Vishwa S. Raj

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 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.

A Guide to Inpatient Cancer Rehabilitation: Focusing on Patient Selection and Evidence-Based Outcomes

Cancer inpatients commonly suffer from impairments that can prohibit safe discharge home from the acute care inpatient medical service and thus require transfer to a postacute inpatient rehabilitation facility. It has been demonstrated in multiple studies that cancer rehabilitation inpatients are able to make statistically significant functional improvements and at a similar pace as their noncancer counterparts. Medical fragility and reimbursement regulations are concerns that affect acceptance and triage of cancer rehabilitation inpatients. Strategies to rehabilitate these challenging patients include considering risk factors for medical complications, consult‐based inpatient rehabilitation, and improved communication and coordination with oncology teams.

Palliative Care and Physiatry in the Oncology Care Spectrum: An Opportunity for Distinct and Collaborative Approaches

As cancer evolves from a terminal illness to a chronic medical condition, so too does the view of clinical services. Palliative care and physical medicine and rehabilitation (PM&R) will increase in acceptance because they provide a valuable resource. The overarching theme is improving cancer-related symptoms or treatment-related side effects, improving patient health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision making. Managing symptom burden may improve therapy participation/performance. PM&R and palliative care departments are well-equipped to develop patient-centered care protocols, and could play an important role in developing a universal measure of performance status.

Response to editorial by Richard Crevenna, MD, regarding “cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services” by Silver et al.

Richard Crevenna, MD, provided insightful comments in his editorial response to our article entitled “Cancer Rehabilitation and Palliative Care: Critical Components in the Delivery of High-Quality Oncology Services” [1]. We were impressed by Dr. Crevenna’s description of the recent initiatives in interdisciplinary care, particularly in symptom management, at the Comprehensive Cancer Centre of the Medical University of Vienna. Notable were the inclusion of a rehabilitation tumor board and the integration of rehabilitation services into a clinic dedicated to symptom management which extends beyond issues typically associated with rehabilitation (e.g., mucositis and nausea). We believe that this type of interdisciplinary collaboration is critical to the success of well-designed cancer rehabilitation programs. The need to support interdisciplinary collaboration is precisely why we wrote this article. In fact, the genesis of our article was Dr. Julie Silver’s invitation from the Multinational Association of Supportive Care in Cancer (MASCC) leadership to be a plenary speaker at the 2015 annual meeting in Copenhagen, Denmark. Though not related by design, this meeting followed a landmark cancer rehabilitation “state of the science” initiative in the USA that was led by the Rehabilitation Medicine Department (RMD) at the National Institutes of Health (NIH) in collaboration with the National Center for Medical Rehabilitation Research (NCMRR) and the National Cancer Institute (NCI). In a variety of ways, every author on this paper participated in and supported this undertaking. During a conference at the NIH in June 2015, early findings were reported by workgroups comprised of subject matter experts. We anticipate publication of reports by the subject matter experts who participated in this cancer rehabilitation initiative. Dr. Silver co-chaired the Clinical Integration Work Group (CIWG) with Ana Acevedo, MD, a physiatrist from the NIH RMD. The CIWG developed preliminary recommendations in three related categories: education (preparing the workforce

Inpatient cancer rehabilitation: past, present, and future perspectives

Purpose of reviewAs cancer transitions from a terminal diagnosis to a chronic medical condition, viewpoints must also change regarding how rehabilitation fits into the continuum of care. The purpose of this review is to describe the history of inpatient rehabilitation, the current state as it relates to delivery of care for the oncology survivor, and the future models that may improve patient access.Recent findingsInpatient rehabilitation can provide an intensive setting for interdisciplinary interventions. Care is typically provided in inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and long-term care hospitals (LTCH).SummaryEach setting has evolved over time to accommodate medical complexity, but an understanding of the regulatory requirements for participation is necessary to integrate oncology populations. Future models should focus on effectiveness and efficiency, especially in context of cost and outcomes. Opportunities may exist to utilize inpatient rehabilitation for innovative programs within both oncology and rehabilitation.

