Diseases of the Esophagus (2017) 30, 1–12

DOI: 10.1111/dote.12514

Review Article

The physiotherapist and the esophageal cancer patient: from prehabilitation to

rehabilitation

E. M. Guinan,1 J. Dowds,2 C. Donohoe,3 J. V. Reynolds,3,4 J. Hussey1

1
Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland, 2 Department of Physio-

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therapy, St James’s Hospital, Dublin, Ireland, 3 Department of Surgery, St James’s Hospital Dublin, Dublin, Ireland,
and 4 Trinity Translational Medicine Institute, Department of Surgery, Trinity College Dublin, Dublin, Ireland

SUMMARY. Esophageal cancer is a serious malignancy often treated with multimodal interventions and complex
surgical resection. As treatment moves to centers of excellence with emphasis on enhanced recovery approaches,
the role of the physiotherapist has expanded. The aim of this review is to discuss the rationale behind both the
evolving prehabilitative role of the physiotherapist and more established postoperative interventions for patients with
esophageal cancer. While a weak association between preoperative cardiopulmonary fitness and post-esophagectomy
outcome is reported, cardiotoxicity during neoadjuvant chemotherapy and/or radiotherapy may heighten postoper-
ative risk. Preliminary studies suggest that prehabilitative inspiratory muscle training may improve postoperative
outcome. Weight and muscle loss are a recognized sequelae of esophageal cancer and the functional consequences
of this should be assessed. Postoperative physiotherapy priorities include effective airway clearance and early mobi-
lization. The benefits of respiratory physiotherapy post-esophagectomy are described by a small number of studies,
however, practice increasingly recognizes the importance of early mobilization as a key component of postoperative
recovery. The benefits of exercise training in patients with contraindications to mobilization remain to be explored.
While there is a strong basis for tailored physiotherapy interventions in the management of patients with esophageal
cancer, this review highlights the need for studies to inform prehabilitative and postoperative interventions.
KEY WORDS: esophageal cancer, physical therapy modalities, postoperative complications, rehabilitation.

INTRODUCTION

Esophageal cancer is a debilitating disease, frequently

diagnosed at an advanced stage and traditionally
Address correspondence to: Dr Emer Guinan, BSc, PhD,
Discipline of Physiotherapy, Trintiy Centre for Health Sciences, St
associated with poor outcomes. Despite considerable
James’s Hospital, Dublin 8, Ireland. Email: emguinan@tcd.ie advances, surgical resection remains the mainstay of
J. V. Reynolds and J. Hussey are joint senior authors. treatment with curative intent. Surgery carries signif-
Author contributions: Dr Emer Guinan is a research fellow and
physiotherapist specializing in exercise oncology and works
icant risks of major morbidity, and in-hospital mor-
predominantly with the esophageal cancer clinical trials tality up to 5%, consequently strategies to reduce
programme at St James’s Hospital. She completed the literature postoperative complication are of considerable impor-
review for this paper and led the drafting of the manuscript
through all stages. Ms Joanne Dowds is a clinical specialists
tance.1
physiotherapist in respiratory with expertise in postoperative Physiotherapists play a key role in enhancing car-
management of patients undergoing esophagectomy. She was diopulmonary function and managing pulmonary
involved with drafting the manuscript with particular emphasis on
postoperative management and clinical practice points. Dr Clare
complications following esophagectomy.2 Tradition-
Donohoe is a specialist registrar in upper gastrointestinal surgery ally, physiotherapy focused on postoperative care,
at St James’s Hospital and Professor John Reynolds is the but the role is evolving to include surgical pre-
Professor of surgery at St James’s Hospital and the national lead
for the management of esophageal cancer in Ireland. They both
habilitation and Enhanced Recovery After Surgery
provided surgical expertise for the content of the manuscript and (ERAS). ERAS provides a multidisciplinary, stan-
contributed to the manuscript development. Professor Juliette dardized postoperative pathway for the management
Hussey is a Professor in Physiotherapy at Trinity College Dublin
with a special interest in exercise oncology. She is principle
of patients on a common clinical course.3 A meta-
investigator for a number of exercise trials in esophageal cancer St analysis of ERAS pathways in colorectal surgery
James’s Hospital. She provided expertise for the content of the reported reduced hospital stay (−2.55 [95% CI −3.24,
manuscript and contributed to manuscript development.


