Samman Shahpar

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.

Cancer Rehabilitation: Do Functional Gains Relate to 60 Percent Rule Classification or to the Presence of Metastasis?

Literature supporting the benefits of inpatient rehabilitation for cancer patients is increasing. Many cancer patients, however, do not qualify for inclusion in the Centers for Medicare and Medicaid 60% rule and consequently may not receive services. The benefit of inpatient rehabilitation in this specific cancer group has not been investigated and is the focus of this study.

Functional Outcomes of an Interdisciplinary Outpatient Rehabilitation Program for Patients with Malignant Brain Tumors

Malignant brain tumors cause significant impairments in function because of the nature of the disease. Nevertheless, patients with malignant brain tumors can make functional gains equivalent to those with stroke and traumatic brain injury in the inpatient rehabilitation setting. However, the efficacy of outpatient rehabilitation in this population has received little study.

Update on Brain Tumors: New Developments in Neuro-oncologic Diagnosis and Treatment, and Impact on Rehabilitation Strategies

Brain tumors can be a source of functional impairment to patients due to neurologic sequelae associated with the tumor itself as well as treatment side effects. As a result, many of these patients may require rehabilitation services. Surgery, chemotherapy, and radiation therapy have been longstanding, primary treatment modalities in the management of brain tumors, though these treatments continue to evolve given new developments in research and technology. A better understanding of the diagnostic workup and current treatment standards helps the physiatrist and rehabilitation team identify rehabilitation services needed, recognize potential side‐effects from anticipated or concurrent treatments, and coordinate care with referral sources. The purpose of this article is to review these new advances in diagnosis and treatment of patients with brain tumors, as well as discuss the rehabilitation implications for this population, including factors such as rehabilitation approach, timing of concomitant treatment, cost management, and coordination of care.

Evaluation of the Cost of Comprehensive Outpatient Therapies in Patients with Malignant Brain Tumors

Objective The aim of this study was to compare the cost of comprehensive outpatient therapy (day rehabilitation) in individuals with malignant brain tumors to those with stroke and traumatic brain injury. Design This was a prospective, nonrandomized, longitudinal study of 49 consecutive adults with malignant brain tumors enrolled in the 6 day rehabilitation sites of 1 institution over 35 months. The control group was composed of 50 patients with brain injury and 50 patients with stroke, who were also enrolled in the day rehabilitation program during the same period. A comparison was made of the total Medicare cost and the cost per day of day rehabilitation in patients with malignant brain tumors compared with the control group. Results The patients with malignant brain tumors had lower total cost and cost per day than did the combined traumatic brain injury and stroke group during day rehabilitation (F2,143 = 3.056 [P = 0.05] and F2,142 = 5.046 [P = 0.008], respectively). Conclusions The cost of comprehensive outpatient rehabilitation in patients with malignant brain tumors is less expensive than that of patients with traumatic brain injury or stroke, which are neurological diagnoses commonly seen in day rehabilitation. This study shows that cost should not be a barrier to providing outpatient therapies to this patient population.

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.

Health-Related Quality of Life and Cancer-Related Symptoms during Interdisciplinary Outpatient Rehabilitation for Malignant Brain Tumor

Objective The aim of the study was to determine the relationships between functional outcomes, clinical symptoms, and health-related quality of life among patients with malignant brain tumors receiving interdisciplinary outpatient rehabilitation. Design A prospective study of 49 adults with malignant brain tumors participating in outpatient therapies was performed. Outcome measures included the Functional Assessment of Cancer Therapy-Brain (FACT-Br) for health-related quality of life and the Patient-Reported Outcome Measures Instrument Survey (PROMIS) Depression and Pain Behavior scales measured at admission, discharge, 1 and 3 mos after discharge. Day Rehabilitation Outcome Scale (DayROS), a functional measure, was measured at admission and discharge. Results The FACT-Br scores, PROMIS pain, and PROMIS depression scores did not significantly change. There were many negative associations seen between FACT-Br and PROMIS depression (all P < .0001) and less associations with PROMIS pain. There was a positive correlation between Day Rehabilitation Outcome Scale and FACT-Br (P = .0058) and a negative association with PROMIS pain (P = .028), but not with PROMIS depression. There were no correlations between Day Rehabilitation Outcome Scale gains and change in PROMIS depression, FACT-Br total, or PROMIS pain. Conclusions Health-related quality of life, pain, and depression did not worsen. Patients who reported less depression and pain had better reported health-related quality of life. Level of function was also associated with HRQOL and pain, but not depression.

Poster 32 Functional Consequences of Permanent Paraplegia Following Nelaribine Treatment in T-Cell Acute Lymphoblastic Leukemia: A Case Report

Case/Program Description: A 41-year-old woman with high grade, ER/PR-, HER2invasive ductal carcinoma of the left breast who developed severe bilateral medial thigh pain and weakness two and a half weeks after finishing her fourth chemotherapy cycle with doxorubicin, cyclophosphamide, and docetaxel (a Taxane). Initial laboratory work findings revealed CPK 254 U/L, ESR >120 mm/hr, and CRP 31.9 mg/L. On exam, she had severe tenderness to superficial palpation in the medial aspect of both thighs. Pain limited knee extension but ankle dorsiflexion, hallux extension, and plantarflexion were full strength. We obtained MRI of both thighs which demonstrated diffuse intramuscular induration involving the quadriceps muscles compatible with myositis, with greater involvement of the vastus medialis, and large peripherally enhancing intramuscular abscesses. Setting: Community teaching hospital. Results: Surgery attempted aspiration of the abscesses but no fluid returned. Subsequent dissection to the level of the femur on both sides did not reveal any evidence of infection. Biopsies were obtained from each vastus medialis for pathologic examination which demonstrated mild inflammation. Surgical cultures were negative. The patient left against medical advice the following day, only to return eight days later with left thigh pain. An ultrasound of the left thigh demonstrated a hypoechoic mass suggestive of an abscess. An incision and drainage was done and again no purulence was found. Repeat exploration did not identify any infection. Cultures were also negative. The patient improved subsequently and was discharged home in good condition. Discussion: Taxane-induced myositis is an uncommon complication in this class’ side effect profile. Our present case differs from previous case reports in that we obtained muscle biopsies which whereas the others did not. Conclusions: Physiatrists with an interest in cancer rehabilitation should be aware of this uncommon cause of myositis as the use of Taxanes for breast and other solid tumors continues to rise. Level of Evidence: Level V