Sarah M. Eickmeyer

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.

North American medical schools' experience with and approaches to the needs of students with physical and sensory disabilities.

Purpose To determine the nature and frequency of impairments and related underlying conditions of medical students with physical and sensory disabilities (PSDs), and to assess medical schools’ use of relevant publications in setting admission criteria and developing appropriate accommodations. Method A 25-item survey addressed schools’ experiences with students known to have PSDs and their related policies and practices. The survey instrument was directed to student affairs deans at all 163 accredited American and Canadian medical schools. The authors limited the survey to consideration of PSDs, excluding psychiatric, cognitive, and learning disabilities. Results Eighty-six schools (52.8%) responded, representing an estimated 83,327 students enrolled between 2001 and 2010. Of these students, 0.56% had PSDs at matriculation and 0.42% at graduation. Although 81% of respondents were familiar with published guidelines for technical standards, 71% used locally derived institutional guidelines for the admission of disabled applicants. The most commonly reported accommodations for students with PSDs included extra time to complete tasks/exams (n = 62), ramps, lifts, or accessible entrances (n = 43), and dictated/audio-recorded lectures (n = 40). All responding schools required students’ demonstration of physical examination skills; requirements for other technical skills, with or without accommodations, varied considerably. Conclusions The matriculation and graduation rates of medical students with PSDs remain low. The most frequent accommodations reported were among those required of any academic or clinical setting by the Americans with Disabilities Act. There is a lack of consensus regarding technical standards for admission, suggesting a need to reexamine this critical issue.

Anatomy and Physiology of the Pelvic Floor

Understanding the anatomic relationship of the pelvic floor muscles with the pelvic girdle, spine, and hips aids the rehabilitation provider in diagnosis, management, and appropriate referrals. The bony anatomy of the pelvic girdle consists of 3 bones and 3 joints. The pelvic floor muscles are comprised mainly of the levator ani muscles with somatic innervation from the lumbosacral plexus. The bony and muscular pelvis is highly interconnected to the hip and gluteal musculature, which together provide support to the internal organs and core muscles. Pelvic floor physiology is centered on bladder and bowel control, sexual functioning, and pregnancy.

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.

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.

When Teams Fumble: Cancer Rehabilitation and the Problem of the “Handoff”

Who is the patient’s “team captain?” Who is responsible for defining the goals of treatment and the plan of care? And, ultimately, who is responsible for discussing prognosis and treatment options, particularly if a patient has a life-limiting condition? In the last 50 years we have witnessed a marked increase in medical specialization with concomitant fragmentation of health care. In a single episode of acute inpatient cancer care, a patient may have an inpatient hospitalist, a medical oncologist, a surgeon, a radiation oncologist, an intensivist, and other specialists as needed, not to mention the accompanying house staff—all of whom may rotate on and off service at regular intervals. It is possible that the patient may have no contact with any of these physicians beyond the episode of care. Indeed, if he or she has a primary care physician, that physician may not even be in the loop regarding decision-making until the patient is discharged from the hospital back to the primary care physician’s care. Physiatrists are increasingly finding themselves as another episodic provider in the cancer patient’s care. It’s not surprising. Patients with complex cancers increasingly are surviving, often with associated temporary or permanent disability. The 5-year relative survival for female breast cancer patients alone, for example, has improved from 63% in the early 1960s to a remarkable 90% today [1]. Some of these patients will undoubtedly have disabilities. Recognizing the need to care for cancer patients with disabilities, the National Cancer Act of 1971 “declared cancer rehabilitation as an objective and directed funds to the development of training programs and research projects.” Indeed, the National Cancer Institute sponsored a National Cancer Rehabilitation Planning Conference in 1972 and identified 4 objectives in the rehabilitation care of patients with cancer: (1) Psychosocial support, (2) optimization of physical functioning, (3) vocational counseling, and (4) optimization of social functioning [2]. Indeed, cancer rehabilitation has grown as a subspecialty area of interest in PM&R, although it still lacks formal certification. I am grateful that Dr. Sarah Eickmeyer suggested we tackle some of the ethics issues with which she and her colleagues struggle in the care of cancer patients in rehabilitation. Dr. Eickmeyer is an attending physician at Froedtert Hospital and the Zablocki VA in Milwaukee, Wisconsin. She notes that patients with cancer in acute inpatient rehabilitation often have medically complex cases, require close monitoring of multiple medical issues, and are known to have a greater rate of acute care transfers and readmissions during their inpatient rehabilitation stays. Physiatrists may have to balance poor prognosis with appropriate goal setting and discharge planning. Not uncommonly, rehabilitation teams also may find that the understanding of the patient and family about prognosis can be contradictory to that of oncology providers and the rehabilitation team, creating multiple opportunities for misunderstanding as well as difficulties in setting appropriate rehabilitation goals. Thus, the issue of clinical handoffs becomes even more critical to affect a high-quality plan of care in rehabilitation. Dr. Eickmeyer posed the following case for consideration:

Poster 149: The Race for Readmission Reduction: An Internal Review of 30-day Readmission Rates

Disclosures: David Sherwood: I Have No Relevant Financial Relationships To Disclose Objective: Assess the 30-day readmission rate (TDRR) of our postacute rehabilitation unit against a national benchmark. Design: A literature review identified readmission rates from inpatient rehabilitation facilities (IRF) and acute care hospitals. 30-day readmission data froma6-month period in2017was collected for 344 total discharges. Health System data identified 86 patients readmitted in a 30-day period. Review of these 86 charts excluded 41 direct transfers, 6 planned, and 2 repeat readmissions. The remaining 37 charts were than reviewed for factors which correlated with higher readmission rates previously. Setting: Post-acute inpatient rehabilitation unit affiliated with academic hospital. Participants: PM&R residents Interventions: Not applicable Main Outcome Measures: 30-day readmission rate over a 6-month period. Results: The 30-day readmission rate for our IRF over a 6-month period in 2017 was 10.8% (37/344). Acute transfers and planned readmissions accounted for 13.7% of our total discharges (47/344) and were excluded. Published benchmarks exist between 12.4% by Daras et al (2017) and 13.06% per Medicare. The rate described by Jencks, et al for TDRR from acute care hospitals is 19.6%. Debility was the most common readmission diagnosis at 51% (19/37), followed by ischemic stroke and neuromuscular disorder at 13.5 % (5/37) and 8% (3/37). The most common readmission diagnoses were mentation change at 16% (6/37), followed by pain, gastrointestinal, and weakness, each with 10.8 % (4/37), and sepsis, cardiac, and debility each with 8.1% (3/37). Conclusions: Our TDRR is lower than published benchmarks for postacute inpatient rehabilitation hospitals. Our readmitted patient population is similar in demographics and comorbidities to other studies. These preliminary data suggest that national initiatives regarding TDRR for both IRF and acute care hospitals would be applicable resourceswhen planning quality interventions to reduce readmission. Future studies should aim to improve the consistency of TDRR data and to differentiate variables correlate highly with readmission, such as debility. Level of Evidence: Level V

The Rehabilitation of Advanced Heart Failure Patients After Left Ventricular Assist Device: A Narrative Review

Because more patients with advanced heart failure are receiving a left ventricular assist device (LVAD) as destination therapy or a bridge to transplantation, there is increasing attention on functional outcomes and quality of life after LVAD implantation. Rehabilitation providers in the acute inpatient rehabilitation setting increasingly will treat patients with an LVAD and should understand the exercise physiology, medical management, rehabilitation considerations, and outcomes after rehabilitation for patients with an LVAD. The purpose of this article is to provide the physiatrist with a comprehensive understanding of the rehabilitation of patients with advanced heart failure and LVAD implantation. Changes in relevant organ system physiology and exercise physiology after LVAD are summarized. Safety of rehabilitation and program considerations for acute inpatient rehabilitation are reviewed. Recommendations for medical management and prevention of secondary complications seen in patients with an LVAD are outlined. A discussion of outcomes after acute inpatient rehabilitation, the dual diagnosis of stroke and LVAD placement, and long‐term cognitive, functional, and quality‐of‐life outcomes after LVAD placement is presented.

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 52 Acute Hallucinosis Related to Amantadine Use in the Setting of Traumatic Brain Injury: A Case Report

Disclosures: Mohammad Aalai: I Have No Relevant Financial Relationships To Disclose Objective: To track sleep quality in an Inpatient Rehabilitation Facility (IRF) setting using standardized survey tools and correlate to functional outcome measures. Design: Prospective IRB study. Setting: Inner city Acute IRF serving patients of low socioeconomic status. Participants: 32 subjects of all diagnoses. Interventions: Not applicable. Main Outcome Measures: Pittsburgh Sleep Quality Index(PSQI), Functional Independence Measure(FIM), Insomnia Symptom Questionnaire (ISQ). Results: Of the 32 patients studied so far, 88% had poor premorbid sleep (PPS) defined as PSQI>5 (sensitivity 89.6% and specificity 86.5%). The average PSQI score was 9.4. 30% had no change in cognitive FIM scores from admission to discharge. 64% did not achieve the region adjusted average (RAA) cognitive FIM change. 55% of the PPS patients had no change in sleep quality at discharge and 21% had a decrement. Average length of stay (LOS) was 16 days. 93% of the patients did not achieve region adjusted mean length of stay efficiency. 69% of patients did not achieve the RAA total FIM gain. Patients deemed to have insomnia by ISQ had higher than average PSQI scores. Conclusions: Patients in an urban IRF setting have poor premorbid sleep quality due to various socioeconomic and psychosocial factors. Patients in this studywith higher PSQI scores prior to admission to IRF did not achieve average FIM gains. Further screening and quality control measures are necessary to ensure those identified as high risk patients maximize their outcomes during IRF stay. This may include environmental alterations as well as changes in therapy and nursing schedule. Level of Evidence: Level I