C 2016 International Society for Diseases of the Esophagus 1
2 Diseases of the Esophagus
−1.85] days) and overall complication rates (rela-
tive risk 0.53 [95% CI 0.44, 0.64]) with standardized
protocols. In esophagectomy, length of stay (LOS)
studies report a difference of up to 3 days in hos-
pital in patients on ERAS versus non-ERAS path-
ways,4–6 largely driven by a reduction in minor and
serious complication rates. Prehabilitation and early
mobilization are two key components of ERAS in
which physiotherapy plays a key role. The aim of this
paper is to review the literature describing the ratio-
nale for physiotherapy interventions in the manage-
ment of patients undergoing esophagectomy.
METHODS
This paper provides a narrative review of the literature
examining the role of the physiotherapist through
the management of patients with esophageal cancer.
The review discusses the complete patient journey,
from diagnosis, through neoadjuvant treatment and
post-esophagectomy. The role of exercise manage-
ment and physiotherapy interventions in this complex
cancer are considered from a multiple literature
sources and in addition to esophageal cancer specific
work. Studies specific to esophageal cancer were
identified through a search of the key databases
EMBASE, PubMed, CINAHL, and Scopus using a
combination of key terms including ‘o/esophageal
cancer’, ‘o/esophagectomy’,’ ‘o/esophageal surgery’,
‘neoadjuvant treatment’, ‘chemotherapy’, ‘radio-
therapy’, ‘radiation therapy’, ‘chemoradiotherapy’,
‘multimodal treatment’, ‘physical therapy modali-
ties’, ‘chest physiotherapy’, ‘chest physical therapy’,
‘physical function/ing’, ‘postoperative pulmonary
complications’, ‘physical activity’, ‘fitness’, ‘phys-
ical performance’, ‘physical capacity’, ‘exercise’,
‘strength’, ‘cachexia’, and ‘functional status’. A
manual search of relevant reference lists was also
completed. All papers in the English language pub-
lished up until August 2015 were considered for
inclusion.
EMERGING ROLE FOR PHYSIOTHERAPY
PRE-ESOPHAGECTOMY
Esophagectomy remains one of the most complex
cancer surgical procedures. Postoperative pulmonary
complications (PPC) are the most serious morbidity
following esophagectomy with rates as high as 45%7
and are the leading cause of postoperative mortality,
accounting for over 50% of in-hospital deaths.8 Cura-
tive treatment can involve either surgical resection
only or multimodality involving esophagectomy and
either neoadjuvant chemoradiotherapy or periopera-
tive chemotherapy protocols, with the CROSS9 and
MAGIC10 protocols the most common approaches
for each, respectively.
Preoperative assessment aims to determine surgical
candidacy, anticipate postoperative care require-
ments, and reduce postoperative complications.
Physiotherapists have a role in evaluating pre-
operative cardiopulmonary fitness and physical
functioning, established predictors of major surgical
outcome,11 that are amenable to prehabilitative
interventions.
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Cardiopulmonary function
Perhaps surprisingly, a relatively weak association
has been reported between cardiopulmonary exer-
cise testing (CPET) and esophagectomy outcome
(Table 1). In 81 patients undergoing thoraco-
abdominal resection, patients aged 65 years with a
working capacity <80W experienced highest post-
operative mortality.12 In a cohort of 91 patients
undergoing transthoracic esophagectomy (TTE)
VO2 max correlated with cardiopulmonary complica-
tions and a preoperative VO2 max >800 mL/min/m2
cut-point to determine surgical candidacy was pro-
posed,13 however, this value requires independent
validation. Two further studies, however, reported no
association between VO2 peak and postoperative out-
come. In a cohort of 78 patients, while preoperative
VO2 peak was lower in patients who developed PPCs,
AT <11 mL/min/kg did not predict morbidity and
no other predictive value could be determined.14 A
study on 108 patients undergoing esophago-gastric
resection suggested that AT <9 mL/kg/min may
predict cardiopulmonary complications, although
weak sensitivity (74%) and specificity (57%) limits
clinical application. Field tests can also estimate
cardiopulmonary fitness and correlate with VO2 max
in thoracic surgery.15 In 51 patients undergoing
esophageal resections, all patients who completed
340 m walking preoperative were alive at day 30 post-
operatively (median distance 470 m, n = 5 deaths),16
however, further work in this area is required.
While cardiopulmonary function is a relatively
weak independent predictor of esophagectomy out-
come, the well-established role of CPET in predicting
outcome in other major surgery15,17 justifies the need
to explore methods of optimizing cardiopulmonary
fitness pre-esophagectomy. Studies in thoracic surgery
suggest that while preoperative moderate-to-vigorous
intensity aerobic exercise program improve aerobic
capacity in patients awaiting pulmonary resec-
tion,18,19 feasibility issues exist due to the need for
multiple supervised classes (5–6 classes/week) between
diagnosis and surgery limiting their success.19 In
contrast, in patients (n = 39) with rectal cancer,
6-weeks aerobic exercise training, completed
during the recovery period between neoadjuvant
Table 1 Cardiopulmonary fitness as a predictor of outcome following esophagectomy

Population
N (male/female) Age
Study (SD) Characteristics Preoperative Assessment Results

