Abstract
Background: Cancer rehabilitation is vital for managing treatment-related complications such as pain, fatigue, weakness, swelling, and respiratory difficulties. Physiotherapy addresses these challenges through manual therapy, electrotherapy, chest physiotherapy and structured exercise programmes. Despite its benefits, fragmented referral pathways, limited specialised training and low awareness hinder integration into oncology care. This study explores physiotherapists’ perceptions of cancer rehabilitation to improve referrals, service integration and inform curriculum development.
Objectives: To explore physiotherapists’ perceptions and experiences of cancer rehabilitation, and its integration within public tertiary hospitals in KwaZulu-Natal.
Method: A qualitative descriptive design was used. Semi-structured interviews with 18 physiotherapists were analysed thematically.
Results: Four major themes that emerged from participating physiotherapists were the necessity of integrating physiotherapy management into cancer medical care, gaps in undergraduate training, the importance of multidisciplinary team awareness, late patient referrals, resource shortages, limited knowledge about the disease and physiotherapy’s management effectiveness in addressing post-cancer complications.
Conclusion: Participants believed that integrating physiotherapy into cancer rehabilitation is crucial. Participants highlighted the need for oncology-focused training, improved multidisciplinary team collaboration and streamlined referral systems. Addressing resource shortages and empowering physiotherapists in clinical decision-making were seen as essential steps forward.
Clinical implications: Integrating physiotherapy into cancer management and clinical guidelines can improve service delivery, enhance multidisciplinary collaboration and address systemic barriers to optimise outcomes for cancer patients.
Keywords: cancer; cancer rehabilitation; physiotherapy; undergraduate curriculum; muscle weakness.
Introduction
Cancer rehabilitation is a form of supportive medical care aimed at improving the physical, psychological and functional well-being of individuals undergoing or recovering from cancer management. Cancer therapies, including surgery, chemotherapy, radiotherapy and immunotherapy, are often associated with side effects and complications that can significantly impact patients’ quality of life (Chowdhury, Brennan & Gardiner 2020). Common post-treatment complications include pain, swelling, fatigue, muscle weakness, reduced range of motion, poor joint flexibility and difficulty performing activities of daily living (ADLs). Respiratory complications and reduced exercise tolerance may also arise, particularly in patients with thoracic or pulmonary involvement (Chowdhury et al. 2020; Stout et al. 2021).
Physiotherapists play a crucial role in addressing these complications through interventions such as manual therapy, electrotherapy, chest physiotherapy and structured exercise programmes, which support functional recovery and enhance patients’ overall quality of life (Stout et al. 2021; Stuiver et al. 2019). Despite the well-documented benefits of physiotherapy in cancer care, its integration into rehabilitation services remains limited by several challenges. Key barriers include a lack of awareness among multidisciplinary teams (MDTs) regarding the role of physiotherapy in oncology (Brennan et al. 2022; Chowdhury et al. 2020; Nareeba et al. 2023), poorly structured referral pathways, staffing shortages and insufficient funding for physiotherapy services (Lubuzo, Hlongwana & Ginindza 2023). The lack of knowledge of the interdisciplinary roles among the MDT members has been cited as one of the common barriers that hinder optimal patient care (Maddocks et al. 2018; Thethwayo et al. 2024). This often results in poor communication and poor referral pathways among the healthcare professionals, ultimately affecting the patients’ outcomes (Thethwayo et al. 2024).
Furthermore, cancer patients often lack the knowledge and resources needed to access appropriate rehabilitation. Incorporating oncology rehabilitation into the undergraduate physiotherapy curriculum could address these gaps by better preparing students for clinical practice and ensuring a smoother transition into professional roles.
The present study aimed to explore physiotherapists’ perspectives on integrating physiotherapy into cancer management, their experiences with cancer rehabilitation and the barriers limiting physiotherapy interventions for post-cancer patients. Understanding these perspectives is critical to informing MDTs, raising awareness about the importance of timely physiotherapy referrals and recognising the role of physiotherapy in enhancing rehabilitation outcomes (Stuiver et al. 2019). Furthermore, this study may stimulate further research into oncology rehabilitation in South Africa, contributing to the development of context-specific rehabilitation guidelines and improving the quality of care for cancer survivors.
