Using Performance Status to Identify Risk of Acute Care Transfer in Inpatient Cancer Rehabilitation.

OBJECTIVE: To identify patient factors associated with acute care transfer (ACT) among cancer survivors admitted for inpatient medical rehabilitation. DESIGN: An exploratory, observational design was used to analyze retrospective data from electronic medical records. SETTING: Data were obtained from 3 separate inpatient rehabilitation hospitals within a private rehabilitation hospital system in the Northeast. PARTICIPANTS: Medical records were reviewed and analyzed for a total of 416 patients with a confirmed oncologic diagnosis treated in 1 of the inpatient rehabilitation hospitals between January and December 2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of an ACT. Covariates included the adapted Karnofsky Performance Scale (KPS) for inpatient rehabilitation, demographic information, admission date, re-admission status, discharge destination, and cancer-related variables, such as primary cancer diagnosis and presence/location of metastases. RESULTS: One in 5 patients (21.2%) were transferred to acute care. Patients with hematologic cancer had a higher risk of ACT compared with those with central nervous system (CNS) cancer. Lower functional status, measured by the adapted KPS, was associated with a higher likelihood of ACT. Patients with an admission KPS score indicating the need for maximum assistance had the highest transfer rate (59.1%). CONCLUSIONS: These findings highlight the medical complexity of this population and increased risk of an interrupted rehabilitation stay. Considering patients' performance status, cancer type, and extent of disease may be important when assessing the appropriateness of IRF admission relative to patient quality of life. Earlier and improved understanding of the patient's prognosis will allow the cancer rehabilitation program to meet the patient's unique needs and facilitate an appropriate discharge to the community in an optimal window of time.

Embracing Complexity-the Role of Cancer Rehabilitation in Restoring and Maintaining Function and Quality of Life in Cancer Survivors with Radiation Fibrosis Syndrome.

Purpose of Review: Despite more than 6 decades of growth and transformation, the field of cancer rehabilitation has considerable room to evolve if it is to live up to its full potential. This article will discuss the importance of this evolution in the context of radiation late effects and serve as a call for the clinical and operational expansion of the field so that it can become a key component of comprehensive cancer care. Recent Findings: The clinical and operational challenges inherent in cancer survivors with radiation late effects necessitate different thinking with respect to how rehabilitation professionals evaluate and manage patients as well as how our institutions equip these professionals to practice at the highest possible level. Summary: To achieve its promise, the field of cancer rehabilitation must evolve to embrace fully the scope, scale, and complexity of issues faced by cancer survivors with radiation late effects. Better engagement and coordination of the care team are needed to deliver this care and ensure our programs are robust, sustainable, and flexible.

Under recognition and treatment of lymphedema in head and neck cancer survivors - a database study.

PURPOSE: Head and neck cancer (HNC) will be diagnosed in approximately 54,000 Americans in 2022 with more than 11,000 dying as a result. The treatment of HNC often involves aggressive multimodal therapy including surgery, radiotherapy, and systemic therapy. HNC and its treatments are associated with multiple painful and function-limiting neuromusculoskeletal and visceral long-term and late effects. Among these is head and neck lymphedema (HNL), the abnormal accumulation of protein rich fluid, in as many as 90% of survivors. Though HNL is common and potentially contributory to other function-limiting issues in this population, it is notoriously understudied, underrecognized, underdiagnosed, and undertreated. This study seeks to determine the incidence of HNC-related lymphedema diagnosis and treatment in a large US healthcare claims repository database. METHODS: A retrospective observational cohort design and data from an integrated US healthcare claims repository-the IBM MarketScan Commercial Claims and Encounters (CCAE) and Medicare Supplemental and Coordination of Benefits (MDCR) Databases spanning the period April 1, 2012 through March 31, 2020. RESULTS: Of the 16,654 HNC patients eligible for evaluation, 1,082 (6.5%) with a diagnosis of lymphedema were identified based on eligibility criteria. Of the 521 HNC patients evaluated for lymphedema treatment, 417 (80.0%) patients received 1.5 courses of MLD, 71 (13.6%) patients were prescribed compression garments, and 45 (8.6%) patients received an advanced pneumatic compression device. CONCLUSION: HNL in this population of HNC survivors was underdiagnosed and treated compared with contemporary assessments HNL incidence.

Translation of Karnofsky Performance Status (KPS) for use in inpatient cancer rehabilitation.