Liedman et al. 81 (64/16) Age not Patients undergoing combined Cardiopulmonary exercise test Age In a multi-variate model, middle aged patients
(1995) reported thoracoabdominal resection Pre-existing lung condition (65 years) had an increased risk of postoperative
mortality at a working capacity of ≤ 80W while older
patients (75 years) were at increased risk ≤100W.
Patients with a history of pulmonary disease, had a
higher postoperative mortality across all age groups
at a working capacity ≤ 80W.
Nagamatsu et al. 91 (88/3) 59 (range Patients undergoing curative Cardiopulmonary exercise test Significantly lower VO2 max/m2 in patients who
(2001) 38–74) years esophagectomy with developed cardiopulmonary complications
cervicothoracoabdominal 3-field (P < 0.0001). ROC curve analysis identify that a
lymphadenectomy via right VO2 max of 800 mL/min/m2 was associated with
thoracotomy for squamous cell cardiopulmonary complications. The rate of
carcinoma cardiopulmonary complications was 86% in patients
with a VO2 max < 699 mL/min/m2 , 44% with a
VO2 max 700–799 mL/min/m2 , 10% with a VO2 max
800–1099 mL/min/m2 and 0% with a
VO2 max > 1100 mL/min/m2 AT/m2 was not
associated with cardiopulmonary complications
(P = 0.12).
Murray et al. 51 Age and gender Patients undergoing ISWT monitoring heart rate and Median distance achieved during ISWT was 470 m
(2007) not reported esophagogastrectomy oxygen saturation All patients who completed 340m were alive at day
30. Five patients who completed a distance of
<340 m died within 30 days post-surgery.
Forshaw et al. 78 (64/14) 65 (9) Consecutive patients undergoing Cardiopulmonary exercise test Significantly lower VO2 peak (P = 0.04) in patients
(2008) years esophagectomy who developed cardiopulmonary complications [19.2
(5.1) mL/kg/min vs. 21.4 (4.8) mL/kg/min].
Moyes et al. 108 (83/25) 66 (9) High risk patients undergoing Cardiopulmonary exercise test Mean AT in patients with cardiopulmonary
(2013) years esophagogastric cancer resection complications was 9.9 mL/min/kg vs.
11.2 mL/min/kg in patients with no cardiopulmonary
complications (P = 0.05) Mean VO2 peak in patients
with cardiopulmonary complications was
14.6 mL/min/kg vs. 16.6 mL/min/kg in patients with
no cardiopulmonary complications (P = 0.07) ROC
curve analysis identified that an AT of 9 mL/min/kg
predicted cardiopulmonary complications (sensitivity
74%, specificity 57%) (P = 0.04)

AT, anaerobic threshold; ISWT, incremental shuttle walk test; ROC, receiver operator curve; SD, standard deviation.
Physiotherapy and esophageal cancer 3

