Neurorehabilitation for Adults with Brain and Spine Tumors.

Central nervous system (CNS) malignancies (i.e. brain and spine tumors) and their treatments can result in a multitude of neurologic deficits. Patients with CNS malignancies experience physical, cognitive, and psychosocial sequelae that can impact their mobility and quality of life. Neurorehabilitation can play a critical role in maintaining independence, preventing disability, and optimizing safety with activities of daily living. This review provides an overview of the neurorehabilitation approaches for patients with CNS malignancies, neurologic impairments frequently treated, and rehabilitation interventions in various health care settings. In addition, we will highlight rehabilitative outcomes between patients with nononcologic neurologic conditions compared to brain and spine tumors. Finally, we address medical challenges that may impact rehabilitation care in these medically complex cancer patients.

Function in Cancer Patients: Disease and Clinical Determinants.

Patients with cancer often experience changes in function during and after treatment but it is not clear what cancer types, and associated clinical factors, affect function. This study evaluated patient-reported functional impairments between specific cancer types and risk factors related to disease status and non-cancer factors. A cross-sectional study evaluating 332 individuals referred to cancer rehabilitation clinics was performed at six U.S. hospitals. The PROMIS Cancer Function Brief 3D Profile was used to assess functional outcomes across the domains of physical function, fatigue, and social participation. Multivariable modeling showed an interaction between cancer type and cancer status on the physical function and social participation scales. Subset analyses in the active cancer group showed an effect by cancer type for physical function (p < 0.001) and social participation (p = 0.008), but no effect was found within the non-active cancer subset analyses. Brain, sarcoma, prostate, and lymphoma were the cancers associated with lower function when disease was active. Premorbid neurologic or musculoskeletal impairments were found to be predictors of lower physical function and social participation in those with non-active cancer; cancer type did not predict low function in patients with no evidence of disease. There was no differential effect of cancer type on fatigue, but increased fatigue was significantly associated with lower age (0.027), increased body mass index (p < 0.001), premorbid musculoskeletal impairment (p < 0.015), and active cancer status (p < 0.001). Anticipatory guidance and education on the common impairments observed with specific cancer types and during specific stages of cancer care may help improve/support patients and their caregivers as they receive impairment-driven cancer rehabilitation care.

Increasing cancer rehabilitation awareness and referrals in the Veterans Health Administration-A quality improvement initiative.

OBJECTIVE: To expand access to comprehensive rehabilitation services among veterans with cancer by increasing cancer rehabilitation referrals in a Veterans Affairs (VA) hospital. DESIGN: A rapid cycle improvement approach based on the Institute of Healthcare Improvement's Model for Improvement was used to assess and optimize the cancer rehabilitation referral process. In this quality improvement project, our cancer rehabilitation workgroup developed an electronic screening tool within the VA electronic patient record system to streamline cancer rehabilitation referrals. Providers could complete an optional Cancer Rehabilitation (CaRe) Screen that consisted of 12 questions related to patient symptoms and function. If the screen was positive, a nonvisit electronic consult was automatically generated and sent to a physiatrist for review. The physiatrist would then triage patients to appropriate services including physiatry, physical therapy, occupational therapy, speech therapy, rehab psychology, and other rehabilitation services. RESULTS: A total of 90 referrals were placed between 2019-2021. A total of 84% of the patients referred were male, 73% were white. The top cancer types referred were lung (27%), blood (23%), gastrointestinal (12%), and prostate (10%). There were 19 referrals in 2019, 13 in 2020, and 58 in 2021. The electronic screening tool was implemented in mid-2021. Advanced practice providers placed 48% of consults. Of the referrals placed in 2021, 13% of consults were initiated through the electronic screening tool. The most common rehabilitation-related referrals placed after initial cancer rehabilitation triage included physical therapy (n = 47, 35.1%), physiatry (n = 28, 20.9%), and occupational therapy (n = 24, 17.9%). CONCLUSIONS: Implementing an electronic screening tool can streamline cancer rehabilitation referrals and increase access to cancer rehabilitation services for Veterans with cancer. Ongoing work is required to refine the referral process and educate providers and patients on the importance of cancer rehabilitation in the cancer care continuum.

Transmission of Bias in the Medical Record Among Physical Medicine and Rehabilitation Trainees.

