Decreased Bed Mobility Function Is Associated With Postdischarge Mortality for Cancer Patients in Inpatient Rehabilitation.

OBJECTIVE: The establishment of rehabilitation goals for hospitalized cancer patients depends on accurate medical prognosis and matching goals to clinical timelines. Current tools for estimating prognosis are limited. We hypothesized that bed mobility is a predictor of mortality in cancer patients admitted to inpatient rehabilitation. DESIGN: In a retrospective cohort of 187 subjects with nonneurologic cancer admitted to inpatient rehabilitation, Functional Independence Measure scores and 6-mo mortality were analyzed. RESULTS: In the cohort, survival rate was 71% at 6 mos. In univariate analysis, discharge bed mobility score (odds ratio = 0.75, 95% confidence interval = 0.61-0.90, P = 0.003), bed mobility Functional Independence Measure gain (odds ratio = 0.66, 95% confidence interval = 0.51-0.85, P = 0.002), and bed mobility Functional Independence Measure efficiency (odds ratio = 0.011, 95% confidence interval = 0.00032-0.21, P = 0.006) were inversely associated with 6-mo mortality after discharge from inpatient rehabilitation facility. In multivariate analysis with additional motor Functional Independence Measure items, only bed mobility (odds ratio = 0.73, 95% confidence interval = 0.54-0.97, P = 0.029) and grooming (odds ratio = 0.79, 95% confidence interval = 0.63-0.99, P = 0.041) were independently associated with mortality. CONCLUSIONS: Lower discharge and lower change in bed mobility Functional Independence Measure scores are associated with mortality in cancer patients in inpatient rehabilitation. Bed mobility could serve as a clinical tool for estimating medical prognosis in hospitalized cancer patients and should be validated in prospective studies.

Soft tissue sarcoma affecting the right shoulder of a man with paraplegia from a remote traumatic spinal cord injury: a case report.

INTRODUCTION: People with spinal cord injury (SCI) are getting older due to a combination of increased life expectancy and older age at the time of injury. This trend makes it more likely for these patients to have other chronic health conditions including cancer. Inevitably relatively rare cancers such as soft tissue sarcomas (STS), which are more common with advancing age, will occur in some SCI patients. The present case represents the first report of a limb STS in a patient with chronic paraplegia from a traumatic SCI. CASE PRESENTATION: We report a case of a 50-year-old right handed male with a T6 chronic, complete SCI (American Spinal Injury Association Impairment Scale A) who presented with a large mass involving his right shoulder musculature that was determined to be a high grade spindle cell sarcoma. The patient was followed closely by Physiatry over an approximately 6-month time course including prior to his tumor diagnosis, during the pre-radiation and pre-surgical planning phase, and then post-operatively for his acute inpatient rehabilitation. He was successfully discharged home to live alone in his accessible apartment complex. DISCUSSION: This case is the first ever reported case of a person living with a traumatic SCI who subsequently developed a limb STS. In addition to its novelty, this case illustrates how health conditions such as rare cancers are presenting more often as the chronic SCI population is getting older, which creates both unique diagnostic and management challenges for cancer rehabilitation specialists.

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

BACKGROUND: 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. OBJECTIVE: To investigate functional gains made during inpatient rehabilitation by patients impaired by cancer, and to compare the functional gains made during inpatient rehabilitation for patients impaired by cancer in relation to the presence or absence of metastatic disease and compliance or noncompliance with the Medicare 60% rule. SETTING: Freestanding university-affiliated rehabilitation hospital. PARTICIPANTS: A total of 176 adult patients admitted for inpatient rehabilitation due to cancer. METHODS: Retrospective chart review of patients admitted for inpatient rehabilitation with deficits identified related to cancer. MAIN OUTCOME MEASURES: Demographic data including cancer type, presence of metastasis, age, gender, marital status, ethnicity, length of stay (LOS), discharge destination, and transfer to acute care. Functional status including admission and discharge Functional Independence Measure Score (FIM), total, motor, and cognitive FIM gains, total, motor, and cognitive FIM efficiency for the study sample, for patients with and without a diagnosis compliant with the 60% rule and for patients with and without metastatic disease. RESULTS: In all, 176 cases met inclusion criteria. An admission coded diagnosis that was compliant with the 60% rule was present in 97 cases (55.1%). In 153 cases, the presence or absence of metastatic disease was known. Metastatic disease was present in 69 cases (45%). All groups (total sample, metastatic versus nonmetastatic, compliant versus noncompliant) made significant functional gains. Patients with a diagnosis noncompliant with the 60% rule had higher admission total FIM (P = .001), discharge total FIM (P = .014), admission motor FIM (P = .005), admission cognitive FIM (P = .008), and discharge cognitive FIM (P < .001) scores than those with a compliant diagnosis. Patients with metastatic disease had higher admission total FIM (P = .026) and admission (P = .001) and discharge (P = .02) cognitive FIM scores than patients with nonmetastatic disease. There were no significant differences between groups regarding total, motor, or cognitive FIM gains or total motor or cognitive FIM efficiencies. Differences in age, length of stay, and admission motor and discharge FIM scores between groups were related to cancer types and source of impairment. CONCLUSION: Patients with functional limitations resulting from cancer or its treatment made significant functional gains in inpatient rehabilitation. There were no significant differences in functional gains made by those with or without metastatic disease or those compliant versus noncompliant with the 60% rule. The presence of metastatic disease or a diagnosis not compliant with the 60% rule does not preclude cancer patients from making significant functional gains.

Perceived Quality of Life With Spinal Cord Injury: A Comparison Between Emergency Medicine and Physical Medicine and Rehabilitation Physicians.