BACKGROUND: Better tools are needed to predict functional decline and oncologic prognosis in inpatient cancer rehabilitation. The Karnofky Performance Status (KPS) is a widely used scale of functional performance in oncology, although the scale differs from current rehabilitation terminology. Use of the KPS in inpatient rehabilitation may support a shared method of communication between cancer rehabilitation providers and the primary oncology teams. OBJECTIVE: To establish interrater reliability for translation of the KPS for use in inpatient cancer rehabilitation. DESIGN: Retrospective interrater reliability review. SETTING: A large inpatient rehabilitation hospital system. PARTICIPANTS: Fifty randomized charts were chosen for review from a larger database of all patients admitted to an inpatient cancer rehabilitation program in 2020. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The KPS scale was translated into common inpatient rehabilitation grading consistent with the Continuity and Assessment Record and Evaluation (CARE) Item Set to support its use in this specialty area. Additionally, a list of best practice guidelines and scoring instructions were created to assist raters in determining appropriate levels within the scale. Members of the inpatient cancer rehabilitation team scored all patients within the larger database (n = 424) throughout 2020. A blinded rater completed retrospective chart reviews to score the 50-chart sample. A two-way random effects model was used to calculate an intraclass correlation coefficient (ICC) for the KPS scores at each of three time points (premorbid, admission, and discharge). RESULTS: The KPS interpretation for rehabilitation proved to be statistically reliable for the 50-chart sample. The premorbid KPS interrater reliability was acceptable (ICC = 0.67; 95% confidence interval [CI]: 0.40-0.82), admission KPS reliability was good (ICC = 0.88, 95% CI: 0.78-0.93), and discharge reliability was excellent (ICC = 0.96; 95% CI: 0.91-0.98). CONCLUSION: The KPS translation at three time points (premorbid, admission, and discharge) during the inpatient rehabilitation continuum has acceptable interrater reliability.

Prevalence of function-limiting late effects in Hodgkin lymphoma survivors.

BACKGROUND: Hodgkin lymphoma (HL) is highly curable, but survivors often develop function-limiting impairments. Screening guidelines for neuromuscular and musculoskeletal late effects are not as well recognized across medical disciplines. Early identification and management of functional late effects are instrumental in improving the longitudinal care of HL survivors. OBJECTIVE: To define the prevalence of neuromuscular, musculoskeletal, visceral, oncologic, and other late effects affecting function and quality of life (QOL) in HL survivors. DESIGN: A retrospective cohort analysis. SETTING: Outpatient cancer rehabilitation clinic. PARTICIPANTS: One hundred HL survivors. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence of neuromuscular, musculoskeletal, visceral, oncologic, and other late effects contributing to functional impairment and disability in HL survivors. RESULTS: Among the 100 HL survivors, 43% received chemotherapy, 94% radiation therapy, and 38% a combination of chemo-radiation for their initial cancer treatment. Nearly all HL survivors were diagnosed with myelopathy (83%), radiculoplexopathy (93%), mononeuropathy (95%), and localized myopathy (93%). Musculoskeletal sequelae included dropped head syndrome (83%), cervicalgia (79%), shoulder girdle dysfunction (73%), and dysphagia (42%). Visceral disorders included cardiovascular (70%), pulmonary (44%), endocrine (63%), gastrointestinal (29%), and genitourinary (11%) dysfunction. Lymphedema affected 21% of survivors and 30% had a history of a secondary malignancy. Pain (71%), fatigue (45%), and dyspnea (43%) were major function-limiting impairments. Nearly all (95%) of survivors were referred to at least one therapy discipline including physical therapy, occupational therapy, speech and language pathology, and/or lymphedema therapy. CONCLUSION: Neuromuscular, musculoskeletal, visceral, oncologic, and other late effects are extremely common in HL survivors seeking physiatric evaluation. Multiple function-limiting disorders can coexist in HL survivors with the potential to severely compromise function and QOL. Safe and effective rehabilitation may depend on the physiatrist's ability to identify, evaluate, and manage the multitude of complex and often interrelated functional late effects seen in HL survivors.

Ultrasound-guided superficial serratus plane block for persistent post-mastectomy pain: four case reports.

BACKGROUND: Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including medications, physical therapy, exercise interventions, cognitive-behavioral psychology, psychosocial interventions, and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain. METHODS: We report four cases of patients with PPMP that were treated using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews. RESULTS: We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB. CONCLUSION: These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of "tightness" relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Cancer Rehabilitation: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 1.

Individuals with cancer commonly experience functional impairments. Symptoms may present immediately or years to decades following their treatment. These impairments may include fatigue, pain, neuropathy, lymphedema, or radiation fibrosis syndrome and have the potential to deleteriously impact their function and quality of life. Cancer rehabilitation is a comprehensive resource that facilitates maximizing and maintaining cancer survivors' physical, social, psychological, and vocational functioning. This article covers the common functional impairments experienced by cancer survivors and the treatment strategies used in cancer rehabilitation. Application of these services can enhance the ongoing care for cancer survivors.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2.

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Clinical Evaluation and Management of Cancer Survivors with Radiation Fibrosis Syndrome.