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4 Diseases of the Esophagus
chemoradiotherapy and surgery, ameliorated aerobic
fitness levels to pre-chemoradiotherapy levels.20 There
are no similar trials pre-esophagectomy.
Inspiratory muscle training (IMT) involves
breathing exercise designed to improve inspiratory
muscle function and strength and represents an
emerging preoperative intervention. Preoperatively,
IMT demonstrates better feasibility than aerobic
training and may reduce PPCs through improve-
ments in preoperative maximum inspiratory pressure
(PImax).21,22 A landmark study prescribing 2 weeks
low intensity (30% PImax) prior to cardiac surgery
(n = 279) reduced the incidence of PPCs by 50%
(n = 25/139 intervention vs. n = 48/137 control).21
The same IMT prescription improved inspiratory
muscle strength and endurance in 83 patients under-
going esophagectomy but did not impact PPC rates.23
In a separate study, however, higher intensity training
(60–80% PImax) reduced hospital LOS by a median
of 4.5 days following esophagectomy (n = 39).22
In this study, while all patients experienced some
PPC, the high intensity training group experienced
more low grade PPCs (n = 16/20 patients) than high
grade PPCs (n = 4/20) compared to a lower intensity
protocol (n = 8/19 low grade and n = 11/19 high
grade). These results suggest that while low intensity
training improves inspiratory muscle function,22,23
higher intensity training may be required to optimize
esophagectomy outcomes22 (Table 2). The ongoing
PREPARE trial is prescribing high intensity IMT
(60% PImax) in a large cohort pre-esophagectomy
(target n = 248) which will provide further insight
into the prehabilitative application of IMT.24
Of note, advances in multimodal treatment
approaches to esophageal cancer, such as the
CROSS9 and MAGIC trials10 may establish these
regimens as standard of care for locally advanced
cancers, however, cardiopulmonary toxicities exist for
both treatment modalities. Lung tissue damage is a
recognized sequelae of thoracic radiation25 associated
with higher postoperative mortality.26 Specialists
centers report higher PPC rates following chemora-
diotherapy, particularly in patients with greatest
lung tissue damage,25 however, this has not been
reflected to date in clinical trials.26 A retrospective
review at our center reported that patients treated
with chemoradiotherapy and surgery experienced a
higher incidence of postoperative adult respiratory
distress syndrome (ARDS) (n = 9/88 vs. 1/98) and
respiratory failure (n = 12/88 vs. 4/98) compared
with surgical intervention alone.27 Furthermore,
declines in cardiopulmonary fitness are reported
with chemotherapy [2.5 mL/kg/min (95% CI 1.55,
3.47 mL/kg/min decline in VO2 peak)]28 and chemora-
diotherapy (30W decline in working capacity).29
Cardiopulmonary toxicity may preclude surgery
and impact outcome in patients receiving multiple
toxic agents or with borderline fitness. In one report,
survival at 1 year post-esophagectomy was associated
with prechemotherapy fitness but only in patients
who completed all prescribed chemotherapy (n = 39)
(hazard ratio 0.84, 95% CI 0.73–0.97) suggesting
that higher baseline fitness is required to cope with
multimodal interventions.28 In a cohort treated with
chemoradiotherapy (n = 26), patients who experi-
enced a reduction in fitness to ≤ 80W experienced
higher postoperative mortality (n = 5/6) compared to
post-treatment fitness >100W (n = 0/11).29 This area
will require ongoing investigation and consideration
as use of multimodal treatment approaches increases.
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Functional performance
Loss of weight and muscle mass can present at diag-
nosis and progress during neoadjuvant therapy30 with
patients at risk of developing sarcopenia and cancer
cachexia.31 Weight loss during neoadjuvant treatment
predicts survival.32 Poor performance status including
low activity participation adversely impacts postoper-
ative risk.11,33 Subjectively, patients report a decline
in functional performance during treatment and into
survivorship,34,35 however, objective quantification to
inform rehabilitation needs is lacking.31
Several algorithms exist for sarcopenia, typically
quantifying muscle mass from staging computerized
tomography scans,36 in addition to clinical measures
of muscle strength and physical performance.37,38
Muscle mass can also be estimated from bioelectrical
impedance analysis and anthropometry, including
mid-arm circumference.39 Hand grip strength <30 kg
in men and <20 kg in women characterize sar-
copenia.37 Walking speeds <1.0 m/s or walking dis-
tance <400 m (6-minute walk test) suggest mobility
restrictions.38 The Short Physical Performance Bat-
tery (SPPB), which assesses lower limb strength,
dynamic balance, and gait, is widely used in the assess-
ment of functional deficits with sarcopenia.37 Other
performance measures include the Timed Up and Go
or Stairs Climb test.
Suboptimal handgrip strength (<25 kg)40 and sar-
copenia36 are both associated with greater mor-
tality, morbidity, LOS, and slower progression to
oral intake following esophagectomy.40 Furthermore,
muscle wasting during neoadjuvant chemoradio-
therapy predicts postoperative mortality41 and corre-
lates with chemotherapy toxicity.36 In a heterogeneous
sample of cancer survivors, patients with SPPB scores
of 7–9 and ≥10 median survival of 10.5 and 13.4 years,
respectively, compared to 5.0 years in patients with
SPPB scores ≤6.42
Interventions for sarcopenia and cachexia tra-
ditionally take a nutritional approach.43 However,
exercise training combined with nutritional sup-
port during neoadjuvant chemoradiotherapy for
esophageal cancer is reported to maintain fitness
and body composition.44 In animal models, exercise
Table 2 Preoperative physiotherapy interventions for esophagectomy

Population Intervention
N (male/female) Age
Study Study Design (SD) Characteristics Intervention Group Control Group Results

Dettling et al. (2013) Participants assigned to 83 (62/21) 66.1 (7.5) Patients scheduled for IMT at a starting load Standard preoperative MIP and inspiratory muscle
intervention or control years (intervention esophagectomy with at of 30% MIP. Resistance physiotherapy including endurance increased in the
group based on travel group) 65.5 (9.6) years least 2 weeks presurgery. increased by 10% based deep breathing, cough intervention group. No
distance to the hospital. (control group) The intervention group on BORG <5. Two techniques difference between the group
were within 40 km travel weeks of training, seven for postoperative pneumonia
distance of the hospital. times per week for (25% vs. 23%, P = 0.84) or LOS
2 weeks presurgery (13.5 days vs. 12 days,
lasting 20 minutes. Six P = 0.08).
sessions were performed
at home and one
supervised
Van Adrichem et al. RCT 39 (29/10) 62.0 (7.1) Patients with proven High intensity IMT Endurance IMT MIP increased in both the
(2014) years (total group) esophageal cancer, (IMT-H) at a starting (IMT-E) using IMT-H (12%) and IMT-E
scheduled for intensity of 60% MIP Threshold device (35%) groups. FEV1 decreased
esophagectomy, able to and progressing to 80% starting at 30% MIP and in the IMT-H group
perform a valid MIP in week 1. Three progressing by 5% based (P = 0.018) and PIF increased
spirometry test, with at supervised training on BORG <5. Seven in the IMT-E group
least 3 weeks pre surgery. sessions per week. Six training sessions per (P = 0.003). IMT-E group were
cycles of six breathes per week, three supervised 2.9 times more likely to develop
training and four unsupervised a PPC than the IMT-H group
lasting 20 minutes (57.9% vs. 20%, P = 0.015).
Shorter LOS in th eIMT-H
group (mean 13.5 day) vs.
IMT-E group (mean 18 day)
(p = 0.01).

