Inpatient Rehabilitation of Patients with Cancer: Efficacy and Treatment Considerations

Importance of Physical Medicine and Rehabilitation in a Patient With Bilateral Lumbosacral Plexopathy Following the Course of Ladiratuzumab Vedotin for Breast Cancer: A Case Report

A 74-year-old female with metastatic triple-negative breast cancer was admitted to the acute care hospital after several ground-level falls and a two-week history of bilateral lower extremity weakness with foot drop, numbness, and tingling. She was on ladiratuzumab vedotin (SGN-LIV1A) and pembrolizumab for four months prior to cancer treatment. Lumbar and sacral imaging studies did not identify neoplastic invasion into the bone or lumbosacral plexus. Electrodiagnostic findings suggested bilateral lumbosacral plexopathy (L3-S1). In the setting of rapid functional decline, medications were reviewed, and SGN-LIV1A was held. On initial evaluation, she required significant assistance with ambulation, transfers, and activities of daily living (ADLs). She remained off SGN-LIV1A and was discharged to acute inpatient rehabilitation. One month following discharge from acute inpatient rehabilitation, she exhibited improvements in right lower extremity strength and foot drop and progressed to modified-independent with ADLs, ambulating with a walker. In a discussion between cancer rehabilitation and oncology with consideration of the timing of presentation, distribution of symptoms, nerve conduction study and electromyography (NCS/EMG) findings, and improvement after SGN-LIV1A discontinuation, the patient was diagnosed with lumbosacral plexopathy from SGN-LIV1A administration. This is the only reported case of lumbosacral plexopathy secondary to SGN-LIV1A and addresses the importance of early consultation with cancer rehabilitation to address sequelae stemming from cancer therapy.

Relationships between reading performance and regional spontaneous brain activity following surgical removal of primary left-hemisphere tumors: A resting-state fMRI study

Left-hemisphere intraparenchymal primary brain tumor patients are at risk of developing reading difficulties that may be stable, improve or deteriorate after surgery. Previous studies examining language organization in brain tumor patients have provided insights into neural plasticity supporting recovery. Only a single study, however, has examined the role of white matter tracts in preserving reading ability post-surgery and none have examined the functional reading network. The current study aimed to investigate the regional spontaneous brain activity associated with reading performance in a group of 36 adult patients 6-24 months following left-hemisphere tumor resection. Spontaneous brain activity was assessed using resting-state fMRI (rs-fMRI) regional homogeneity (ReHo) and fractional amplitude low frequency fluctuation (fALFF) metrics, which measure local functional connectivity and activity, respectively. ReHo in the left occipito-temporal and right superior parietal regions was negatively correlated with reading performance. fALFF in the putamen bilaterally and the left cerebellum was negatively correlated with reading performance, and positively correlated in the right superior parietal gyrus. These findings are broadly consistent with reading networks reported in healthy participants, indicating that reading ability following brain tumor surgery might not involve substantial functional re-organization.

Relationship Between Cachexia and the Functional Progress of Patients With Cancer in Inpatient Rehabilitation

PURPOSE

Although inpatient rehabilitation can improve functional independence in patients with cancer, the role of cachexia in this population is unknown. Our objectives were to:1) Establish prevalence of cachexia in a cohort of cancer patients receiving inpatient rehabilitation and its association with demographic and oncological history.2) Determine the relationship between the presence of cachexia and functional recovery and whether these patients in inpatient rehabilitation have a distinct prognosis.

METHODS

This is a retrospective cohort study of 250 patients over 330 admissions to an inpatient rehabilitation facility. Body weight loss threshold and Weight Loss Grading Scale identified patients with and without cachexia. Main outcomes were functional independence measure scores, discharge destination, and 6-mo survival.

RESULTS

Prevalence of cachexia in inpatient rehabilitation was 59% using consensus body weight loss criteria, and 77% of cancer patients had a Weight Loss Grading Scale score greater than 0. Patients with and without cachexia had similar motor and cognitive gains, although patients with severe cachexia had more limited functional gains ( P < 0.05) and increased odds of acute care return ( P < 0.01). Patients with a Weight Loss Grading Scale score of 4 had decreased survival at 6 mos ( P < 0.05) compared with noncachectic patients.