Research methods and design
Research design
Our study employed a phenomenological qualitative design, using semi-structured interviews with an interview guide consisting of open-ended questions which probed cancer rehabilitation services, their undergraduate training and clinical exposure, experiences with cancer patients, perceived common patient problems, views on the effectiveness of interventions, existing barriers and recommendations for improving oncology physiotherapy services. Qualitative research allows the researchers to delve into the phenomenon or the lived experiences of the healthcare workers who form part of the MDT (Denny & Weckesser 2018; Tenny, Brannan & Brannan 2022; Thethwayo et al. 2024).
Research settings
This study was conducted among the three tertiary hospitals in KwaZulu-Natal that manage cancer patients. Two of the healthcare facilities were in an urban area and one was in a peri-urban area. These healthcare facilities were selected because they are part of the hospitals used for clinical undergraduate training and part of the five hospitals where oncology services are provided in the province of KwaZulu-Natal.
Study population
The study population comprised of physiotherapists based at three tertiary public hospitals in KwaZulu-Natal, with a focus on those directly engaged in the provision of rehabilitation services to cancer patients. Inclusion was limited to physiotherapists formally employed at these institutions who had demonstrable involvement in oncology rehabilitation practice. To ensure the selection of participants with relevant expertise and experience, community service physiotherapists, physiotherapy assistants and those not currently delivering cancer rehabilitation services were excluded.
Recruitment and sampling strategy
The study participants were selected using purposive sampling, a type of non-probability sampling, to select physiotherapists working with cancer patients who were willing participants (Palinkas et al. 2015). Varying age groups, genders and years of work experience were accounted for in the sampling strategy. Potential participants were recruited telephonically and by email invitation by the researchers, which resulted in 18 participants.
Data collection tool
Data collection was facilitated using two primary tools: a digital audio recorder which captured the participants’ responses during interviews and a structured interview guide developed from existing literature (Smulowitz 2017) which aligned with the study objectives. The guide consisted of open-ended questions designed to elicit detailed insights into physiotherapists’ perspectives, experiences and recommendations regarding the integration of physiotherapy into cancer rehabilitation, with particular attention to its effectiveness, limitations and areas for improvement. To ensure methodological rigour, the interview guide was subjected to expert review by two academic qualitative researchers, all of whom were health professionals with experience in oncology and rehabilitation contexts. Their feedback led to minor refinements which were incorporated into the final version of the guide.
Data collection procedure
After approval was granted by the University of KwaZulu-Natal’s Humanities and Social Sciences Research Ethics Committee (HSSREC/00006825/2024), data collection was conducted over an eight-week period. All eligible participants were emailed an information sheet explaining the purpose of the study, voluntary participation and confidentiality measures. Written consent was obtained prior to the start of the study and verbal consent was reaffirmed before each interview. Semi-structured interviews were conducted either face-to-face in private rooms within the hospitals or online for participants who preferred this option. Each interview lasted approximately 45 min and was audio-recorded using a digital recorder while the researcher also documented contextual observations and non-verbal cues in a field notebook. The interviewer maintained a neutral stance throughout and carefully avoided the use of leading questions. Data collection continued until saturation was achieved with no new themes emerging. All recordings were securely stored in a file on a password-protected laptop file, and interviews were transcribed verbatim in preparation for analysis.
Data analysis
A stepwise approach to thematic data analysis, as outlined by Braun and Clarke (2014) and Creswell and Poth (2017), was employed to guide the analytic process. This involved phases of familiarisation with the data, systematic coding, initial theme generation and iterative theme review, culminating in the development of final themes. Interview transcripts were read and re-read to gain an in-depth understanding of the content before identifying codes and emergent themes through an inductive process aligned with the study objectives (Vears & Gillam 2022). Trustworthiness of the findings was enhanced through member-checking whereby selected participants were asked to verify the accuracy of representative quotes and the appropriateness of emerging themes (Denny & Weckesser 2018). Transferability was ensured through detailed documentation of the study context, methodology and purpose, confirming that the results reflected participants’ experiences rather than the researcher’s interpretations (Bertoni et al. 2024). Pseudonyms were used to report participants’ illustrative quotes and maintain anonymity. Dependability was strengthened by peer review of generated codes and themes by the study supervisors, who provided feedback on interpretation. In addition, themes were refined through ongoing discussion and consensus-building among the research team, ensuring credibility and consistency through analyst triangulation.