IMT, inspiratory muscle training; MIP, maximal inspiratory pressure; RCT, randomised controlled trial; SD, standard deviation.
Physiotherapy and esophageal cancer 5

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6 Diseases of the Esophagus
training attenuates inflammation, increases oxidative
capacity, enhances protein synthesis, and improves
body composition, however, there is limited evidence
in humans.45 A combination of resistance training
to improve muscle mass and strength, and aerobic
training to optimize cardiorespiratory function are
recommended for age-related sarcopenia.45 In sar-
copenic patients with chronic obstructive pulmonary
disease (COPD) 12–16 weeks of strength training,
with or without aerobic exercise, improves quadriceps
muscle strength46 and endurance47 and may have a
role as a preconditioning treatment to facilitate higher
intensity aerobic training in deconditioned cohorts.47
Resistance training directly promotes protein syn-
thesis and muscle fiber hypertrophy and, therefore, has
the potential to alleviate the catabolic effects of cancer
cachexia.45 Combined nutrition and exercise pro-
grams may have a particular role in esophageal cancer.
Two ongoing trials are currently examining combined
resistance training and eicosapentaenoic acid supple-
mentation on skeletal muscle mass in cachexic cancer
patients.48,49
EXPANDING THE ROLE OF PHYSIOTHERAPY
POST-ESOPHAGECTOMY
Standardized ERAS pathways are central to post-
esophagectomy management. The aims of ERAS
are to optimize preoperative status, reduce surgical
stress and postoperative complications, and accelerate
recovery through defined, integrated multidisciplinary
team care.
The primary postoperative physiotherapy goals are:
1. Preservation of respiratory function to maintain
adequate gas exchange
2. Primarily avoidance of PPCs and minimizing the
effects of PPCs when they occur
3. Early mobilization and return to physical function
Postoperative pneumonia is the most serious pul-
monary complication,1 adversely associated with out-
come including respiratory failure, intensive care
readmission, and death.8 Symptoms associated with
pneumonia include fever, elevated white blood cells,
infiltrative abnormalities on chest x-ray and evidence
of bacteria growth on sputum culture.50 The incidence
of pneumonia following esophagectomy is reported
to range from 2 to 39%,51 however, reporting is con-
founded by lack of standardized diagnostic criteria
in reporting outcomes.1,52 Other serious pulmonary
complications include respiratory failure requiring
reintubation and ARDS.1 Respiratory failure defined
as inspiratory muscle weakness insufficient to gen-
erate pressure for alveolar ventilation and resul-
tant mechanical ventilation can occur in up to 15%
of esophageal resections.53 Supportive treatments
include noninvasive ventilation (NIV), or mechan-
ical ventilation while treating the underlying cause.54
While NIV was once a contraindication it can be
administered with caution following esophagectomy.
Therapeutic use of NIV for acute respiratory failure
postoperatively can reduce intubation rates, incidence
of ARDS, and intensive care LOS.55 NIV has also
been found to reduce intubation rates in patients who
develop ARDS.56 Anastomotic leakage is the primary
concern using post-esophagectomy NIV use. Exces-
sive airway pressures may lead to inhalation of intradi-
gestive air and it is suggested that continuous positive
airway pressures may be preferred over pressure sup-
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port ventilation.57
ARDS represents an acute inflammatory response
of the lung to a direct or indirect insult,58 defined
by hypoxaemia (Pa O2 /FiO2 < 300 mmHg), diffuse
bilateral pulmonary infiltrates and the absence of left
atrial hypertension. The incidence of mild ARDS
(Pa O2 /FiO2 200–300 mmHg) post-esophagectomy is
25–30%59 with a devastating effects on mortality,
morbidity, and quality of life (QOL).60 Factors con-
tributing to ARDS include neoadjuvant chemora-
diotherapy,27 the systematic inflammatory response
to surgery60 and single lung ventilation during TTE
which invokes an ischeamia/reperfusion injury on the
deflated lung and oxygen toxicity and high inflation
pressures in the ventilated lung.59
Postoperative considerations – pain
Postoperative pain management is an essential com-
ponent of post-esophagectomy care. While physio-
therapists do not play a direct role in pain man-
agement, inadequate pain control is often described
as a barrier to physiotherapy interventions, particu-
larly early mobilization.61 Pulmonary consequences
of postoperative pain include impaired ventilation,
reduced forced residual capacity, sputum retention,
rapid shallow breaths, and the development of atelec-
tasis, hypoxaemia, and ineffective coughing.62,63
Physiotherapists should assess and document pain
levels at rest and during activities such as mobi-
lizing64,65 using tools such as the Visual Analog
Score (VAS) or the verbal rating scores (VRS).65
Adequate pain relief (VRS score <4 at rest or
dynamic VRS score <6) allows comfortable mobi-
lization and airway clearance.66 The consequences of
inadequate pain control can include ineffective secre-
tion clearance, failure to achieve mobility goals, and
increased susceptibility to pulmonary complications.
Thoracic epidural is the most effective analgesia fol-
lowing thoracic or upper gastrointestinal surgery. It
reduces pneumonia rates by facilitating earlier mobi-
lization, reducing opioid consumption and improving
cough,67 however, mild hypotension is not uncommon
due to suppression of the sympathetic nervous
system. Hypotension is usually treated with low dose