ABSTRACT: Stigmatizing language can negatively influence providers' attitudes and care toward patients, but this has not been studied among physiatrists. An online survey was created to assess whether stigmatizing language can impact physical medicine and rehabilitation trainees' attitudes toward patients. We hypothesized stigmatizing language would negatively impact trainees' attitudes. Participants were randomized to a stigmatizing or neutral language vignette describing the same hypothetical spinal cord injury patient. Questions were asked about attitudes and assumptions toward the patient, pain management based on the vignette, and general views regarding individuals with disabilities. Between August 2021 and January 2022, 75 US physical medicine and rehabilitation residency trainees participated. Thirty-seven (49.3%) identified as women; 52 (69.3%) were White, and half (50.6%) received the stigmatized vignette. Participants exposed to stigmatizing language scored 4.8 points lower ( P < 0.01) on the provider attitude toward patient scale compared with those exposed to neutral language. There were no significant differences in the disability attitude scores between the two groups ( P = 0.81). These findings may indicate that stigmatizing language in the medical record may negatively affect physical medicine and rehabilitation trainees' attitudes toward patients. Further exploration is needed to identify the best way to educate trainees and reduce the propagation of bias in the medical record.

Cancer Rehabilitation Veterans Affairs Extension for Community Healthcare Outcomes Virtual Education Program: A Model for Virtual Learning in the COVID-19 Era.

ABSTRACT: Rehabilitation is important in the care of patients with cancer for improving function, pain, and quality of life. However, only a small number of clinicians are formally trained in cancer rehabilitation. Virtual learning environments may play a promising role in cancer rehabilitation education, especially in the coronavirus pandemic era where in-person learning is not readily available. A national, interprofessional cancer rehabilitation education program involving a monthly longitudinal webinar series and a 2-day virtual bootcamp was developed through the US Department of Veterans Affairs Extension for Community Healthcare Outcomes to improve Department of Veterans Affairs clinician understanding of cancer rehabilitation and ultimately increase the availability of cancer rehabilitation services in the Veterans Health Administration. From March 2020 to July 2022, 923 individuals participated with an average of 72 participants per session and 204 participants per session in the bootcamp. Participants' most common disciplines were physical therapy, occupational therapy, nursing, medicine (physicians), advanced practice providers, speech therapy, and pharmacy. Participants reported improved knowledge of cancer rehabilitation and anticipated that the knowledge would change their practice. Virtual education can be a useful means to educate Department of Veterans Affairs-based healthcare professionals about cancer rehabilitation and improve access to rehabilitation services for veterans with cancer.

Physical function and fatigue recovery at 6 months after hospitalization for COVID-19.

INTRODUCTION: There are an increasing number of individuals with long-term symptoms of coronavirus-19 disease (COVID-19); however, the prognosis for recovery of physical function and fatigue after COVID-19 is uncertain. OBJECTIVE: To report the changes in functional recovery between 1 and 6 months after hospitalization of adults hospitalized for COVID-19 and explore the baseline factors associated with physical function recovery. DESIGN: A prospective cohort study. SETTING: Tertiary care hospital. PARTICIPANTS: U.S. adult COVID-19 survivors. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Telephone interviews assessed three outcome domains: basic and instrumental activities of daily living (ADLs) performance, fatigue, and general physical function (Health Assessment Questionnaire [HAQ]). RESULTS: The age of participants (n = 92) ranged from 22 to 95 years (54.3 ± 17.2). Across outcome domains, a majority (63%-67%) of participants developed new ADL impairment, fatigue, or worsening HAQ severity by 1 month. Of those, 50%-79% partially or fully recovered by 6 months, but 21%-50% did not recover at least partially. Fifteen to 30% developed new impairment between 1 and 6 months. For those without any improvement in ADL impairments at 6 months, lower socioeconomic status was significantly more common (p = .01) and age ≥ 65 (p = .06), trending toward being more common. CONCLUSION: In this cohort, a substantial proportion of the participants who developed new ADL impairment, worsening fatigue, or HAQ severity after hospitalization for COVID-19 did not recover at least partially by 6 months after discharge. Evaluating functional status 1 month after discharge may be important in understanding functional prognosis and recovery after hospitalization for COVID-19.

Intensive care unit-acquired weakness and the COVID-19 pandemic: A clinical review.

Patients with severe cases of coronavirus disease 2019 (COVID-19) often become critically ill requiring intensive care unit (ICU) management. These individuals are at risk for developing ICU-acquired weakness (ICUAW), a multifactorial condition in which polyneuropathy, myopathy, and/or disuse muscle atrophy result in motor weakness. This weakness is thought to contribute to the long-term functional disability frequently observed in survivors of critical illness. This review discusses the current evidence regarding the epidemiology, pathophysiology, evaluation, risk factors, and rehabilitation-specific management of ICUAW in patients with COVID-19. Because of the novelty of COVID-19, the exact prevalence of ICUAW is not well delineated among COVID-19 patients. However, ICUAW has been reported in this population with retrospective studies showing weakness occurring in up to 45.5% of patients with severe COVID-19. There are multiple risk factors for developing ICUAW among COVID-19 patients, including premorbid health status, sepsis, multiple organ failure, mechanical ventilation, immobilization, neuromuscular blockade, corticosteroid use, and glycemic control. ICUAW is more likely to occur after prolonged mechanical ventilation and long hospital stays and can be diagnosed with manual muscle and electrodiagnostic testing. Although the long-term sequela of COVID-19 after ICU stays is not fully studied, increasing evidence indicates significant risk for this population developing long-term functional impairments. Establishing postacute rehabilitation programs for COVID-19 survivors will be important for recovery of endurance, mobility, and function.