Ethical considerations
Ethical clearance was granted by the Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu-Natal (reference number: HSSREC/00006825/2024) and the Department of Health, and gatekeeper permissions were obtained from the selected hospitals. Study participants were sufficiently informed about the research. They were made fully aware of their freedom to withdraw from the study, with a no harm or insult clause, before signing the informed consent form. Also, their permission to record the interviews was requested and granted. Participants’ names and identities were kept anonymous using pseudonyms during the data collection, analysis and reporting of the study results. Each interview was conducted in a secluded area with audio recording kept in a file on a password-protected laptop.
Results
The study had a total of 18 participants, consisting of 15 women and 3 men. The majority (50%) of the participants were aged between 31 and 40 years, with a mean age of 35.3 years. The majority of participants’ experience (72%) was over 7 years, with a mean of 7.1 years, as illustrated in Table 1.
| TABLE 1: Baseline of participants’ demographic characteristics. |
The analysed data identified four major themes and several sub-themes (Table 2) which collectively captured the physiotherapists’ perspectives on cancer rehabilitation services within public tertiary hospitals in KwaZulu-Natal, South Africa.
| TABLE 2: Themes and subordinate themes on the perspective of cancer rehabilitation among physiotherapists. |
Theme 1: Perspectives on integrating physiotherapy in cancer management
This theme emerged from participants relating to their thoughts or opinions on integrating physiotherapy in cancer management following their experiences working with cancer patients. Under this theme, three subordinate themes emerged, namely the necessity to integrate physiotherapy in cancer management, the effectiveness of physiotherapy interventions in cancer rehabilitation and the lack of cancer-specific rehabilitation in undergraduate syllabi.
Sub-theme 1.1: Necessity to integrate physiotherapy in cancer management
Participating physiotherapists expressed agreement on the importance and necessity of integrating physiotherapy intervention in cancer management and rehabilitation. This agreement serves as a step towards advocating for baseline service delivery to cancer patients.
‘Well, I think we play a vital role because generally patients that are living with cancer, they do have different types of disabilities that they experience during their time with us, during chemo treatment times. So, we play a role because we want to make them as functional as possible. We want them to still be able to live quite a functional life … So, there is a role for us when it comes to our cancer patients. It just depends on what their difficulties are and how we can help them.’ (Participant 03, 9 years of experience)
Sub-theme 1.2: Physiotherapy intervention effectiveness in cancer rehabilitation
Participants believed that physiotherapy interventions are very effective in cancer rehabilitation as physiotherapy plays a vital role in rehabilitation, offering significant benefits across various stages of cancer care. The extracts below evidence this:
‘Physiotherapy, our interventions have been effective in that patient’s post surgery, most of them post surgery, were able to mobilise. They were discharged with minimal complications … And patients, for the most part, were discharged quickly.’ (Participant 01, 18 years of experience)
‘I’ve seen it work a lot in patients with lymphoedema, but pressure stockings are scarce …’ (Participant 16, 8 years of experience)
Sub-theme 1.3: Lack of cancer-specific rehabilitation in undergraduate syllabus
Participants reported that physiotherapy intervention in cancer rehabilitation was not covered in the undergraduate syllabus; hence, they were inadequately exposed. The lack of cancer-specific rehabilitation content in undergraduate physiotherapy syllabi was said to be a significant gap in education.
‘I can’t remember. I mean, I did certain blocks and stuff, but I can’t remember seeing specific cancer patients. I think after I graduated, and I started working in the public sector, that’s when I came into contact with a lot more cancer patients.’ (Participant 01, 18 years of experience)
Theme 2: Perceived common patients’ problems that require physiotherapy post cancer intervention
This theme emerged as participants expressed how physiotherapy plays a critical role in addressing a range of physical and functional problems that patients commonly experience following cancer interventions. Participants further alluded that these issues often stem from the disease itself or the side effects of treatments such as surgery, chemotherapy, radiation therapy and immunotherapy. Under this theme, four sub-themes emerged which are perceived loss of mobility, respiratory problems, paralysis and muscle weakness after cancer intervention.