CONCLUSIONS

These data suggest that there is a relationship between cachexia and recovery for cancer patients that should be further studied in rehabilitation settings.

Factors Associated with Unplanned Transfer of Patients with Brain Tumor from Inpatient Rehabilitation Unit to Primary Acute Care Units

Inpatient rehabilitation should be assessed to improve each functional domain in patients with brain tumor. However, no previous study has reported risk factors for unplanned transfer of this patient population to primary acute care units during a comprehensive inpatient rehabilitation. The objective of this study was to investigate the percentage of unplanned transfer of brain tumor rehabilitation inpatients to primary acute care units compared with stroke patients and factors associated with such unplanned transfer. Data of 137 patients with brain tumor who were transferred to the department of physical and rehabilitation medicine were retrospectively reviewed. For comparison, data of 438 patients with subacute stroke were also obtained. Included patients were divided into an unplanned transfer group and a control group based on whether they required a transfer to another department for acute care before completing their comprehensive inpatient rehabilitation. Reasons for unplanned transfers were classified based on medical or surgical conditions. The incidence of unplanned transfers to the medical or surgical department was significantly higher in patients with brain tumor (15.3%) than in stroke patients (7.1%) (p < 0.05). Most of unplanned transfers occurred within two weeks of the comprehensive inpatient rehabilitation for patients with brain tumor. There was a significantly higher incidence of unplanned transfers in patients with a primary tumor than in those with a metastatic tumor (15.9% vs. 4.8%, p < 0.05). In addition, the frequency of chemotherapy or radiotherapy was significantly (p < 0.05) higher in the unplanned transfer group than in the control group. The most common cause of an unplanned transfer was a neurologic cause (90.0%) in patients with brain tumor and an infectious disease such as pneumonia (51.6%) in stroke patients. In conclusion, these results demonstrated a higher incidence of unplanned transfers in patients with brain tumor than in stroke patients during intensive inpatient rehabilitation. Proportions of those with neurological problems were relatively higher in patients with brain tumor than in patients with subacute stroke.

Predictors of functional outcomes in adults with brain tumor undergoing rehabilitation treatment: a systematic review

INTRODUCTION

The number of diagnosed brain tumors (BT) has increased in recent years. The results of treatment of patients with surgery, chemotherapy and radiotherapy are also improving and their survival rate has increased significantly. Symptoms of the disease and side effects of oncological treatment may reduce the functional performance of patients. It is so important to conduct rehabilitation in this group of patients. The aim of this systematic review is to identify predictors of effective rehabilitation in aspects of physical functioning of BT patients. The study was registered with health and social care, welfare, public health, education, crime, justice and international development departments, where there is a health-related interest outcome PROSPERO. We have received registration number is: CRD42021269398.

EVIDENCE ACQUISITION

To find relevant publications, the algorithm of keywords ("brain tumor") AND (rehabilitation OR "physical activity" OR exercise OR "physical therapy") was used. The search was conducted in PubMed, Web of Science, PEDro, ClinicalTrials.gov and Cochrane Library. Information was extracted using the PICO format (i.e., participants, intervention, comparison, outcomes).

EVIDENCE SYNTHESIS

the initial search identified a total of 1122 results, and 21 articles met the criteria and were selected for analysis.

CONCLUSIONS

The results present that rehabilitation is an important and safe cancer encouraging therapy, brings functional benefits. The type of rehabilitation program, especially in BT patients, depends on many factors such as time and type of oncological treatment, general conditions which is strongly related to the general functioning of the patient. It still is a need for clinical research into the safety and effectiveness of rehabilitation interventions already during radio or chemotherapy in this group of cancer patients.