Hospital-Based Rehabilitation for Recurrent Glioblastoma

You are asked to evaluate a previously healthy 45-year-old man for admission to your hospital-based inpatient rehabilitation unit. He was diagnosed 10 months ago with glioblastoma multiforme (GBM), which presented with gradually increasing right hemiparesis and word-finding difficulty. Initial imaging results indicated a large left temporoparietal mass with significant edema and a slight left to right shift. He was taken to surgery immediately for resection; pathology results confirmed GBM with minimal tumor at the margins. He underwent standard radiation therapy (RT; 60 Gy over 6 weeks) using focal, fractionated external beam RT with concomitant and adjuvant temozolomide, which resulted in a rather remarkable symptomatic improvement. At the end of 6 weeks of treatment, the hemiparesis was nearly resolved and the word-finding issues had completely resolved. He ambulated with a straight cane and was even able to return to work part time in his investment firm. Ten days prior to your practice partner’s recent evaluation, he was brought to the emergency department with sudden-onset tonic-clonic seizures. He was intubated, and intravenous phenytoin was administered. Magnetic resonance imaging showed substantial recurrence of the tumor with mild mass effect. The neurosurgery team decided against a debulking surgery and initiated oral steroids (dexamethasone, 6 mg every 6 hours). After extensive discussions with the radiation oncologist and based on the extent of the recurrence, his young age, his good functional status prior to admission, and the time from the last course of RT, he was given a second, short course of RT. After 3 days of RT, he experienced a second seizure, and levetiracetam, 1000 mg twice a day, was added to his medication regimen. Two days later a fever and shortness of breath developed, and a chest radiograph revealed that he had pneumonia, which was likely a result of aspiration in relation to the second seizure. A 10-day course of intravenous antibiotics was prescribed. Despite these complications, he improved in both level of alertness and in the movement of his right arm and leg. At your consultation assessment, you found the patient to be a well-developed, middle-aged man with obvious right hemiparesis. He was slightly lethargic but arousable when engaged in conversation. Manual muscle testing revealed 3/5 strength in right lower extremity and 2/5 strength in the right upper extremity. His verbal expression was moderately poor, as he could offer 3-4 single-word answers but was unable to offer multiword answers to open-ended questions. His comprehension appeared to be intact for simple information at the bedside examination. A modified-texture diet and nectar-thick liquid had been initiated, apparently as a result of poor alertness during meals. Initially, he had barely met his caloric and hydration needs, but his intake had modestly improved during the preceding 48 hours. Functionally, he could stand but required the moderate assistant of 2 persons because of poor balance and motor control. He required at least moderate assistance in all activities of daily living. Current medications included dexamethasone, 6 mg by mouth every 6 hours, a proton pump inhibitor for gastric ulcer prophylaxis, phenytoin, 400 mg/d, and levetiracetam, 2000 mg/d for seizure treatment, an intravenous antibiotic, and subcutaneous heparin for deep venous thrombosis prophylaxis. The patient had been divorced for about 2 years. His ex-wife cares for their 3 children (ages 5, 7, and 9 years), but none had any consistent contact with the patient before the GBM diagnosis. Since the diagnosis, the ex-wife has visited occasionally and recently had begrudgingly been reinstated as the patient’s health care proxy. The patient was a successful financier with private insurance and no other social supports identified other than his ex-wife. He lives alone in a 2-story, single home with no steps in and one flight to the bedroom and full bathroom.

Poster 30: Treatment of Neck Lymphedema Following Neck Dissection for Laryngeal Cancer: A Case Report

ation program. Main Outcome Measures: Parasympathetic activity measured by high frequency power through heart rate variability spectral analysis was the primary outcome measure. Results: The differences between the pre and post values of low and HF HRV, of the ESAS anxiety score, and of the summed ESAS score were compared using a Wilcoxon signed rank test. No statistically significant differences were found in HF HRV power between the pre and post relaxation program. However, the summed ESAS scores were significantly lower after the relaxation program (P .001). There was also a trend of decrease in the ESAS anxiety score (P .086). There was no correlation between the change in HRV HF and change in the ESAS anxiety score. Conclusions: A brief guided relaxation program can significantly improve symptoms as measured by ESAS, but not HF HRV power.