noradrenaline.68 While patients on low dose inotropes
can be mobilized with appropriate blood pressure
monitoring it requires a high level of clinical reasoning
to manage the benefit versus risk and often will have
to be deferred.69
Airway clearance
Alterations in rib cage dynamics, reductions in
pulmonary function and pain post esophagectomy
impedes airway clearance, the precursor to many
PPCs.62 While chest physiotherapy is an integral com-
ponent of postoperative rehabilitation, only a small
number of studies have examined the role of chest
physiotherapy following esophagectomy (Table 3).
In a retrospective review of 184 patients, rates of
PPCs dropped from 26 to 8% after TTO following
the introduction of respiratory physiotherapy, with
patients who did not receive chest physiotherapy being
almost four times more likely to experience PPCs
(OR 3.942 [95% CI 1.085–14.218]).70 Physiotherapy
may be beneficial for both open and laparoscopic
procedures.71,72 A retrospective review of 70 patients
following esophagectomy reported a lower incidence
of PPCs in those who received chest physiotherapy
(n = 1/40 atelectasis and 1/40 pneumonia) compared
to patients who did not receive chest physiotherapy
(n = 1/30 atelectasis and 3/30 pneumonia).72 Another
study reported improvements in FEV1 immediately
post chest physiotherapy in patients following both
thoracotomy (n = 12) and thoracoscopic (n = 22)
esophagectomy.71 Given the complexity of esophagec-
tomy and the risk of PPC, better quality studies are
needed to inform physiotherapeutic strategies post-
surgery.
Incentive spirometers are mechanical devices, which
encourage patients to take long deep inspirations
through visual feedback of inspiratory volume or
flow. They are used widely clinically, however, prac-
tice is unstandardized and they do not reduce PPCs
following upper abdominal,73 cardiac,74 or thoracic
surgery including esophagectomy.75 Despite these
concerns, early use of incentive spirometry is recom-
mended in several ERAS protocols.4,76,77
Adventitious breath sounds, changes in respira-
tory rate, dyspnoea, ineffective cough, orthopnoea,
and restlessness are the best clinical indicators of
ineffective airway clearance.78 Cough effectiveness
(inspiratory to near vital capacity, compression to
increase thoracic pressure, and fast air expulsion79 )
can be assessed objectively by peak cough flow
(PCF), with healthy values ranging from 240 to
500l per second varying with gender and age.80 In
respiratory and neuromuscular disease values above
160l/second are required to clear airway secretions
and promote weaning from ventilation.81 Such data
are lacking in postsurgical cohorts, however, in a
Physiotherapy and esophageal cancer 7
small group (n = 21) following cardiac surgery sup-
ported coughing, where the patient supports their sur-
gical wound, either through the use of their hands,
or a separate support, in addition to performing
a maximal inspiration, was associated with higher
PCF [200.8 (82.4) L/minute] versus both unsupported
cough [162.9 (61.0)] and standard supported cough
without maximum inspiration [174.3 (71.0)].82 Such
techniques warrant further investigation post thora-
cotomy, laparotomy, and esophagectomy.
Early mobilization
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Early mobilization is described as any low intensity
movement that aims to optimize cardiopulmonary
function including moving in bed, sitting out of bed,
standing, ambulating on the spot, or hallway ambu-
lation.83 Mobilization involving an upright position
utilizing the effect of gravity increases pulmonary
function to the greatest extent,2 therefore, extended
periods sitting out of bed are encouraged post-
esophagectomy, with many ERAS protocols speci-
fying minimum time requirements.76,84 While in bed,
high sitting or a Fowler position where the head of
bed is elevated up to 45◦ is recommended to reduce
post-esophagectomy gastroesophageal reflux.77 Gas-
troesophageal reflux is described in up to 80% of
patients post-esophagectomy, often worse in supine
than in standing and can compromise the integrity of
the anastomosis.85 High sitting and particularly sit-
ting out of bed optimizes basal ventilation/perfusion
matching86 and is therefore applied prophylactically
post-esophagectomy to prevent postoperative compli-
cations including atelectasis.2
While early mobilization is a key element of
ERAS4,76 and a structured postoperative mobiliza-
tion regime is recommended,87 studies examining the
benefits of early mobilization following esophagec-
tomy are lacking and recommendations are based
on best clinical practice. While mobilization goals
vary across different clinical pathways, mobilization
starts early, sometimes on the day of surgery4,76,77,88
but almost always by postoperative day (POD)#1
and frequent bouts of activity during the early post-
operative days are advised.66 Recommendations for
POD#1 range from sitting out of bed for ≥2 hours
to short walks (10 m/100–200 feet). Typically, on
POD#7 patients should be mobilizing independently
and suitable for discharge, however, clinician judge-
ment should be used to alter and progress therapy
based on individual assessment.68
Delayed mobilization increases postoperative mor-
bidity and complication risk.89 In 72 patients under-
going abdominal surgery, PPC risk increased by three-
fold (odds ratio 3.0, 95% CI 1.2–8.0) for each day
patients did not mobilize >10 m from the bed.89
Others have reported low ‘uptime’ following upper
abdominal surgery and thoracic surgery.61,90
Table 3 Postoperative physiotherapy interventions