Long-Term Outcomes of Patients with Primary Brain Tumors after Acute Rehabilitation: A Retrospective Analyses of Factors

Although primary brain tumors are relatively rare, they cause significant morbidity and mortality due to the high rates of neurological impairment. The purpose of this study was to examine the physical and functional outcomes of patients with primary brain tumors who had undergone inpatient rehabilitation. This was a retrospective study which recruited 163 patients who had been admitted for inpatient rehabilitation. Rehabilitation outcomes, including the Functional Independence Measure (FIM) and Glasgow Outcome Scale (GOS), were recorded up to 1 year post-discharge. The majority of patients (79.1%) had low-grade (WHO Class I-II) tumors, 35 (21.5%) were diagnosed with GBM and 52 (31.9%) had recurrent brain tumors. Rehabilitation outcomes were sustained, with 125 (76.7%) and 113 (69.3%) patients having a GOS of ≥4 at 6 months and 1 year after discharge, respectively. A GOS of ≥4 at 1 year was negatively associated with high-grade tumors (p < 0.001) and radiotherapy (p = 0.028), and positively associated with a higher discharge FIM motor score (p < 0.001) and the presence of a caregiver after discharge (p = 0.034). Our study demonstrates significant positive functional benefits from 4 weeks of inpatient neuro-oncological rehabilitation for patients with primary brain tumors, as well as the importance of supportive care from caregivers.

Changes in health-related outcomes among colorectal cancer patients undergoing inpatient rehabilitation therapy: a systematic review of observational and interventional studies

BACKGROUND

Colorectal cancer (CRC) and its treatment can lead to several physical and psychosocial impairments. Cancer rehabilitation aims to reduce morbidity and improve quality of life. The objective of this review was to summarize and evaluate evidence on changes in health-related outcomes among CRC patients undergoing inpatient rehabilitation therapy and on the effectiveness of such treatment.

MATERIAL AND METHODS

We conducted a systematic literature search including the electronic databases Pubmed and Web of Science to find observational and interventional studies, which investigated changes in health-related outcomes among CRC patients undergoing multidisciplinary inpatient rehabilitation programs or treatment effects. Study findings were synthesized narratively.

RESULTS

Eleven studies were eligible and included in this review. Eight patient cohort studies addressed outcomes such as physical and functional status, fecal incontinence, anxiety and depression, and quality of life. Positive changes during rehabilitation therapy were observed for physical health (functional and physical status, fecal incontinence), and several dimensions of quality of life. Study findings concerning anxiety and depression were not conclusive. Studies that additionally conducted long-term follow-ups indicated that the improved health status after rehabilitative treatment waned over time. One RCT reported no effect of inpatient rehabilitation on distress and two randomized trials reported effects of exercise intensity on oxidative stress and immune response. Sample sizes were low (<100 included CRC patients) in eight studies and only the RCT included a comparison group (non-rehabilitants).

CONCLUSION

The scientific evidence level was very limited. Due to the lack of a comparison group in most studies, we were only able to evaluate changes during/after inpatient rehabilitation therapy but not the effectiveness of treatment. However, study findings suggest that physical health and functional independence improve during inpatient rehabilitation, but improvements wane over time. Further large representative studies, in particular RCTs with long-term follow-up, are essential to evaluate the effectiveness of inpatient rehabilitation and identify determinants of treatment success.

Time to treatment initiation and outcomes in high-grade glioma patients in rehabilitation: a retrospective cohort study

Aims: To investigate wait time (WT) for chemoradiation and survival in post-op high-grade glioma (HGG) patients admitted to inpatient rehabilitation compared with those discharged home. Materials & methods: A total of 291 HGG patients (14.4% grade III and 84.9% grade IV) were included in this retrospective cohort study. Patients were grouped by disposition following surgery. Results: Median length of stay was longer in acute inpatient rehabilitation facility (AIRF) patients (10d) compared with patients discharged home (3d). AIRF admission was associated with higher odds of excessive treatment delay. Median survival for AIRF patients less than for patients discharged home (42.9 vs 72.71 weeks). WT was not associated with survival even after adjusting for prognostic factors. Conclusion: HGG patients discharged to rehabilitation facilities have longer length of stay, longer WT and shorter survival compared with patients discharged home.

Effectiveness of Physical Therapy- and Occupational Therapy-Based Rehabilitation in People Who Have Glioma and Are Undergoing Active Anticancer Treatment: Single-Blind, Randomized Controlled Trial

BACKGROUND

It is recommended that people with gliomas engage in rehabilitation, but high-quality evidence to support this recommendation is lacking.

