Amy H. Ng

Levorphanol for Treatment of Intractable Neuropathic Pain in Cancer Patients

Neuropathic pain in cancer patients is often difficult to treat, requiring a combination of several different pharmacological therapies. We describe two patients with complex neuropathic pain syndromes in the form of phantom limb pain and Brown-Sequard syndrome who did not respond to conventional treatments but responded dramatically to the addition of levorphanol. Levorphanol is a synthetic strong opioid that is a potent N-methyl-d-aspartate receptor antagonist, mu, kappa, and delta opioid receptor agonist, and reuptake inhibitor of serotonin and norepinephrine. It bypasses hepatic first-pass metabolism and thereby not subjected to numerous drug interactions. Levorphanols unique profile makes it a potentially attractive opioid in cancer pain management.

A Survey Regarding the Knowledge, Attitudes, and Beliefs of Graduates of Cancer Rehabilitation Fellowship Program

Currently there are limited options for physiatrists to further subspecialize in cancer rehabilitation. Since 2007, few cancer rehabilitation fellowship programs have been started. There is currently absolutely no information about such training programs and their graduates. This study is the first to survey a small number of graduates from two cancer rehabilitation fellowship programs. The purpose of this study was to report characteristics, attitudes, and beliefs of cancer rehabilitation fellowship graduates. Graduates of cancer rehabilitation fellowship programs from 2008 through 2015 responded to a 26-question survey. Information collected included exposure to cancer rehabilitation prior to fellowship training, usefulness of fellowship training program, information about current practice, and suggested areas of improvement. The setting of the study is online survey. Participants were graduates of two cancer rehabilitation fellowship programs from 2008 through 2015. Participants were contacted via email about completion of an online survey and information was collected anonymously. Primary outcome measure was satisfaction of respondents with their fellowship training program in meeting the rehabilitation needs of their cancer patients. Sixteen responses, with a response rate of 89%, were recorded. Sixty-three percent of the respondents had exposure to cancer rehabilitation prior to post-graduate year 3 (PGY-3). Majority of graduates had practice involving at least 50% of care to cancer patients. Fifty percent indicated that their position was specifically created after their job interview. Career development was one of the major areas of suggested improvement in training. Graduates of cancer rehabilitation fellowship programs strongly value their training. Majority of the graduates were able to continue their career into jobs that were primarily cancer rehabilitation related. Further work needs to be done to define this subspecialty further and incorporate building practice as part of this training.

Patient-Reported Usefulness of Acute Cancer Rehabilitation

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.

Frequency of venous thromboembolism events during acute inpatient rehabilitation in a comprehensive cancer centre

OBJECTIVE To determine the frequency of venous thromboembolism, possible predictors, and the association between venous thromboembolism and Functional Independence Measure (FIM) scores and length of stay among cancer patients admitted to the inpatient rehabilitation unit at a cancer centre. DESIGN Retrospective analysis of patients admitted to acute inpatient rehabilitation from September 2011 to June 2013. Subject/patients: Cancer patients in the acute inpatient rehabilitation unit within a tertiary cancer centre. METHODS International Classification of Diseases (ICD-9) codes identified deep vein thrombosis, pulmonary embolism, and inferior vena cava filter. RESULTS Venous thromboembolism occurred in 32/611 patients (5.2%): 23/611 (3.8%) during the course of hospitalization before admission to rehabilitation, and 9/611 patients (1.5%) during rehabilitation. Patients with lower extremity oedema at admission (p = 0.0218) had a higher chance of subsequently developing venous thromboembolism. Patients with venous thromboembolism during rehabilitation had a significantly lower FIM transfer score at admission to rehabilitation (p = 0.0247), a longer length of stay in rehabilitation (p = 0.0013) and overall hospitalization (p = 0.0580). CONCLUSION Cancer patients with low FIM transfer scores and lower extremity oedema are at higher risk of venous thromboembolism. Patients with these clinical findings at admission may require measures for more aggressive surveillance for the presence of venous thromboembolism. Patients with venous thromboembolism had an increased length of stay in rehabilitation, but ultimately did not have significant differences in FIM score changes.

Irreversible Spinal Cord Injury Following Intrathecal Chemotherapy: A Case Report

addition to PO Baclofen to treat spasticity, the patient was also fitted with a dynamic left-upper-extremity splint to gradually stretch the arm and relieve the elbow contracture. Modifying, bilateral ankle-foot orthoses were used for 2 hours a day during bed rest to maintain range of motion and prevent contractures. Discussion: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC Virus (JCV), activated during immunosuppression. It is characterized by subacute neurological decline that typically results in progressive weakness, sensory loss, dysarthria, ataxia, hemianopsia, and cognitive impairment. Despite the progression of this disease, rehabilitation therapy with our patient shows the possibility of improved function after certain decline. After approximately 4 weeks of acute inpatient rehabilitation, our patient showed improvements with dynamic sitting, bed mobility, feeding, transferring, ambulation across level surfaces, wheelchair propulsion, and static standing balance. Conclusions: While likely under-reported, to the best of the authors’ knowledge, we describe the first case of functional improvement in a patient with PML after inpatient rehabilitation. This case also highlights the importance of how increased functional ability can increase patient safety and decrease caretaker burden.

Poster 423 The Efficacy of Early Use of Intrathecal Baclofen After Anoxic Brain Injury: A Case Series Report

in a cervical transforaminal epidural steroid injection (CTFESI). Design: Retrospective review. Setting: University hospital. Participants: 198 consecutive patients who underwent a CT angiogram of the neck at a university hospital. Interventions: Not applicable. Main Outcome Measures: A neuroradiologist documented VA location in relation to the neural foramen on axial views of CT angiograms. All cervical levels were evaluated but focus was placed on commonly injected levels of C4-7. The VA is not in the neural foramen at C7-T1 and this level was not evaluated. The distance was measured from VA to ideal needle location for a CTFESI. Other data were collected including severity of foraminal stenosis, loss of disc height, medical history and demographic data. Analysis was done to see if any factor correlated with VA proximity to the ideal needle location with CTFESIs. Results: The VA was located in the posterior foramen in 27% of patients in at least one level from C4-7. The VA was within 2mm of ideal needle location in 26% of patients in at least one level from C4-7. Severity of foraminal stenosis correlated with the VA being located in closer proximity to typical needle location (P .0001). Conclusions: The VA can sometimes be in close proximity to the typical target location of a CTFESI. This proximity correlates with the severity of foraminal stenosis. The interventionalist should be mindful of this and consider looking at the T2 axial MRI before doing CFTESIs.