Julie K. Silver

Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes.

Cancer prehabilitation, a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patients health to reduce the incidence and the severity of current and future impairments. There is a growing body of scientific evidence that supports preparing newly diagnosed cancer patients for and optimizing their health before starting acute treatments. This is the first review of cancer prehabilitation, and the purpose was to describe early studies in the noncancer population and then the historical focus in cancer patients on aerobic conditioning and building strength and stamina through an appropriate exercise regimen. More recent research shows that opportunities exist to use other unimodal or multimodal prehabilitation interventions to decrease morbidity, improve physical and psychological health outcomes, increase the number of potential treatment options, decrease hospital readmissions, and reduce both direct and indirect healthcare costs attributed to cancer. Future research may demonstrate increased compliance with acute cancer treatment protocols and, therefore, improved survival outcomes. New studies suggest that a multimodal approach that incorporates both physical and psychological prehabilitation interventions may be more effective than a unimodal approach that addresses just one or the other. In an impairment-driven cancer rehabilitation model, identifying current and anticipating future impairments are the critical first steps in improving healthcare outcomes and decreasing costs. More research is urgently needed to evaluate the most effective prehabilitation interventions, and combinations thereof, for survivors of all types of cancer.

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

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Cancer Rehabilitation with a Focus on Evidence-Based Outpatient Physical and Occupational Therapy Interventions

Cancer rehabilitation is an important part of survivorship as a distinct phase of treatment. Although cancer rehabilitation may involve many disciplines, this article specifically covers evidence-based treatment in physical and occupational therapy. Patients may need physical and occupational therapy services for a variety of cancer-related or cancer-treatment-related problems, including pain, fatigue, deconditioning, and difficulty with gait. They may also have problems resuming their previous level of function, which can impact on activities of daily living, instrumental activities of daily living, return to previous home and community activity levels, and return to work. This review discusses the role of physical and occupational therapy in helping cancer patients improve pain and musculoskeletal issues, deconditioning and endurance effects, fatigue, balance and falls, and lymphedema and psychosocial problems.

Polio survivors: falls and subsequent injuries.

Silver JK, Aiello DD: Polio survivors: Falls and subsequent injuries. Am J Phys Med Rehabil 2002;81:567–570. Objective This study examines the frequency of falls in polio survivors and their resulting morbidity. Design Two groups, fallers vs. nonfallers, were investigated in this descriptive study. A total of 233 polio survivors volunteered to complete a structured questionnaire on fall history and sequelae. Results Of the study participants, 64% had fallen within the previous year, and 61% had falls for which they received medical attention, including 35% who had at least one fracture. There was not a correlation between age and falling, but there was a strong correlation between tripping and falling. Conclusions Falls with resultant injuries are a significant issue for polio survivors that warrants further study. Because tripping was predictive of falling in this sample, bracing should be considered as a treatment or preventative measure.

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.

Cancer rehabilitation may improve function in survivors and decrease the economic burden of cancer to individuals and society.

BACKGROUND Cancer and its treatment may cause physical impairments and psychological distress in survivors. Rehabilitation is a critical component of quality cancer care, returning survivors to their highest functional potential. OBJECTIVE This overview focuses on the benefits of multidisciplinary cancer rehabilitation - including improving physical function, reducing psychological distress, promoting return to work and, therefore, decreasing the economic burden of cancer and its treatment on individuals and society in general. METHODS Relevant literature was identified through a search of the PubMed database and reviewed for its relevance to cancer rehabilitation and the topic of this article. Search terms included, but were not limited to, cancer rehabilitation, cancer prehabilitation, disability, return to work, employment, and unemployment. RESULTS Cancer survivors are less likely to be employed and take more sick leave than workers without a history of cancer. Pain, musculoskeletal issues, deconditioning, fatigue, balance, psychosocial issues, and lymphedema are most amenable to rehabilitation. CONCLUSION Overall health and the need for work accommodations must be addressed in order to improve return to work and subsequent productivity in cancer survivors. Survivors are usually best served by a multidisciplinary care team comprising members who can address the myriad impairments affecting survivor function.

Piriformis syndrome : Assessment of current practice and literature review

Although piriformis syndrome was initially described in 1928, it has remained a nebulous and controversial diagnosis. A literature review reveals that there is no consensus on the diagnosis or treatment of piriformis syndrome. In addition, a survey of 75 physiatrists revealed that whether the diagnosis of piriformis syndrome even exists is controversial. This survey and literature review examines the diagnosis and treatment of piriformis syndrome. The fact that it remains controversial is likely due to a lack of objective clinical trials.

CANCER PREHABILITATION AND ITS ROLE IN IMPROVING HEALTH OUTCOMES AND REDUCING HEALTH CARE COSTS

OBJECTIVES To examine the current state of cancer prehabilitation care and the impact that it may have on health-related and financial outcomes. DATA SOURCES Clinical trials, reviews and meta-analyses. CONCLUSION Research demonstrates that prehabilitation interventions may improve physical and/or psychological outcomes and help patients function at a higher level throughout their cancer treatment. Establishing a baseline status at diagnosis provides an opportunity to gain insight into the burden that cancer and its treatment can place on survivors with respect to physical and psychological impairments, function, and disability. Targeted interventions may reduce the incidence and/or severity of future impairments that often lead to reduced surgical complications, hospital lengths of stay, hospital readmissions, and overall health care costs. Thus, cancer prehabilitation is an opportunity to positively impact patient health-related and financial outcomes from diagnosis onward and, by decreasing the financial impact that cancer can have on individuals, may prove to be a sound investment for patients, hospitals, payers and society. IMPLICATIONS FOR NURSING PRACTICE Nurses, and particularly navigators, have an opportunity to significantly impact care through patient screening, prehabilitation assessments, documentation of baseline patient status and, in some cases, especially when impairments are not present at baseline, provide interventions designed to improve physical and psychological health before the start of upcoming oncology treatments and reduce the likelihood of patients developing future impairments.

Nonparalytic polio and postpolio syndrome

We describe four cases of postpolio syndrome with typical histories, physical examination results, and electrodiagnostic evidence of extensive anterior horn cell disease, as well as the putative pathophysiology of postpolio syndrome in persons with histories of nonparalytic polio and the diagnostic implications for individuals older than 40 yr of age who are experiencing unexplained new weakness, fatigue, and muscle or joint pain. Although the diagnosis of postpolio syndrome traditionally has required a remote history of paralytic polio, many persons such as the ones described here with typical symptoms of postpolio syndrome have no clear history of paralytic disease and are being misdiagnosed. With this in mind, we believe that the diagnostic criteria for postpolio syndrome should be modified to include the following: a history of remote paralytic polio or findings on history, physical examination results, and laboratory studies compatible with poliovirus damage of the central nervous system earlier in life.

Early Onset Dystonia Following Traumatic Brain Injury

Dystonia, a movement disorder resulting from dysfunction of the basal ganglia and thalamus, has not been described during the acute post-traumatic period after severe traumatic brain injury. We reported three patients who developed early onset dystonia after sustaining severe closed head injuries. The first patient went on to complete resolution of the dystonia; the second patient improved and had minimal residual dystonia that did not limit function; and the third patient became frankly agitated at which time the dystonic features became difficult to track. In contrast, delayed onset dystonia after traumatic brain injury has been reported to be relatively persistent. All of our patients also presented with autonomic instability. Because injuries that cause damage to the basal ganglia and thalamus may also affect the nearby hypothalamus, both dystonic posturing and autonomic instability may result.