OBJECTIVE

This study assesses the effectiveness of a physical therapy- and occupational therapy-based rehabilitation intervention compared with usual rehabilitation care for quality of life (QoL) during active anticancer treatment.

DESIGN

This study was a randomized controlled trial.

SETTING

The study took place in Odense University Hospital, Denmark.

PARTICIPANTS

The trial included people with gliomas who were functionally independent.

INTERVENTION

The participants were randomly assigned to a supervised rehabilitation intervention or usual rehabilitation care during the active anticancer period. The supervised rehabilitation included physical therapy and occupational therapy-based interventions.

MEASUREMENTS

The primary outcome was the between-group difference in the overall QoL from baseline to the 6-week follow-up. It was self-rated with the global health status (GHS)/QoL domains from the European Organization for Research and Treatment of Cancer Questionnaire. Eighty-eight participants per group were required to find a 10% between-group difference from baseline to the 6-week follow-up. Secondary outcomes were the health-related QoL domains, symptomatology, and functional performance.

RESULTS

A total of 64 participants were included (32 in the intervention group and 32 in the control group). At follow-up, the intervention group self-rated a nonsignificantly better score for GHS/QoL than the control group (adjusted mean difference = 8.7% [95% confidence interval = -4.36 to 21.79]). Compared with the control group, the intervention group had consistently better results on self-rated secondary outcomes, including cognitive functioning (β = 16.2) and fatigue (β = -13.4), and objectively measured aerobic power (β = 2.6).

LIMITATIONS

The number of participants and duration of follow-up were inadequate to determine if the intervention was superior to the current usual rehabilitation care.

CONCLUSIONS

The physical therapy- and occupational therapy-based rehabilitation intervention did not affect GHS/QoL. However, the trial found promising significant effects on both objective and self-reported secondary outcomes, making rehabilitation efforts during active anticancer treatment promising.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review

Purpose

Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC.

Methods

This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach.

Results

Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs.

Conclusion

Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

Bleeding Events in Thrombocytopenic Patients With Cancer Undergoing Acute Rehabilitation

Objectives:

To determine incidence of bleeding in thrombocytopenic patients with cancer undergoing acute inpatient rehabilitation.

Design:

This is an observational cross-sectional retrospective study.

Setting:

Acute inpatient academic rehabilitation facility.

Participants:

Adult patients admitted to acute inpatient rehabilitation with functional impairments secondary to cancer.

Methods:

Electronic records were reviewed for thrombocytopenic patients with cancer to determine platelet counts, bleeding events during rehabilitation, and anticoagulant medications prescribed.

Main outcomes measurements:

Type and number of bleeding events, severity of bleeding by World Health Organization criteria.

Results:

Of the 278 patients with cancer admitted to acute rehabilitation over a 27-month time frame, 119 had at least one platelet count <150 000/µL. In all, 37 (31.1%) had a history of a bleeding event prior to the rehabilitation admission and 34 (28.6%) had at least one bleeding complication during their stay. Most events (87.5%) were of low grade (Grade 1 and 2 World Health Organization criteria). There was no association between platelet counts <11 000 or counts 11 000 to 20 000/µL and the occurrence of bleeding ( P = .106 and P = .319, respectively). Although anticoagulants were common, there was no association found with a bleeding event and either anticoagulation status (receiving or not on such agents), specific anticoagulant or antiplatelet agents, or a combination.

Conclusions:

Bleeding events in patients with cancer with thrombocytopenia during acute rehabilitation stay are not uncommon but are typically mild in severity and not associated with the degree of thrombocytopenia. Patients taking anticoagulants when platelet levels rose did experience bleeding events, but not at a statistically greater rate than those not taking such medications.

Mobility Functional Outcomes of Neurofibromatosis Patients: A Preliminary Report

OBJECTIVE

The aim of the study was to describe the mobility outcomes of neurofibromatosis (NF) patients who received acute inpatient rehabilitation.