OBJECTIVES: To define radiation fibrosis and radiation fibrosis syndrome; review the basics of radiotherapy, the pathophysiology of radiation injury, and the principles of clinical evaluation and management of the common late effects resulting from radiation therapy for cancer treatment. DATA SOURCES: Peer-reviewed journal articles, book chapters, Internet. CONCLUSION: There is no cure for radiation fibrosis syndrome, but supportive treatment of its clinical sequelae can potentially result in improved function and quality of life. IMPLICATIONS FOR NURSING PRACTICE: The sequelae of radiation fibrosis syndrome can often be improved with early detection and supportive care by a multidisciplinary team including cancer rehabilitation physiatrists, oncologists, oncology nurses, nurse practitioners, physical therapists, occupational therapists, and speech and language pathologists.

The Role of the Headmaster Collar (Cervical) for Dropped Head Syndrome in Hodgkin Lymphoma Survivors.

BACKGROUND: Dropped head syndrome is a potential late neurologic complication of radiation therapy in survivors of Hodgkin lymphoma. There is limited evidence for conservative management of this condition. OBJECTIVE: To discover patient utilization patterns of the commonly prescribed Headmaster Collar (cervical) in Hodgkin lymphoma survivors with radiation-induced dropped head syndrome. DESIGN: Questionnaire-based retrospective observational study. SETTING: Single-site academic cancer center. PATIENTS: Twenty-six Hodgkin lymphoma survivors treated with radiation therapy involving the mantle who were prescribed a Headmaster Collar for dropped head syndrome. METHODS OR INTERVENTIONS: Patients were interviewed by phone with a structured set of questions. MAIN OUTCOME MEASUREMENTS: Compliance, patterns of use, individual modifications, and side effects of collar use. RESULTS: Although 58% of patients who were prescribed a Headmaster Collar eventually discontinued its use, 62% of all patients used the collar for more than 6 months. The majority of users wore the collar for up to 3 hours per day, usually for static seated activities. Thirty-eight percent of patients made personal modifications to their collar, most commonly the addition of extra padding. All but one patient had complaints about the collar, most commonly discomfort, rigidity, and confinement. CONCLUSIONS: The Headmaster Collar (cervical) is often utilized for a few hours a day, for longer than 6 months, to help with static seated activities. Insights from this study might help to improve future orthotic designs with better long-term compliance rates for the treatment of radiation-induced dropped head syndrome. LEVEL OF EVIDENCE: IV.

The Underutilization of Rehabilitation to Treat Physical Impairments in Breast Cancer Survivors.

Breast cancer survivors can experience multiple neuromuscular, musculoskeletal, pain, and functional disorders as a result of their cancer and its treatment. Common disorders include shoulder dysfunction, postmastectomy syndrome, chemotherapy-induced peripheral neuropathy, axillary cording, lymphedema, and a host of others. Cancer rehabilitation is a process that helps breast cancer and other survivors to obtain and maintain the highest possible physical, social, psychological, and vocational functioning within the limits created by cancer and its treatments. There are good data supporting the safety and efficacy of cancer rehabilitation in the treatment of many breast cancer-related impairments, including shoulder dysfunction and lymphedema, among others. Despite the goals and efficacy of cancer rehabilitation, there is a marked underuse of services. The reasons for this phenomenon are many, but broadly result from a lack of knowledge about cancer rehabilitation on the part of patients and referring clinicians, limited access to services, and suboptimal adherence. This article explores underutilization of cancer rehabilitation in breast cancer survivors and provides an opportunity to consider ways to improve this gap in care.

Peripheral nervous system injury after high-dose single-fraction image-guided stereotactic radiosurgery for spine tumors.

OBJECTIVE The object of this study was to determine the percentage of high-dose (1800-2600 cGy) single-fraction stereotactic radiosurgery (SF-SRS) treatments to the spine that result in peripheral nervous system (PNS) injury. METHODS All patients treated with SF-SRS for primary or metastatic spine tumors between January 2004 and May 2013 and referred to the Rehabilitation Medicine Service for evaluation and treatment of neuromuscular, musculoskeletal, or functional impairments or pain were retrospectively identified. RESULTS Five hundred fifty-seven SF-SRS treatments in 447 patients resulted in 14 PNS injuries in 13 patients. All injures resulted from SF-SRS delivered to the cervical or lumbosacral spine at 2400 cGy. The overall percentage of SF-SRS treatments resulting in PNS injury was 2.5%, increasing to 4.5% when the thoracic spine was excluded from analysis. The median time to symptom onset following SF-SRS was 10 months (range 4-32 months). The plexus (cervical, brachial, and/or lumbosacral) was affected clinically and/or electrophysiologically in 12 (86%) of 14 cases, the nerve root in 2 (14%) of 14, and both in 6 (43%) of 14 cases. All patients experienced pain and most (93%) developed weakness. Peripheral nervous system injuries were CTCAE Grade 1 in 14% of cases, 2 in 64%, and 3 in 21%. No dose relationship between SF-SRS dose and PNS injury was detected. CONCLUSIONS Single-fraction SRS to the spine can result in PNS injury with major implications for function and quality of life.

