages. Or, the appropriate psychological sup-
port given, starting at the early stage of the disease,
will definitely contribute to the treatment of patients.
Comprehensive research is required on this topic.
Conclusion
Since the life span of even metastatic lung cancer
patients is increasing, the need for satisfactory and
effective applications to enhance the functional status
and life quality of lung cancer patients from the earli-
est stage is necessary.
Ozalevli
Due to the age factor, comorbid conditions,
complex symptoms, and multiple factors resulting
from the disease and treatment, the need for appropri-
ate physiotherapy and rehabilitation applications,
especially for advanced lung cancer patients whose
care is difficult, is increasingly obvious. Since there
are few studies on the topic, it is thought that phy-
siotherapy techniques, the effectiveness of which has
been proved in patients with severe pulmonary dis-
ease, can be used on advanced lung cancer patients.
All the physiotherapy approaches should be planned
and applied as individual programs tailored to these
patients following a comprehensive evaluation.90
However, well-designed, prospective, adequately
powered and randomized-controlled trials are needed
to prove the efficacy of physiotherapy and pulmonary
rehabilitation in general for patients with advanced
lung cancer.
Conflict of interest
The authors declared no conflicts of interest.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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