DESIGN

This is a retrospective study of 62 consecutive neurofibromatosis patients of any age who received physical medicine and rehabilitation consultations at a comprehensive cancer center. Postoperative, inpatient rehabilitation admission and discharge functional independence measures (FIM scores) of transfers and gait and length of hospital stay were obtained from 37 patients who were transferred to inpatient rehabilitation (acute rehabilitation) and 25 who had an alternative disposition (consultation only).

RESULTS

Mean age was 34 yrs. Both groups had similar postoperative FIM transfer and gait scores; however, at approximately postoperative day 10, the consultation only group was discharged with median FIM of 5 (supervision level) as compared with the acute rehabilitation group FIM of 4 (P = 0.000). The acute rehabilitation group had improved mobility FIM scores from postoperative to rehabilitation admission and again from rehabilitation admission to discharge (P < 0.0001). At discharge, the acute rehabilitation group ambulated a significantly longer distance (500 f. vs. 300 ft) (P = 0.04). The median length of hospital stay for the acute rehabilitation and consultation only groups was 20 and 10 days, respectively (P = 0.004).

CONCLUSIONS

Acute inpatient rehabilitation leads to improvement in mobility-associated FIM scores for neurofibromatosis patients minimizing caregiver needs at home.

Comparative Analysis of the Trends in Medical Utilization of Cancer Inpatients in Korea

Objectives

Cancer has attracted worldwide attention. The incidence and prevalence are increasing, and it is the main cause of death. The purpose of this study was to identify the characteristics of hospitalized cancer patients.

Methods

This study is a secondary data study using the Korean National Hospital Discharge In-depth Injury Survey Data conducted annually by the Korea Centers for Disease Control and Prevention. Using these data, we extracted inpatients who principal diagnosis is cancer for nine years from 2005 to 2013.

Results

According to the analysis, the annual trend of cancer inpatients is steadily increasing. In 2025, it is expected to increase to about 670,000 inpatients. A cancer diagnosis created a change in medical utilization depending on the characteristics of patients and hospital. Men are more at risk of cancer than women. The number of hospital beds and hospital days were inversely proportional to cancer inpatients. There was also a difference in the equity of medical utilization by region. Other cancer management policies should be based on sex.

Conclusion

Populations between the ages of 45 and 64 years should be a priority in cancer policy. Because of the long-term hospitalization of patients with death as the outcome, a terminal cancer patient care facility is needed. These conclusions can provide a basis for various health policies.

A Guide to Inpatient Cancer Rehabilitation: Focusing on Patient Selection and Evidence-Based Outcomes

Cancer inpatients commonly suffer from impairments that can prohibit safe discharge home from the acute care inpatient medical service and thus require transfer to a postacute inpatient rehabilitation facility. It has been demonstrated in multiple studies that cancer rehabilitation inpatients are able to make statistically significant functional improvements and at a similar pace as their noncancer counterparts. Medical fragility and reimbursement regulations are concerns that affect acceptance and triage of cancer rehabilitation inpatients. Strategies to rehabilitate these challenging patients include considering risk factors for medical complications, consult-based inpatient rehabilitation, and improved communication and coordination with oncology teams.

Short-term effectiveness of inpatient cancer rehabilitation: A longitudinal controlled cohort study

Background: Inpatient rehabilitation for cancer patients has been demonstrated to improve patients' health related quality of life (HRQoL) effectively. The purpose of this study was to compare changes in general health and HRQoL of cancer patients who were referred to inpatient rehabilitation (IR) with those in two control groups who underwent outpatient management either with advice for inpatient rehabilitation (A+) or without (A-). Methods: In this naturalistic, longitudinal, controlled cohort study, changes in general health and HRQoL were assessed at either discharge of acute hospital or start of rehabilitation (baseline) and at the follow-up 3 weeks later or end of rehabilitation. Outcome variables included general health and HRQoL assessed by the Short Form 36 (SF-36) and the Functional Assessment of Cancer Therapy (FACT), and fatigue (FACT-F), depression and anxiety by the Hospital Anxiety and Depression Scale (HADS). Changes on the scores were compared with bivariate and multivariate analyses using standardized mean differences (SMD). Results: IR patients (n=133) were on average older, reported lower HRQoL and health, and suffered more frequently from carcinoma than patients of the A+ (n=30) and the A- (n=82) groups. In the IR patients, pain, physical functioning, mental health, vitality, and fatigue improved significantly compared to the A+ controls. Compared to the A- group, the bivariate effects were lower but still statistically significant on many scales. Conclusions: IR showed moderate, statistically significant superior effects over outpatient management of cancer patients after acute treatment. Findings indicate that inpatient cancer rehabilitation can be recommended as an effective management after acute treatment. As today, referrals to inpatient rehabilitation for cancer patients are still not based on structured standardized procedures, the implementation of such screening is needed to address patients' needs and to render the potential for rehabilitation more reliable.