Sub-theme 2.1: Perceived muscle weakness in patients after cancer intervention
Participants mentioned that most cancer survivors commonly present with weakness and fatigue following chemotherapy and prolonged immobility.
‘So generally, it’s weakness, where they haven’t been mobilised for a while. The medication for the cancer … has weakened them.’ (Participant 12, 10 years of experience)
Sub-theme 2.2: Perceived respiratory problems in patients before and after cancer intervention
Participants mentioned that some post-cancer patients present with respiratory problems such as pneumonia, decreased exercise tolerance and lung collapse. Respiratory problems are commonly perceived in cancer patients both before and after intervention, depending on the type of cancer, its location and the treatments used.
‘And some cancers also affect lungs, and we can help with the respiratory, yeah, physio.’
‘… [T]hey all ICU-acquired weakness, pneumonia and they struggle with lung collapse.’ (Participant 06, 9 years of experience)
Sub-theme 2.3: Perceived paralysis in patients after cancer intervention
Participants highlighted how some cancer patients are likely to acquire paralysis because of cancer that affects the spinal cord (metastasis), leading to paraplegia, such as in osteosarcoma, which can cause paralysis or lead to amputation:
‘Paraplegic, quadriplegic, urinary incontinence, for elderly gogos with cervical cancer. What else? The patients with leukopoiesis sarcoma end up being amputated. So, they end up being amputees …’ (Participant 10, 8 years of experience)
Sub-theme 2.4: Perceived loss of mobility in patients after cancer intervention
Participants explained that some post-cancer patients struggle with mobility as a result of treatment such as radiotherapy and chemotherapy. The following quote elaborates further on the struggles experienced by cancer patients:
‘… [T]hey might have issues with mobility, especially with pelvic kind of cancers. There might be issues with mobility, where we have to prescribe walking aids or strengthen certain muscles to assist them to keep mobile. They might, of course, with radiotherapy; sometimes the tissues shrink and it causes limitations in mobility of joints as well.’ (Participant 05, 6 years of experience)
Theme 3: Barriers in integrating physiotherapy and cancer management
Barriers to integrating physiotherapy into cancer management emerged as one of the overarching themes that highlighted the significant challenges in the rehabilitative care of cancer patients. These barriers are further elaborated in the three sub-themes discussed as follows.
Sub-theme 3.1: Lack and late referrals by medical practitioners
Participants mentioned that there is a lack of referral to physiotherapy for the rehabilitation of post-cancer patients. Participants further echoed that some patients are referred late by medical practitioners, which results in poor outcomes of the patient’s recovery.
‘… [P]oor referral system on our healthcare professionals because even if the patient doesn’t know about physiotherapy at home, but when they get to the hospital, when they get diagnosed, and the doctor or the nurse can see that, oh, this patient is unable to get up actually, they can get referred.’ (Participant 17, 7 years of experience)
‘I can just say that doctors don’t refer in time. They only refer patients when they are on the end stage of cancer. They don’t see a need of referring on the early stages of the cancer. Usually, we get referrals when they are about to die on stage four.’ (Participant 06, 9 years of experience)
Sub-theme 3.2: Lack of awareness and knowledge within the multidisciplinary team about the physiotherapy role in oncology management
The lack of knowledge was one of the most common barriers, as participants mentioned that the MDT members are often unaware of the role of physiotherapy in cancer rehabilitation.
‘Where I am right now, what I’ve been exposed to is, there’s a barrier of just a lack of theoretical knowledge. For us as physiotherapists and for other medical staff, it’s like, I’m not going to refer this patient because what are they going to do for her or him? So if maybe other colleagues know what we are about, especially when it comes to cancer patients, maybe they can refer more or interpret us more as a team in improving the health outcomes of that patient … ’ (Participant 14, 3 years of experience)
Sub-theme 3.3: Shortage of staff and equipment
Participants highlighted that the shortage of staff posed a barrier to continuity of rehabilitative care with some of these patients after they are discharged, as there are not enough physiotherapists in the selected hospitals.
