Jack B. Fu

Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services.

Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their respective roles in comprehensive oncology care, and highlights how these services can contribute complementary components of essential quality care. An understanding of how cancer rehabilitation and palliative care are aligned in goal setting, but distinct in approach may help facilitate earlier integration of both into the oncology care continuum—supporting efforts to improve physical, psychological, cognitive, functional, and quality of life outcomes in patients and survivors.

Inpatient cancer rehabilitation: the experience of a national comprehensive cancer center.

Objective: Cancer rehabilitation is an important but often underutilized treatment in the comprehensive care of the cancer patient. Cancer patients have varying levels of access to rehabilitation services. Acute inpatient, inpatient consultation-based, and outpatient-based cancer rehabilitation services have been described in the literature. We will discuss acute inpatient cancer rehabilitation and some of its outcomes at the University of Texas MD Anderson Cancer Center in Houston, TX, which is the only national comprehensive cancer center to have its own acute inpatient rehabilitation unit dedicated solely to cancer patients. Design: We retrospectively reviewed the inpatient medical records of consecutive inpatients admitted to the acute inpatient cancer rehabilitation unit from September 2008 to August 2009 for the following information: patient age, sex, primary tumor type, rehabilitation diagnoses, length of stay, discharge destination, and payer source. Results: From September 2008 to August 2009, the physical medicine and rehabilitation service at MD Anderson Cancer Center had 1098 inpatient consultations, of which 427 patients were admitted to the inpatient rehabilitation unit with a mean length of stay of 11 days. Of the 427 patients, 73 (17%) were patients with primary neurologic-based tumor, 71 (16%) were patients with hematologic-based tumors, 48 (11%) were sarcoma patients, 35 (8%) were gastrointestinal tumor patients, 27 (6%) were head and neck tumor patients, 25 (6%) were prostate and bladder cancer patients, 24 (6%) were lung cancer patients, 22 (5%) were melanoma patients, 20 (5%) were breast cancer patients, 15 (4%) were renal cancer patients, 14 (3%) were gynecologic cancer patients, and 53 (12%) were patients with other types of cancer. Of the 427 patients admitted to acute inpatient rehabilitation at MD Anderson Cancer Center, 324 (76%) were discharged home, 72 (17%) went back to acute care service, 15 (4%) were sent to a skilled nursing facility, 9 (2%) were discharged to palliative care, and 5 (1%) were discharged to a long-term acute care facility. Conclusions: An active inpatient rehabilitation unit within a national comprehensive cancer center receives referrals from patients with a wide variety of tumor types and is able to successfully discharge home 76% of its patients.

Inpatient Rehabilitation Performance of Patients With Paraneoplastic Cerebellar Degeneration

OBJECTIVE To evaluate the functional improvement of rehabilitation inpatients with paraneoplastic cerebellar degeneration. DESIGN Retrospective review. SETTING Referral-based hospitals. PARTICIPANTS Cancer rehabilitation inpatients (N=7) admitted to 3 different cancer centers with a diagnosis of paraneoplastic cerebellar degeneration. INTERVENTION Medical records were retrospectively analyzed for demographic, laboratory, medical, and functional data. MAIN OUTCOME MEASURE FIM. RESULTS All 7 patients were white women (median age, 62y). Primary cancers included ovarian carcinoma (n=2), small cell lung cancer (n=2), uterine carcinoma (n=2), and invasive ductal breast carcinoma (n=1). Mean admission total FIM score was 61±23.97. Mean discharge total FIM score was 73.6±29.35. The mean change in total FIM score was 12.6 (P=.0018). The mean length of rehabilitation stay was 17.1 days. The mean total FIM efficiency was .73. Of the 7 patients, 5 (71%) were discharged home, 1 (14%) was discharged to a nursing home, and 1 (14%) was transferred to the primary acute care service. CONCLUSIONS To our knowledge, this is the first study to demonstrate the functional performance of a group of rehabilitation inpatients with paraneoplastic cerebellar degeneration. Despite the poor neurologic prognosis associated with this syndrome, these patients made significant functional improvements in inpatient rehabilitation. When appropriate, inpatient rehabilitation should be considered. Further studies with larger sample sizes are needed.

Return to primary service among bone marrow transplant rehabilitation inpatients: An index for predicting outcomes

OBJECTIVE To assess rehabilitation inpatient risk of return to primary (RTP) service in patients with bone marrow transplant (BMT). DESIGN Retrospective review. SETTING Inpatient rehabilitation unit within a tertiary referral-based cancer center. PARTICIPANTS All patients with BMT (131) who were admitted a total of 147 times to inpatient rehabilitation between January 1, 2002, and April 30, 2010. INTERVENTIONS None. MAIN OUTCOME MEASURES We analyzed RTP service and demographic information, cancer characteristics, medications, hospital admission characteristics, and laboratory values. RESULTS A total of 61 (41%) of 147 of BMT admissions were transferred from the inpatient rehabilitation unit back to the primary service. Of those transferred back, 23 (38%) of 61 died after being transferred back to the primary service. Significant or near-significant relationships were found for a platelet count of <43,000 per microliter (P<.01); a creatinine level of >0.9 milligrams/deciliter (P<.01); the presence of an antiviral agent (P=.0501); the presence of an antibacterial agent (P=.0519); the presence of an antifungal agent (P<.05); and leukemia, lymphoma, or multiple myeloma diagnosis (P<.05). Using 5 of these factors, the RTP-BMT index was formulated to determine the likelihood of return to the primary team. CONCLUSIONS Patients with BMT have a high rate of transfer from the inpatient rehabilitation unit back to the primary service. The RTP-BMT index score can be a useful tool to help clinicians predict the likelihood of return to the primary acute care service.