Clinical Evaluation and Management of Radiation Fibrosis Syndrome.

Radiation fibrosis syndrome describes the multiple neuromuscular, musculoskeletal, visceral, and other late effects that result from radiation-induced fibrosis. Radiation can damage the spinal cord, nerve roots, plexus, local peripheral nerves, and muscles within the radiation field. This constellation is known as a "myelo-radiculo-plexo-neuro-myopathy" and can result in pain, sensory loss, weakness, and other signs and symptoms. Although there is no curative treatment for radiation damage, supportive management of symptoms can be helpful in restoring and maintaining function and quality of life.

Rehabilitation of people with spinal cord damage due to tumor: literature review, international survey and practical recommendations for optimizing their rehabilitation.

BACKGROUND/OBJECTIVES: People with spinal cord dysfunction (SCDys) due to tumor (benign and malignant) pose enormous rehabilitation challenges. Objectives were: conduct literature search regarding epidemiology, clinical features and outcomes for SCDys due to tumor following rehabilitation, the ideal setting for rehabilitation and practical considerations for rehabilitation; and propose framework and practical considerations for managing people with SCDys due to tumor in spinal rehabilitation units (SRUs). DESIGN: Survey of rehabilitation health care professionals, consensus opinion from experts and literature search. SETTING: Workshop at International Spinal Cord Society and American Spinal Injury Association combined annual meeting, May 16, 2015, Montréal, Canada. PARTICIPANTS: Workshop attendees and experts in the rehabilitation of people with SCDys due to tumor. OUTCOMES MEASURES: Reports of services offered to people with SCDys due to tumor, including whether those with benign and malignant tumors are admitted into rehabilitation, any admission criteria used and the rational for declining admission. RESULTS: Most respondents (n = 33, 83%) reported that people with benign tumors were routinely admitted for rehabilitation but only 18 (45%) reported that people with malignant tumors were routinely admitted. A range of criteria and reasons for declining admission were given. Evidence from the literature and the opinion of experts support the admission of people with SCDys due to tumor into specialist SRUs. CONCLUSIONS: A framework and practical considerations for managing people with SCDys due to tumor in SRUs are proposed. Patients with tumor causing SCDys should be given greater access to specialist SRU in order to achieve the best outcomes.

Toward a National Initiative in Cancer Rehabilitation: Recommendations From a Subject Matter Expert Group.

The health care delivery system in the United States is challenged to meet the needs of a growing population of cancer survivors. A pressing need is to optimize overall function and reduce disability in these individuals. Functional impairments and disability affect most patients during and after disease treatment. Rehabilitation health care providers can diagnose and treat patients' physical, psychological, and cognitive impairments in an effort to maintain or restore function, reduce symptom burden, maximize independence and improve quality of life in this medically complex population. However, few care delivery models integrate comprehensive cancer rehabilitation services into the oncology care continuum. The Rehabilitation Medicine Department of the Clinical Center at the National Institutes of Health with support from the National Cancer Institute and the National Center for Medical Rehabilitation Research convened a subject matter expert group to review current literature and practice patterns, identify opportunities and gaps regarding cancer rehabilitation and its support of oncology care, and make recommendations for future efforts that promote quality cancer rehabilitation care. The recommendations suggest stronger efforts toward integrating cancer rehabilitation care models into oncology care from the point of diagnosis, incorporating evidence-based rehabilitation clinical assessment tools, and including rehabilitation professionals in shared decision-making in order to provide comprehensive cancer care and maximize the functional capabilities of cancer survivors. These recommendations aim to enable future collaborations among a variety of stakeholders to improve the delivery of high-quality cancer care.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline.

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

Carpal tunnel syndrome in breast cancer survivors with upper extremity lymphedema.

INTRODUCTION: Lymphedema has long been considered a risk factor for median nerve compression at the wrist and carpal tunnel syndrome (CTS). This association is based on limited and poor quality data. We analyzed the association between lymphedema and CTS. METHODS: Breast cancer survivors with upper extremity lymphedema and electrophysiologically confirmed CTS were assessed retrospectively. The severity of lymphedema was graded using the National Institutes of Health Common Terminology Criteria for Adverse Events (CTCAE) v4.03. The severity of CTS was graded in accordance with accepted criteria. RESULTS: Nineteen patients (38 sides) met the criteria for analysis. There was no association between presence of lymphedema and CTS (P = 0.66) or between lymphedema severity and CTS severity (P = 0.79). There were no cases of infection or worsening lymphedema as a result of needle EMG. CONCLUSIONS: These findings do not support lymphedema as an etiologic factor in the pathogenesis of CTS.