Behavioral dysregulation exacerbated by intrathecal baclofen in an adolescent with severe traumatic brain injury.

This is a case of a 19-year-old male with a history of remote severe traumatic brain injury (TBI) with an intrathecal baclofen (ITB) pump for dystonia management. Given concern for lack of efficacy despite increasing doses of ITB, his catheter was evaluated and found to be epidural rather than intrathecal. The baclofen dose was down-titrated and he underwent catheter revision. Post-op, his baclofen dose was up-titrated and complicated by significant behavioral changes including aggressive physical and verbal behaviors resulting in hospitalization. Work-up was negative for infection, new neurologic pathology, and epileptic activity. Psychiatric medications were adjusted but the behaviors persisted. Due to concern that the increased baclofen dose was causing his mood instability, his pump was down-titrated. As the dosage decreased, the frequency of outbursts also decreased. Throughout these dose adjustments, his dystonia remained stable and overall functional status improved. This is one of the first cases demonstrating that ITB may exacerbate mood instability in patients with TBI.

Patient-reported functional outcomes 30 days after hospitalization for COVID-19.

BACKGROUND: Many coronavirus disease 2019 (COVID-19) survivors experience persistent symptoms, such as fatigue, dyspnea, and musculoskeletal pain. However, less is known about the impact of COVID-19 on longer term functional outcomes. OBJECTIVE: To evaluate patient-reported activity of daily living (ADL) function and fatigue symptoms 30 days after hospitalization for COVID-19. DESIGN: Cross-sectional study. SETTING: Tertiary care university hospital. PARTICIPANTS: Adults 18 years or older hospitalized for COVID-19 and survived to 30 days after discharge. METHODS: A standardized telephone questionnaire was administered 30 days after hospital discharge. MAIN OUTCOME MEASURES: Ability to perform basic and instrumental ADLs and fatigue symptoms severity (Patient-Reported Outcome Measurement Information System [PROMIS] Fatigue Short Form 7a) were assessed by self-report. RESULTS: Participants (n = 55) were 22-95 years old. Compared to pre-COVID hospitalization, 52% developed new difficulty and 6% new dependence with performing basic ADLs (bADLs), 48% developed new difficulty and 11% new dependence with instrumental ADLs (iADLs), and 69% experienced a clinically significant worsening in their fatigue symptom severity. The average fatigue symptom severity T-score before hospitalization was 44.2 ± 7.4 and after hospitalization was 54.5 ± 9.8. In exploratory multivariate analyses, each additional COVID symptom at presentation was associated with a predicted increase of 1.43 units (95% confidence interval [CI], 0.45-2.42) in the 30-day fatigue symptom severity T-score, each additional day of hospitalization was associated with an 1.2 times increased odds of worsening fatigue (95% CI, 0.98-1.5; p = .08), and each unit increase in baseline body mass index was associated with 0.8 times decreased odds of new bADL or iADL dependence at 30 days (95% CI, 0.65-0.99). CONCLUSIONS: New functional impairments are common at 30 days after discharge among survivors of hospitalization for COVID-19. Early rehabilitation, advance care planning, and referrals to appropriate therapies should be considered in postacute COVID-19 care to maximize patients' functional outcomes. However, ongoing research is still needed regarding management of these patients.

Is the risk of lymphedema life-long following treatment for gynecologic cancer?-A case report.

Lymphedema is a common complication following oncologic surgeries and is classically described to occur months to a few years after these procedures. A 64 year-old woman with history of total abdominal hysterectomy and bilateral salpingo-oophorectomy developed right-sided lower extremity lymphedema 7 years after the surgeries. Lymphographic imaging performed approximately twenty years after the original surgeries revealed development of subclinical, asymptomatic lymphedema on the contralateral lower extremity. This delayed presentation of lymphedema after initial injury, is the first described case of subclinical lymphedema without detectable lymphatic injury, making it important to continuously monitor patients at risk for lymphedema long-term.

Multi-segment bioimpedance can assess patients with bilateral lymphedema.