Population Intervention
N (male/female) Age
8 Diseases of the Esophagus

Study Study Design (SD) Characteristics Intervention Group Control Group Results

Gosselink et al. Randomized controlled 67 (56/11) (27 for
(2000) trial esophagectomy) 58 (13)
years (intervention
group) 61 (14) years
(control group)
Nakatsuchi et al. Randomized controlled 36 (34/2) (14 for
(2005) trial (thorascopic thoracoscopy, 22 for
surgery vs. thoracotomy) thoracotomy) 61.8 (8.4)
years (thoracoscopy
group) 58.9 (9.3) years
(thoracotomy group)
Nakatsuchi et al. Cohort study 184 (154/30) 64.0 (7.7)
(2008) years
Patients undergoing Preoperative instruction Preoperative instruction No difference between
elective thoracic surgery on breathing exercises, on breathing exercises, groups for recovery of
either for either lung or uses of IS, coughing, uses of IS, coughing, pulmonary function
esophageal resection pain management on pain management on post-surgery, occurrence
dearly mobilization. dearly mobilization. of postoperative
Postoperative Postoperative complications or
instruction to perform instruction to perform hospital LOS.
two sets of 5–10 slow two sets of 5–10 slow
maximal inspiratory maximal inspiratory
maneuvres with volume maneuvres with breath
feedback incentive holding every hour
spirometer every hour
Patients undergoing Thoracoscopic surgery Thoracotomy surgery Acute improvement in
esophagectomy, Preoperative chest Preoperative chest vital capacity, FEV1 and
three-region lymph node physiotherapy, physiotherapy, peak expiratory flow
dissection and respiratory training and respiratory training and with postoperative chest
reconstructive surgery respiratory muscle respiratory muscle physiotherapy in both
for thoracic esophageal training for 1–2 weeks. training for 1–2 weeks. groups on POD3.
cancer Postoperative chest Postoperative chest Improved coughing
physiotherapy, coughing physiotherapy, coughing ability from level II to
instruction, respiratory instruction, respiratory level III in both groups.
training, inspiratory training, inspiratory
muscle training from day muscle training from day
2 and exercise therapy. 2 and exercise therapy
Patients with squamous Multivariate analysis of factors associated with rate of Patients who did not
cell carcinoma of the postoperative pulmonary complications including: sex, receive chest
thoracic oesophagus age, % VC, %FEV1, respiratory physiotherapy, physiotherapy were
who underwent a corticosteroid medications, comorbid pulmonary or almost four times more
one-step subtotal cardiac disease, use of neoadjuvant therapy likely to develop PPCs
esophagectomy than patients who did
(OR 3.942 (95% CI
1.085–14.218),
P = 0.0371)

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 Physiotherapy and esophageal cancer 9

intervention group (15%) vs.

(P < 0.05), characterized by

drainage (2 days) and lower

bronchopneumonia (n = 1
intervention vs. 3 control),
Lower rate of PPCs in the

intervention vs. 2 control)

reduced right hemithorax
the control group (37%)

less antibiotics (3 days),

reintubation rate (n = 1
intervention vs. 1/30
atelectasis (n = 1/40
lower frequency of
Results

control),
Fig. 1 Physiotherapy practice points for interventions post-
esophagectomy