‘And also, if we can have more people, then it will also be easier to follow up with them. Frequently, I think …
No, when they get referred to us. So, if we can have more staff, more physios. So, it will be easier to follow up even at nearest clinics. Because right now, we book patients monthly or every second month.’ (Participant 18, 13 years of experience)
‘We do, the problem, because right now we don’t have the walking aid, if we have lymphedema patients, we don’t have compression stockings. So, yeah, that’s also a problem … ’ (Participant 14, 3 years of experience)
Theme 4: Recommendations for improving physiotherapy services
Participating physiotherapists offered insightful recommendations to improve the rehabilitative care of cancer patients. These include educating and raising awareness among the MDT as well as integrating physiotherapy and cancer rehabilitation in the undergraduate curriculum. This is summarised in the following sub-themes:
Sub-theme 4.1: Educate and raise awareness among the multidisciplinary teams about the role of physiotherapy in cancer rehabilitation
In order to ensure that cancer patients receive timely and effective rehabilitative care, participants recommended education for the MDT on the role and effectiveness of physiotherapy intervention in cancer rehabilitation.
‘… [E]ven in a work set-up, it would also be nice to have seminars and things about cancers and what are the new breakthroughs and what part we play as physio.’ (Participant 09, 10 years of experience)
‘… [I]t would be nice to have workshops for medical and rehabilitation staff on oncology in one seminar … ’ (Participant 13, 4 years of experience)
Sub-theme 4.2: Integration of physiotherapy and cancer rehabilitation in undergraduate curriculum
Participants advocated that cancer rehabilitation should be included in the undergraduate curriculum for students to gain adequate exposure in treating patients with cancer, as cancer is becoming a more common condition.
‘I think that it would be nice to include it in undergrad. Because we don’t realise, you know, what a big part it is. And it’s becoming more and more common these days. So, it’s important to include that in the syllabus, I would think … ’ (Participant 11, 9 years of experience)
‘So even if there’s just one module that does it, it would be beneficial to, I think, future physiotherapists. Especially from being a fourth year to come save and then being employed in a hospital that deals with cancer like [names the hospital] … ’ (Participant 15, 4 years of experience)
Discussion
This study explored physiotherapists’ perspectives on cancer rehabilitation services within public tertiary hospitals in KwaZulu-Natal, South Africa, addressing a notable gap in the local literature. Despite the global recognition of physiotherapy in oncology care, there is limited research on holistic rehabilitation services in the South African context, particularly beyond breast and prostate cancer (Mambondiani 2017). Using a descriptive qualitative approach, the study identified four main themes: perspectives on integrating physiotherapy in cancer management, common patient problems requiring physiotherapy, barriers to integration and recommendations for improving physiotherapy services in oncology.
Perspectives on integrating physiotherapy in cancer management
Participants emphasised the necessity of integrating physiotherapy into cancer care, noting that post-cancer patients commonly experience functional impairments such as shoulder pain, poor exercise tolerance, decreased mobility, respiratory problems, balance deficits, and limitations related to chemotherapy, radiotherapy or surgical interventions. These findings align with existing literature, which demonstrates that physiotherapy interventions can mitigate these impairments, optimise physical function, and enhance patients’ quality of life (Chowdhury et al. 2020; Stout et al. 2021). Participants highlighted that physiotherapy not only addresses physical deficits but also supports psychological and emotional well-being by fostering motivation and hope. However, they acknowledged that physiotherapy cannot cure cancer-related pathology or oncological pain, but it is essential in providing supportive care that improves overall patient outcomes.
Participants also identified a gap in undergraduate training, noting that cancer-specific rehabilitation was inadequately covered in curricula. This lack of early exposure may limit physiotherapists’ preparedness to manage oncology patients effectively, supporting previous calls for integrating oncology content into both entry-level and advanced physiotherapy education (Bertoni et al. 2024; Stuiver et al. 2019).