BACKGROUND: Bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. There are two primary device modalities, through which BIS is used clinically: single-segment bioimpedance (SSB) and multi-segment bioimpedance (MSB), which differ in their mechanisms of gathering measurements. In this cross-sectional study, we study the difference between SSB and MSB in evaluating lymphedema by referencing the results with indocyanine Green (ICG) lymphography. METHODS: Patients with unilateral and bilateral lymphedema, presented to our department, were assessed with both SSB and MSB as part of a pre-lymphatic surgery evaluation between May 1, 2017, and November 31, 2017. Patients were imaged with ICG lymphography to confirm lymphedema presence. Standardized device measurement outputs from SSB and MSB were recorded and statistically analyzed. RESULTS: SSB was more sensitive (0.9) than MSB (0.75) for unilateral lymphedema. However, MSB had the added ability to assess patients with bilateral lymphedema with a sensitivity of 0.56 and specificity of 0.60. Furthermore, MSB had a stronger correlation with relative disease severity compared to SSB and quantified the differential extents of edema. In comparison, SSB provided a manipulated number, which was derived from a comparison of the abnormal to the normal limb. Medical staff reported MSB being easier to perform, and all patients reported the MSB measurement experience being more favorable. CONCLUSIONS: While both SSB and MSB provide diagnostic information on lymphedema, MSB is notably easier to perform, can detect bilateral disease states, and objectively quantifies limb fluid volume, allowing for disease tracking and assessment of surgical and rehabilitative treatment efficacy. On the basis of this study, our department has switched to universal MSB measurement.

Diagnostic accuracy of bioimpedance spectroscopy in patients with lymphedema: A retrospective cohort analysis.

BACKGROUND: Bioimpedance spectroscopy (BIS) is used by healthcare specialists to diagnose lymphedema. BIS measures limb fluid content by assessing tissue resistance to the flow of electric current. However, there is debate regarding the validity of BIS in diagnosing early lymphedema. Indocyanine green (ICG) lymphography has been established as the most accurate diagnostic modality to date for lymphedema diagnosis. In this retrospective study, we test the sensitivity, specificity, and diagnostic accuracy of BIS in diagnosing lymphedema by referencing its results with ICG lymphography. METHODS: Patients presented to the University of Iowa Lymphedema Center from 2015 to 2017 were evaluated with a standardized protocol that included history and physical examination, a validated lymphedema-specific quality-of-life assessment (LYMQOL), circumference -measurement-based index, BIS, and ICG lymphography. Diagnostic accuracy of BIS was assessed using ICG lymphography as a reference test. RESULTS: Fifty-eight patients had positive ICG lymphography results, which confirmed the diagnosis of lymphedema. ICG lymphographic findings consistently correlated with clinical examination, LYMQOL evaluation, and lymphedema indices. By contrast, BIS demonstrated a false-negative rate of 36% - 21 out of 58 patients had normal BIS readings, but a positive ICG lymphography result. The 21 false-negative results occurred in patients with early-stage disease. Sensitivity and specificity for BIS were 0.64 and 1, respectively. CONCLUSION: BIS carries an excessively high rate of false-negative results to be dependably used as a diagnostic modality for lymphedema. ICG lymphography highly correlates with other tracking modalities, and it remains the most reliable tool for diagnosing lymphedema.

Using Geospatial Mapping to Determine the Impact of All-Terrain Vehicle Crashes on Both Rural and Urban Communities.

INTRODUCTION: Deaths and injuries from all-terrain vehicle (ATV) crashes result in approximately 700 deaths each year and more than 100,000 emergency department (ED) visits. Common misconceptions about ATV crashes are a significant barrier to injury prevention efforts, as is the lack of key information about where and how crashes occur. The purpose of this study was to determine ATV crash patterns within a state, and to compare and contrast characteristics of these crashes as a function of crash-site rurality. METHODS: We performed descriptive, comparative, and regression analyses using a statewide off-road vehicle crash and injury database (2002-2013). Comparisons were performed by rurality as defined using the Rural Urban Commuting Area (RUCA) coding system, and we used geographic information system (GIS) software to map crash patterns at the zip code and county levels. RESULTS: ATV crashes occurred throughout the state; 46% occurred in urban and 54% in rural zip code areas. Comparisons of rider and crash characteristics by rurality showed similarities by sex, age, seating position, on vs. off the road, and crash mechanism. Conversely, helmet use was significantly lower among victims of isolated rural crashes as compared to other victims (p=0.004). Crashes in isolated rural and small rural areas accounted for only 39% of all crashes but resulted in 62% of fatalities. In both rural and urban areas, less than one-quarter of roadway injuries were traffic related. Relative crash rates varied by county, and unique patterns were observed for crashes involving youth and roadway riders. During the study period, 10% and 50% of all crashes occurred in 2% and 20% of the state's counties, respectively. CONCLUSION: This study suggests that ATV crashes are a public health concern for both rural and urban communities. However, isolated rural ATV crash victims were less likely to be helmeted, and rural victims were over-represented among fatalities. Traffic was not the major factor in roadway crashes in either rural or urban areas. Unique crash patterns for different riding populations suggest that injury prevention experts and public policy makers should consider the potential impact of geographical location when developing injury prevention interventions.