Systemic anti-cancer treatment, such as chemotherapy and hormone therapy, can result in various physical side effects, including cramps and pain in the muscles (myalgia), joints (arthralgia) and bones (ostealgia). Pain may be mild and intermittent, or severe and persistent.
While the mechanisms of these pains are still not fully understood, recent research has identified several patterns and processes that may improve how we manage such side effects and prevent the disruption or cessation of cancer treatment. For anyone experiencing such side effects, be sure to advocate for yourself and discuss these with a health-care professional, to receive the right support and ensure the best possible treatment outcomes.
Chemotherapy
Some chemotherapy drugs are more likely to cause aches and pain in the joints. Around 86% of people on taxanes report experiencing joint or muscle pain (Fernandes et al, 2016, Smith et al, 2020). This is known as TAPS (Taxane Acute Pain Syndrome), which usually starts around 2 days after receiving chemotherapy and can last up to 7 days.
A study by Asthana et al (2020) found that most people experiencing chemotherapy-induced pain describe it as “aching”, with words such as “burning” and “sharp” occasionally being used in the later stages of treatment. This may suggest that there is initially an inflammatory component, occasionally followed by neuropathic (nerve) pain. Both these types of pains require different pharmacological and non-pharmacological management.
Pain should not be ignored as it can have a potentially significant impact on someone’s day-to-day life. If you are experiencing body or leg pain during chemo, it is firstly important to discuss this with your oncology team. They may wish to prescribe pain relief, refer you to physiotherapy or complementary therapy, adjust your chemotherapy dose or take some tests to rule out other causes for your symptoms.
Hormone Therapy
Hormone therapy and aromatase-inhibitors (AIs) affect the hormone levels in the body and cause physiological changes. AIs reduce the amount of oestrogen to prevent certain breast cancers from growing. Oestrogen plays many important roles, including bone health and remodelling; with lower levels of oestrogen, joints and bones can cause more discomfort and pain. Gupta et al (2020) found approximately 50% of those on AIs report new or worsening joint pain by 1 year after starting their treatment. Only 50% remain fully compliant with AI after 3 years, as treatment is discontinued due to their symptoms. For this reason, it is important to find ways of managing aches and pains, in order to tolerate your full prescription of hormone therapy.
Immunotherapy
As a newer treatment option, the full extent of immunotherapy-related musculoskeletal and rheumatological side effects is not known. A case series by Cretu et al (2021) found in 9 patients on immunotherapy that joint aches started around 10 weeks after starting treatment and were variable in presentation. Interventions varied depending on severity, with some patients improving after 2 weeks of NSAIDs while others had to discontinue treatment and start high-dose steroids to resolve symptoms.
Treatment related aches and pains usually resolve once your treatment has finished, but what can be done in the meantime? Consider trying the following interventions and see what works best for you.
Regular activity
Inactivity contributes to joint and muscle aches, pains and stiffness. Your body was designed to move! Having said this, this can be difficult during cancer treatment. Committing to a gentle exercise routine is hugely beneficial, for a vast number of cancer-treatment related side-effects, including aching joints.
Choose a low-impact exercise, such as walking, swimming or a static bike, that puts minimal stress through your joints. Aim to complete for a short period daily where possible, to increase blood flow and maintain cardiovascular function. Strengthening exercises may also be beneficial, as long as they are pain-free while practising.
Gentle stretching programme
When we are in pain, our muscles become overactive and tense. If not addressed, muscles can become shorter and stiffer, causing reduced range of movement. To prevent this, it is important to introduce gentle stretches daily, to maintain your joint movements and prevent worsening pain.
Heat therapy
By applying a heat source to an area of pain, you are superficially increasing localised body temperature, dilating blood vessels and increasing blood flow to the area, to relax muscles. It can also stimulate thermoreceptors in the skin, overriding pain signals travelling to the brain with non-painful stimuli (known as ‘pain-gate theory’). You can use a hot water bottle, gel packs or hot baths. Note: do not use heat therapy if you have visible fluid collection or swelling in an area, as heat will likely make this worse. Also do not use heat over areas of reduced sensation, as you may burn the skin.
Cold therapy
When a source of cold is applied to an area of the body, it constricts the blood vessels in the local area and reduces blood flow to the area. For this reason, the area will go numb and reduce your pain while the cold is applied. It can also reduce discomfort through pain-gate theory, as described above. When the cold source is removed, blood flow to the area will increase and ‘flush’ away toxins from the area, which can help with healing and reducing swelling. Note: do not use ice over areas of reduced sensation, as you may damage the skin.
Massage
Receiving massage from a trained professional during your chemotherapy, may help manage symptoms of aching, pain, anxiety and restlessness. It is recommended to use light touch over deep muscle massages during cancer treatment and to avoid massaging directly over tumour sites, affected lymph nodes and radiotherapy treatment sites. Trained massage therapists can be found through The General Council for Soft Tissue Therapies.
Acupuncture
There is a growing body of evidence to support the role of acupuncture to manage cancer treatment related aches and pains. A recent guideline (Long et al, 2022) made a strong recommendation for acupuncture in breast cancer patients to relieve aromatase-inhibitor induced arthralgia (joint pain).
Medications
Your doctor will be able to give advice on pain relief, to help you cope with aches and pains during cancer treatment. Recent preliminary evidence (Smith et al, 2020) also suggests that the antihistamine loratadine may help reduce the severity of aching legs during chemotherapy. Research by Gupta et al. (2020) has also found that the antidepressant duloxetine reduced aromatase-inhibitor pain in 70% of treated patients. Other pharmacological options may include non-steroid anti-inflammatories (NSAIDS) steroid injections, bisphosphonates or changing AI medications. It is important to discuss this with your oncology team, who will be able to recommend the best options for you.
Relaxation techniques
While relaxation techniques may not directly address the physiological cause of aches and pains, feeling confident using relaxation techniques to manage your pain can have a huge psychological benefit. Speaking to an occupational therapy, psychologist or hypnotherapist with experience in cancer may help you to perfect these techniques for you to use regularly.
In summary
Successfully managing the side-effects of cancer treatment will improve the quality of your treatment plan, your wellbeing and your life. If you are finding it difficult to manage your aching joints, please do speak to your oncology team about this.
If you would like personalised physiotherapy support, I would love to hear from you. Contact me any time at www.strongerthan.co.uk or hannah@strongerthan.co.uk.
References
Asthana, R., Zhang, L., Wan, B.A. et al. (2020) Pain descriptors of taxane acute pain syndrome (TAPS) in breast cancer patients—a prospective clinical study. Support Care Cancer. 28: 589–598.
Cretu, I., Cretu, B., Cirstoiu, C. et al. (2022) Rheumatological Adverse Events Following Immunotherapy for Cancer. Medicina (Kaunas). 58(1):94.
Ge, L., Wang, Q., He, Y. et al. (2022) Acupuncture for cancer pain: an evidence-based clinical practice guideline. Chin Med. 17(8)
Gupta, A., Lynn Henry, N. and Loprinzi, C (2020) JCO Oncology Practice. 16(11): 733-739.