Common patient problems requiring physiotherapy
The study highlighted several functional and physiological challenges experienced by post-cancer patients, including generalised muscle weakness and fatigue from prolonged immobility or chemotherapy, reduced range of motion, poor joint flexibility, and loss of mobility. Respiratory complications, including pneumonia, lung collapse and decreased exercise tolerance, were also reported, reflecting both disease and treatment-related impacts (Stout et al. 2021). In addition, paralysis resulting from spinal metastases or surgical interventions, including amputations, was noted as a significant rehabilitation concern. These findings underscored the multifaceted role of physiotherapy in addressing musculoskeletal, respiratory, and functional impairments among cancer survivors.
Barriers to integrating physiotherapy in cancer care
Several systemic and educational barriers were identified, including delayed or insufficient referrals, limited awareness among MDT members regarding physiotherapy’s role in oncology, resource constraints such as shortages of staff, equipment and assistive devices, and inadequate oncology-specific training. These findings echo previous studies highlighting misconceptions that patients are ‘too ill’ for physiotherapy, resulting in late referrals and missed opportunities for early intervention (Brennan et al. 2022; Nareeba et al. 2023). Participants emphasised that staff shortages hinder follow-up care, particularly for home-based rehabilitation, and that resource limitations compromise the provision of optimal care.
Recommendations for improving physiotherapy services
To address these barriers, participants recommended increasing awareness among MDT members through seminars, workshops, and active participation of physiotherapists in ward rounds to advocate for early referrals and proactive patient screening. Integration of oncology rehabilitation into undergraduate physiotherapy curricula was emphasised to equip future clinicians with the knowledge and skills required for effective care. Evidence suggests that structured education at both entry-level and advanced training stages can improve confidence and competence in cancer rehabilitation (Dennett et al. 2021; Stuiver et al. 2019). In addition, the allocation of resources, including appropriate equipment and adequate staffing, was highlighted as critical for sustaining comprehensive oncology rehabilitation services. The findings reinforce the importance of integrating physiotherapy within cancer care pathways to address the complex needs of patients and improve recovery outcomes.
Study limitations
The study was conducted in three out of five oncology healthcare service hospitals. Therefore, the generalisation of the study findings should be applied with caution. Not all physiotherapists in the selected hospitals were willing to participate in the study, which led to fewer participants. However, future researchers may use the study findings as a baseline.
Recommendations
To optimise cancer rehabilitation services, this study recommends the development of standardised national guidelines for physiotherapy in oncology. Currently, there are breast cancer, chemotherapy and cancer pain guidelines available. However, there is a lack of rehabilitation guidelines. Educational initiatives for undergraduate curricula are essential to raise awareness and improve competency. These strategies can inform the development of context-specific guidelines tailored for the South African healthcare system, ultimately enhancing the quality and accessibility of cancer rehabilitation services.
Conclusion
This study highlighted the critical role of physiotherapy in cancer rehabilitation within tertiary public hospitals in KwaZulu-Natal. Physiotherapists recognised that post-cancer patients commonly experience functional impairments, including mobility limitations, generalised weakness and respiratory complications, which can be effectively addressed through targeted physiotherapy interventions. Despite its benefits, the integration of physiotherapy into cancer care is constrained by systemic challenges, including delayed or insufficient referrals, limited awareness among MDTs, resource shortages and inadequate oncology-specific training. Strengthening the role of physiotherapy in cancer rehabilitation has the potential to enhance patient outcomes, addressing not only physical impairments but also supporting psychological and emotional well-being. Furthermore, the findings highlight the importance of integrating oncology-focused rehabilitation into undergraduate physiotherapy curricula to better prepare future clinicians for the complexities of cancer care.
Acknowledgements
The authors of this article would also like to extend their acknowledgement to Akhona Sithole, Mluleki Kunene, Sphesihle Kunene, Noluthando Nzimande, Lethukukhanya Sangweni and Ayanda Mbanjwa for their significant contribution to this study and to the participants for their time committed to the study.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
L.M.N., N.S.K., K.S. and J.S.M. conceptualised the topic of study, and analysed and wrote up the study results. J.S.M. provided expert critiques of the article.
Funding information
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author, J.S.M., upon reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency of the authors or the publisher. The authors are responsible for this article’s results, findings and content.
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