Barriers to mobilization following complex surgery

Control Group

postoperative chest
Control group No

include pain,61 hypotension,61,89 painful or restric-

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physiotherapy

tive attachments,91 and subconsciousness.91 Timely

FEV1, forced expiratory volume in one second; IS, incentive spirometer; LOS, length of stay; PPC, postoperative pulmonary complications; VC, vital capacity.
removal of drains and attachments and early dis-
charge to noncritical care environments are key ERAS
Intervention

principles center to mobility progression. The most

common barriers following esophagectomy experi-
enced clinically are inadequate pain control, cardiac
positive airway pressures

instability, and multiple attachments, including the

early mobilization. No
clearance manoeuvres,
Intervention Group

re-expansion, airway
included respiratory
Postoperative chest

nasogastric tube and chest drains. Cardiovascular

Intervention group

physiotherapy that

exercises for lung

issues include arrhythmias, in particular, atrial fibrilla-

tion, peak in incidence at POD#3. Therapists should
carefully plan mobility practice after esophagectomy
to ensure adequate staff to support the patient, access
to portable monitoring equipment, and careful han-
dling of medical attachments.69 Equipment trolleys
may be useful. Assessment of cardiac reserve, epidural
esophagectomy within

on the introduction of
Groups formed based

physiotherapy in July

sequelae, and motor block should be recorded at base-

the 5 previous years.
Patients undergoing
Characteristics

postoperative chest

line. Outcomes to record during mobility include pain

(VAS) exercise intensity (BORG rate of perceived exer-
tion), and record of distance mobilized. Other phys-
iotherapy practice points post-esophagectomy are
2007

detailed in Figure 1.
Population

There is limited research in the acute postopera-

tive stage to inform intensity, frequency, and dura-
Intervention group 56.5
Group 53.5 (12.5) years

tion of exercise other than bedside transfers and

N (male/female) Age

hallway ambulation. As post-esophagectomy ambula-

70 (40/30) Control

tion involves multiple staff, use of equipment such as

(SD)

bedside cycle erometery or upper limb arm crank to

achieve a measurable exercise response may be valu-
(14.2)

able, particularly for patients with barriers to mobi-

lization who would benefit from exercise therapy. In
one preliminary study in a general surgical cohort
(n = 60), patients who completed moderate inten-
(April 2005–June 2007)

group (July 2007–April

Historic control group
Retrospective analysis

sity aerobic exercise on a bedside cycle ergometer

Historic intervention
Study Design

postoperatively experienced fewer episodes of respi-

ratory tract infection (n = 2 cases vs. n = 7 con-
trols) and shorter hospital LOS [8.5 (5.0) days vs. 11
(7.5) days].92 This area requires further investigation
2009)

to establish safety and efficacy. Exercise prescription

according to the exercise principles for critically ill
Table 3 (Continued)

patients would be sensible, i.e. low-moderate intensity,

high frequency, and monitored response.69 A com-
Lunardi et al.

bined resistance training and aerobic exercise program

in 3 weeks immediately following esophagectomy can
(2011)

ameliorate the known reduction in aerobic fitness with

Study

esophagectomy and improve health related QOL.93

10 Diseases of the Esophagus
FINAL COMMENTS AND CONCLUSION
This narrative review discusses evidence examining
the role of physiotherapy, including exercise therapy,
in the management of patients with esophageal cancer
and provides clinical insight from a specialist center.
Traditionally, the role of physiotherapy following
esophagectomy has focused on immediate postoper-
ative care and management of PPCs. While phys-
iotherapy is clearly an integral component of post-
esophagectomy management, the evidence supporting
specific interventions is weak and further work, par-
ticularly into early mobilization and other methods
of exercising patients postoperatively is warranted. As
multimodal treatment options for esophageal cancer
management evolve, the physical needs of patients
presenting for surgery is changing. This review is
consistent with others in recognizing the potential for
preoperative IMT to be efficacious at improving inspi-
ratory muscle function and subsequently postopera-
tive outcome,87 however, we await the results of the
PREPARE trial for further clarity in this area.24 The
feasibility and efficacy of other forms of exercise pre-
habilitation warrant further investigation.
Future trials in this area should also consider the
cost-effectiveness of physiotherapy interventions in
this group. The economic burden of PPCs is well rec-
ognized and characterized by higher hospital costs,
largely due to longer hospital LOS, greater need for
intensive care admissions, and higher rates of read-
missions.94 A recent systematic review examining pre-
operative aerobic exercise training trials found that
no study examined cost-effectiveness.95 Theoretically,
however, shorter hospital LOS is reported with preha-
bilitative trials22,95 and therefore, it follows that hos-
pital costs may be reduced and this should be inves-
tigated further. Our group have previously reported
that the cost of running supervised, twice weekly
exercise training for cancer survivors in the reha-
bilitation setting to be €196 per participant which
included physiotherapy supervision time, equipment
costs, and overheads.96 Postoperatively, a cohort of
patients (n = 119) who received prophylactic inten-
sive chest physiotherapy following pulmonary lobec-
tomy demonstrated a reduced incidence of PPCs and
151.75 less hospital days compared to historic con-
trols (n = 520), leading to an estimated saving of
€89,532.50.
Ongoing research investigating the evolving role of
exercise at many time points along this continuum
is attempting to elucidate what type and intensity of
intervention best to minimize morbidity and mor-
tality.
ACKNOWLEDGMENT
None.
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