Patient-Reported Usefulness of Acute Cancer Rehabilitation

BACKGROUND

Cancer survivors often have unmet needs, and cancer rehabilitation is becoming an integral part of the continuum of care. Understanding the needs and satisfaction of patients undergoing cancer rehabilitation is important for the development of effective programs.

OBJECTIVE

To determine the overall perception of acute inpatient cancer rehabilitation usefulness.

DESIGN

Prospective study.

SETTING

Acute inpatient cancer rehabilitation unit at a National Cancer Institute (NCI) Comprehensive Cancer Center.

PARTICIPANTS

Patients admitted to the acute inpatient cancer rehabilitation unit from September 2014 to July 2015 were approached, and 200 patients enrolled with completed surveys.

METHODS

Patients meeting study criteria were asked to complete a survey about their perception of the rehabilitation received; their attitudes and beliefs on their condition, treatment, functional independence; and their attitudes and beliefs on obtaining health information and psychosocial issues.

MAIN OUTCOME MEASURES

Functional Independence Measure (FIM) scores, FIM efficiency, and results from an anonymous survey with a 22-item Likert-type scale at the end of patients' rehabilitation stay were analyzed.

RESULTS

Of 327 patients admitted, 239 patients (73%) were approached, and 200 patients (84%) were enrolled with completed surveys. Patients agreed or strongly agreed that rehabilitation helped with improving physical function (n = 193, 97%), regaining physical independence (n = 181, 91%), and preparing to deal with self-care tasks (n = 183, 94%). Patients agreed that rehabilitation improved hope (n = 187, 94%), mood (n = 176, 84%), anxiety (n = 180, 90%), and spirituality (n = 182, 94%). FIM score improvements (from admission to discharge) and FIM efficiency (change in FIM score / length of stay) were significant in all functional domains. Overall, respondents believed that their rehabilitation stay was extremely good (n = 128, 64%) or very good (n = 60, 30%).

CONCLUSIONS

Patients perceived their rehabilitation stay as beneficial in multiple respects. Significant improvements in FIM measurements were also found.

LEVEL OF EVIDENCE

IV.

The Intersection of Oncology Prognosis and Cancer Rehabilitation

PURPOSE OF REVIEW

This review examines the delivery of rehabilitation care to cancer patients with relation to disease prognosis. This includes the evaluation when patients are referred for rehabilitation services and the effectiveness of rehabilitation interventions across the cancer continuum.

RECENT FINDINGS

Although prognosticating life expectancy is difficult, referrals for rehabilitation interventions appear to be affected by physician attitudes towards patients with advanced disease, in part because of misconceptions about the nature of rehabilitation for oncology patients. Rehabilitation may also be underutilized in long-term survivors with no evidence of disease. Despite this, our review found that rehabilitation in advanced disease, end-of-life, geriatric cancer patients, and in long-term survivors can be beneficial. There is a relative dearth in studies on rehabilitation interventions specifically at the end-of-life.

SUMMARY

Cancer rehabilitation can be helpful to patients along the spectrum of cancer prognoses. Examining more accurate ways to prognosticate life expectancy, improving communication and education between oncologists and rehabilitation team members, and modifying survivorship plans to include patient education on functional changes over time may improve the delivery of rehabilitation care.