OBJECTIVE: To explore the attitudes of health care providers who treat patients with spinal cord injury (SCI) and examine whether Emergency Medicine (EM) and Physical Medicine and Rehabilitation (PM&R) physicians differ in their judgments about quality of life (QOL) after SCI. DESIGN: Questionnaire survey of PM&R and EM physicians. PARTICIPANTS: Board-certified PM&R and EM physicians listed in the American Academy of Physical Medicine & Rehabilitation and the American College of Emergency Physicians and/or faculty from academic PM&R and EM departments in the United States and Canada. MAIN OUTCOME MEASUREMENTS: Evaluating various aspects of perceived QOL if the physician hypothetically sustained an SCI, including impact on leisure activities, social relationships, happiness, meaningful work, satisfying sexual relationships, and overall QOL. RESULTS: A total of 91 EM physicians and 89 PM&R physicians completed the surveys. PM&R physicians were more likely to agree that they would have a better QOL compared with EM physicians, regardless of the level of injury or aspect of life (P < .01 in all cases). Female physicians, regardless of specialty, were more likely to choose a lower level at which they would choose to die, rather than live, if they sustained an SCI (P = .03). Physicians in both groups were more likely to disagree that they would have a high QOL at a lower level of injury if they disagreed at a higher level of injury (P ≤ .02). CONCLUSIONS: Regardless of specialty, PM&R and EM physicians have their own personal perceptions of QOL with SCI. PM&R physicians tend to believe that they would have a higher QOL with an SCI compared with EM physicians and likely have a more optimistic view of SCI. Patient care may be improved by interdisciplinary discussion, as evidenced by the disparity exhibited by practitioners in these 2 specialties who care for the same patient population.

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

BACKGROUND: Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post-intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. OBJECTIVES: To report on engagement with non-critical care providers and survivors during the 2012 Society of Critical Care Medicine post-intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. PARTICIPANTS: Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. DESIGN: Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. MEETING OUTCOMES: Future steps were planned regarding 1) recognizing, preventing, and treating post-intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post-intensive care syndrome across the continuum of care, including explicit "functional reconciliation" (assessing gaps between a patient's pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post-intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. CONCLUSIONS: Raising awareness of post-intensive care syndrome for the public and both critical care and non-critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Oncologists' and physiatrists' attitudes regarding rehabilitation for patients with advanced cancer.

OBJECTIVE: To determine whether differences in attitude and practice between physiatrists and oncologists exist that may be barriers to patients with advanced cancer receiving rehabilitation services. DESIGN: A survey of medical oncologists' and rehabilitation physicians' self-reported referral attitudes and behaviors regarding rehabilitation services for patients with advanced cancer defined as the prognosis expected to lead to death in 6-12 months. After a prenotification letter, surveys were mailed to a systematically drawn sample. A final survey population of 591 medical oncologists and 464 rehabilitation physicians was created from prenotification and survey mailings. PARTICIPANTS: Practicing physiatrists and oncologists listed in the American Academy of Physical Medicine and Rehabilitation and American Society of Clinical Oncology membership directories. MAIN OUTCOME MEASUREMENTS: Responses to survey questions by physiatrists and oncologists. RESULTS: From 820 surveys mailed, 395 surveys were returned, for a total response rate of 46%. When asked about how a terminal prognosis of patients with advanced cancer affects rehabilitation referral and acceptance, only 8% of medical oncologists said that they would refer a patient with advanced cancer to rehabilitation services regardless of estimated prognosis, whereas 35% of rehabilitation physicians said that they would accept a patient with advanced cancer for rehabilitation services regardless of prognosis. Approximately 70% of both medical oncologists and rehabilitation physicians thought it to be very important that patients with advanced cancer who are referred and accepted into rehabilitation services adequately understand their prognosis before beginning a rehabilitation program. However, only 39% of rehabilitation physicians, compared with 61% of medical oncologists, believed that patients with advanced cancer and in rehabilitation services adequately understood their prognosis (P = .004). As surveyed, a do not resuscitate order had no effect on a medical oncologist's willingness to refer a patient with advanced cancer to rehabilitation services and had minimal effect on a rehabilitation physician's willingness to accept a patient with advanced cancer. CONCLUSION: Medical oncologists and rehabilitation physicians share many similar attitudes with regard to the referral and acceptance of patients with advanced cancer for rehabilitation services. However, medical oncologists see prognosis as a more significant barrier to rehabilitation services than do rehabilitation physicians. Rehabilitation physicians are more likely to believe that the patients with advanced cancer for whom they care do not adequately understand their prognosis.

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

BACKGROUND: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. OBJECTIVES: To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families. PARTICIPANTS: Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge. DESIGN: Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems. MEASUREMENTS AND MAIN RESULTS: Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member. CONCLUSIONS: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

The future of cancer rehabilitation: emerging subspecialty.

In this article, the subject of the future for the field of cancer rehabilitation is embarked upon. Future practice innovation models must involve the appropriate and comprehensive evaluation of cancer patients' rehabilitation needs using better functional measurement tools, as well as the forging of new partnerships through the presence and initiation of physiatric coordinated rehabilitation teams, particularly during the acute phases of treatment. Partnering rehabilitation teams closely with oncology colleagues during surveillance years, through the development of outpatient survivorship clinics for diagnosis and treatment of many of cancer patients' ongoing symptoms and functional limitations, will allow for more comprehensive and coordinated follow-up cancer care. Integration of rehabilitation into palliative care and continued efforts to increase oncology's awareness and acceptance of rehabilitation benefits and expertise are needed. Future education models for medical school, residency, and postresidency training are discussed, as are future research goals to help in placing cancer rehabilitation at the forefront of acute cancer care and survivorship care.