Frequency and reasons for return to acute care in patients with leukemia undergoing inpatient rehabilitation: a preliminary report.

ObjectiveThe aim of this study was to assess the frequency and reasons for return to the primary acute care service among patients with leukemia undergoing inpatient rehabilitation. DesignThis is a retrospective study of all patients with leukemia, myelodysplastic syndrome, aplastic anemia, or myelofibrosis admitted to inpatient rehabilitation at a tertiary referral-based cancer center between January 1, 2005, and April 10, 2012. Items analyzed from patient records included return to the primary acute care service with demographic information, leukemia characteristics, medications, hospital admission characteristics, and laboratory values. ResultsTwo hundred twenty-five patients were admitted a total of 255 times. Ninety-three (37%) of the 255 leukemia inpatient rehabilitation admissions returned to the primary acute care service. Eighteen (19%) and 42 (45%) of the 93 patients died in the hospital and were discharged home, respectively. Statistically significant factors (P < 0.05) associated with return to the primary acute care service include peripheral blast percentage and the presence of an antifungal agent on the day of the inpatient rehabilitation transfer. Using additional two factors (platelet count and the presence of an antiviral agent, both P < 0.11), the Return to Primary–Leukemia Index was formulated. ConclusionsPatients with leukemia with the presence of circulating peripheral blasts and/or an antifungal agent may be at increased risk for return to the primary acute care service. The Return to Primary–Leukemia Index should be tested in prospective studies to determine its usefulness.

Frequency and Reasons for Return to the Primary Acute Care Service Among Patients With Lymphoma Undergoing Inpatient Rehabilitation

To assess the frequency and risk factors for return to the primary acute care service among patients with lymphoma undergoing inpatient rehabilitation.

Botulinum Toxin Injection and Phenol Nerve Block for Reduction of End-of-Life Pain

BACKGROUND Injectable antispasticity agents have been utilized for the reduction of pain. However, there are no reports of its use for end-of-life pain. PATIENT CASE A 62-year-old female with a history of progressive left frontotemporal glioblastoma status post gross total resection, radiation, and chemotherapy presented to the physical medicine and rehabilitation (PM&R) clinic for management of spastic quadriplegia and pain. At the time of presentation to the PM&R clinic she was no longer eligible for further cancer treatment. The patient had been declining neurologically with cognitive changes, weakness, and increasing spasticity. The patient had an Edmonton Symptom Assessment Scale (ESAS) pain score of 8/10 at her visit, as reported by her husband. She exhibited mild to moderate spasticity during the exam. Cognitively, she was unable to follow commands and would fluctuate between being awake for a few minutes and sleeping during the exam. She was not on any oral muscle relaxants and none were started due to her state of hypoarousal. Nine days after the initial consultation she received 700 units of onabotulinum toxin into her bilateral upper limbs and left thigh and a phenol nerve block to her left tibial nerve. At a follow-up visit 28 days later in the palliative care clinic, the ESAS pain score was 0. The patient died 51 days post-injection. CONCLUSION The case report demonstrates the use of injectable antispasticity agents in the reduction of end-of-life pain in a glioblastoma patient.

Comparison of postoperative rehabilitation in cancer patients undergoing internal and external hemipelvectomy.

OBJECTIVE To compare postoperative rehabilitation, functional outcome, and pain management in cancer patients who underwent an internal hemipelvectomy versus an external hemipelvectomy. DESIGN Retrospective study. SETTING Tertiary cancer center. PARTICIPANTS Patients (N=60) who underwent a hemipelvectomy between February 1996 and November 2005 were included in this study (30 internal hemipelvectomy patients and 30 external hemipelvectomy patients). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Hospital and rehabilitation length of stay (LOS), percentage of physiatrist consultation and inpatient rehabilitation, functional status of transfers and ambulation, and pain medication utilization. RESULTS The rate of physiatrist consultation and acute rehabilitation admission were 15 (50%) of 30 and 13 (43%) of 30 for internal hemipelvectomy patients, and 16 (53%) of 30 and 16 (53%) of 30 for external hemipelvectomy patients. Median hospital LOS for external hemipelvectomy patients (37d) was significantly longer than for internal hemipelvectomy patients (19d) (P=0.004); median rehabilitation LOS was similar in both groups (20d for external hemipelvectomy patients versus 22 for internal hemipelvectomy patients; P=0.83). On discharge, 14 (47%) of 30 internal hemipelvectomy patients could ambulate without assistance, whereas only 5 (17%) of 30 external hemipelvectomy patients could do so (P=0.013). The median morphine equivalent daily dose at discharge for external hemipelvectomy patients (150mg) was significantly higher than that for internal hemipelvectomy patients (45mg) (P=0.032). CONCLUSIONS A similar percentage of internal hemipelvectomy and external hemipelvectomy patients were admitted to inpatient rehabilitation. External hemipelvectomy patients had longer hospital LOS, less favorable functional outcome, and required more intense treatment for pain.

Return to the Primary Acute Care Service Among Patients With Multiple Myeloma on an Acute Inpatient Rehabilitation Unit

Pancytopenia, immunosuppression, and other factors may place patients with multiple myeloma at risk for medical complications. These patients often require inpatient rehabilitation. No previous studies have looked at risk factors for return to the primary acute care service of this patient population.

Factors affecting hospital length of stay following pelvic exenteration surgery

Total pelvic exenteration are performed in patients with locally advanced or recurrent pelvic malignances. Many patients have prolong hospital length of stay (LOS), but risk factors are not clearly identified.