Characterization of Cancer Patients in Inpatient Rehabilitation Facilities: A Retrospective Cohort Study

OBJECTIVES

To identify the types of cancer patients admitted to inpatient medical rehabilitation and to describe their rehabilitation outcomes.

DESIGN

Retrospective cohort study.

SETTING

U.S. inpatient rehabilitation facilities (IRFs).

PARTICIPANTS

Adult patients (N=27,952) with a malignant cancer diagnosis admitted to an IRF with a cancer-related impairment between October 2010 and September 2012 were identified from the Uniform Data System for Medical Rehabilitation database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic, medical, and rehabilitation characteristics for patients with various cancer tumor types were summarized using data collected from the Inpatient Rehabilitation Facility-Patient Assessment Instrument. Rehabilitation outcomes included the percentage of patients discharged to the community and acute care settings, and functional change from admission to discharge. Functional status was measured using the FIM instrument.

RESULTS

Cancer patients constituted about 2.4% of the total IRF patient population. Cancer types included brain and nervous system (52.9%), digestive (12.0%), bone and joint (8.7%), blood and lymphatic (7.6%), respiratory (7.1%), and other (11.7%). Overall, 72% were discharged to a community setting, and 16.5% were discharged back to acute care. Patients with blood and lymphatic cancers had the highest frequency of discharge back to acute care (28%). On average, all cancer patient groups made significant functional gains during their IRF stay (mean FIM total change ± SD, 23.5±16.2).

CONCLUSIONS

In a database representing approximately 70% of all U.S. patients in IRFs, we found that patients with a variety of cancer types are admitted to inpatient rehabilitation. Most cancer patients admitted to IRFs were discharged to a community setting and, on average, improved their function. Future research is warranted to understand the referral patterns of admission to postacute care rehabilitation and to identify factors that are associated with rehabilitation benefit in order to inform the establishment of appropriate care protocols.

Symptom Burden and Functional Gains in a Cancer Rehabilitation Unit

BACKGROUND/AIMS

To determine if there is a relationship between patient symptoms and functional improvement on inpatient rehabilitation.

METHODS

Retrospective review of medical records at an American tertiary referral-based cancer center of all patients admitted to an inpatient rehabilitation unit between 3/1/2013-5/20/2013. Main outcome measures included the Edmonton Symptom and Assessment Scale (ESAS) and Functional Independence Measure (FIM).

FINDINGS

The medical records for 71 unique cancer rehabilitation inpatients were analyzed. Statistical analysis of total admission ESAS on total FIM change found no significant relationships. The symptom burden of the patients was mild. Patients demonstrated statistically significant improvements in function and symptoms during inpatient rehabilitation. The mean change in total FIM and total ESAS were an increase of 19.20 and decrease of 7.41 respectively. Statistically significant changes occurred in fatigue, sleep, pain, and anxiety.

CONCLUSION

Both symptom and functional scores improved significantly during inpatient rehabilitation. However, no significant relationships were found between symptoms at admission and improvement in FIM.

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

OBJECTIVE

To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI).

DESIGN

A retrospective cohort design was employed, using data retrieved from administrative databases.

SETTING

Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011.

PARTICIPANTS

Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation.

OUTCOME MEASURES

Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics.

RESULTS

There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%).

CONCLUSION

Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.

Multidisciplinary rehabilitation after primary brain tumour treatment

BACKGROUND

Brain tumours can cause significant disability, which may be amenable to multidisciplinary rehabilitation. However, the evidence base for this is unclear. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews [2013, Issue 1, Art. No. CD009509] on 'Multidisciplinary rehabilitation after primary brain tumour treatment'.

OBJECTIVES

To assess the effectiveness of multidisciplinary rehabilitation in people after primary brain tumour treatment, especially the types of approaches that are effective (settings, intensity).

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library up to Issue 12 of 12, 2014), MEDLINE (1950 to January week 2, 2015), EMBASE (1980 to January week 2, 2015), PEDro (1985 to January week 2 2015), and LILACS (1982 to January week 2, 2015). We checked the bibliographies of papers we identified and contacted the authors and known experts in the field to seek published and unpublished trials.

SELECTION CRITERIA

Controlled clinical trials (randomised and non-randomised clinical trials) that compared multidisciplinary rehabilitation in primary brain tumour with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary rehabilitation in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed study quality, extracted data, and performed a 'best evidence ' synthesis based on methodological quality.

MAIN RESULTS

We did not identify any studies for inclusion in the previous version of this review. For this update, the literature search identified one low-quality controlled clinical trial involving 106 participants. The findings from this study suggest 'low-level' evidence to support high-intensity ambulatory (outpatient) multidisciplinary rehabilitation in reducing short- and long-term motor disability (continence, mobility and locomotion, cognition), when compared with standard outpatient care. We found improvement in some domains of disability (continence, communication) and psychosocial gains were maintained at six months follow-up. We found no evidence for improvement in overall participation (quality of life and societal relationship). No adverse events were reported as a result of multidisciplinary rehabilitation. We found no evidence for improvement in quality of life or cost-effectiveness of rehabilitation. It was also not possible to suggest best 'dose' of therapy.

AUTHORS' CONCLUSIONS

Since the last version of this review, one new study has been identified for inclusion. The best evidence to date comes from this CCT, which provides low quality evidence that higher intensity ambulatory (outpatient) multidisciplinary rehabilitation reduces short- and long-term disability in people with brain tumour compared with standard outpatient care. Our conclusions are tentative at best, given gaps in current research in this area. Although the strength of evidence has increased with the identification of a new controlled clinical trial in this updated review, further research is needed into appropriate and robust study designs; outcome measurement; caregiver needs; evaluation of optimal settings; type, intensity, duration of therapy; and cost-effectiveness of multidisciplinary rehabilitation in the brain tumour population.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.

Cancer rehabilitation education during physical medicine and rehabilitation residency: preliminary data regarding the quality and quantity of experiences

OBJECTIVE

The purpose of this study was to gather descriptive information from residency program directors regarding characteristics of the education and experiences of resident physicians in oncology rehabilitation.

DESIGN

The program directors responded to a 28-question survey. Information collected included general descriptors of residency programs, oncology rehabilitation services lines within the institution, educational and clinical opportunities for trainees, and perceptions of quality for oncology experiences.

RESULTS

Thirty-eight responses, with a response rate of 48%, were recorded. Thirty-two percent of the programs did not have any dedicated faculty for cancer rehabilitation. A majority of the respondents felt that cancer rehabilitation should be an important component of the curriculum. Sixty-six percent of the programs admitted only one to two cancer diagnoses to their inpatient units per week, and 26% had outpatient clinics that focused specifically on rehabilitation needs for oncology patients. A majority of the programs felt that experiences were only average and that residents do not receive adequate exposure to cancer rehabilitation during their training.

CONCLUSIONS

Although cancer rehabilitation is considered an important area of education, quality and quantity of experiences may be improved. Several opportunities may exist to improve such exposure in anticipation of serving the functional needs for a growing population of cancer survivors.

Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship

Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.

The role and efficacy of exercise in persons with cancer

Improvements in cancer screening, diagnosis, and treatment have resulted in an increasing population of cancer survivors with impairments in physical function, cancer-related symptoms, and reduced quality of life. Exercise and physical activity have therapeutic value at multiple points along the cancer disease continuum, spanning disease prevention, treatment, survivorship, prognostic outcomes, and end-of-life issues. Molecular mechanisms for the influence of exercise in persons with cancer include altering tumor initiation pathways and affecting hormonal, inflammatory, immune, and insulin pathways. Physical activity has been found to play a role in the prevention of certain malignancies, including breast, colon, and other cancers. An increasing amount of evidence indicates that physical activity may affect prognostic outcomes in certain cancer diagnoses, especially breast cancer. Structured exercise and physical activity interventions can be helpful in addressing specific survivorship issues, including overall quality of life, cardiorespiratory impairment, cancer-related fatigue, and lymphedema. Exercise also may be helpful during the palliative care phase to alleviate symptoms and increase physical well-being. This article will familiarize physiatrists with the current state of evidence regarding the role and efficacy of exercise in persons with cancer.