Proposing a Cancer Rehabilitation Medicine Curriculum for Physical Medicine and Rehabilitation Trainees.

ABSTRACT: With the rapid growth and rising interest in the subspecialty of cancer rehabilitation medicine, establishing a structured training and educational curriculum in cancer rehabilitation medicine has become more crucial than ever. For those who are responsible for the educational experiences of students, residents, fellows, or other healthcare professionals, this article provides a systematic approach for establishing a curriculum template relevant for cancer rehabilitation medicine training. This included the assessment of general and targeted needs for learners and educators, rotation goals and objectives, educational strategies, implementation, and evaluation and feedback.

The Cancer Rehabilitation Medicine Metrics Consortium: A Path to Enhanced, Multi-Site Outcome Assessment to Enhance Care and Demonstrate Value.

PURPOSE: A primary objective stated at the Cancer Rehabilitation Symposium at the National Institutes of Health was to improve outcome measurement. The purpose of this project was for the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) to develop an assessment tool to evaluate function in cancer patients via a data-driven and methodologically sound process. There is no agreed-upon measure of physical and cognitive function for cancer patients, making it difficult to demonstrate the value of rehabilitation interventions. Cancer patients are a particularly challenging population, with many tumor- and treatment-related variables impacting function. METHODS: Investigators from nine different cancer rehabilitation programs participated in a modified-Delphi process to delineate necessary aspects of an ideal patient assessment tool, including instrument type, domains evaluated, applicability across a range of patient traits, clinical feasibility, and item response characteristics. This involved numerous meetings, data review, and analysis of items involved in patient assessment. RESULTS: The CRMMC developed a 21-item patient-reported outcome measure based on item response theory. The process by which the short form was developed was documented and provides a framework for other clinicians to follow. CONCLUSION: This document provides a framework for rehabilitation providers to follow when developing an assessment tool. This process is described in a stepwise fashion for reproducibility even in different, non-cancer populations.

A Survey Regarding the Knowledge, Attitudes, and Beliefs of Graduates of Cancer Rehabilitation Fellowship Program.

Currently there are limited options for physiatrists to further subspecialize in cancer rehabilitation. Since 2007, few cancer rehabilitation fellowship programs have been started. There is currently absolutely no information about such training programs and their graduates. This study is the first to survey a small number of graduates from two cancer rehabilitation fellowship programs. The purpose of this study was to report characteristics, attitudes, and beliefs of cancer rehabilitation fellowship graduates. Graduates of cancer rehabilitation fellowship programs from 2008 through 2015 responded to a 26-question survey. Information collected included exposure to cancer rehabilitation prior to fellowship training, usefulness of fellowship training program, information about current practice, and suggested areas of improvement. The setting of the study is online survey. Participants were graduates of two cancer rehabilitation fellowship programs from 2008 through 2015. Participants were contacted via email about completion of an online survey and information was collected anonymously. Primary outcome measure was satisfaction of respondents with their fellowship training program in meeting the rehabilitation needs of their cancer patients. Sixteen responses, with a response rate of 89%, were recorded. Sixty-three percent of the respondents had exposure to cancer rehabilitation prior to post-graduate year 3 (PGY-3). Majority of graduates had practice involving at least 50% of care to cancer patients. Fifty percent indicated that their position was specifically created after their job interview. Career development was one of the major areas of suggested improvement in training. Graduates of cancer rehabilitation fellowship programs strongly value their training. Majority of the graduates were able to continue their career into jobs that were primarily cancer rehabilitation related. Further work needs to be done to define this subspecialty further and incorporate building practice as part of this training.

Characteristics of Cancer Rehabilitation Fellowship Training Programs in the USA.

Cancer rehabilitation is emerging as a specialized field within Physical Medicine and Rehabilitation. The purpose of this systemic review is to summarize the various cancer rehabilitation fellowship programs in the USA and the scope of training in this discipline. Currently, four institutions offer such a training program. All of the fellowship directors were contacted about characteristics of their programs. The oldest program has been in existence since 2007. All of these programs are 1 year in duration and have between one and two fellowship positions annually. There have been total of 29 graduates as of July 2017. With regard to cancer rehabilitation care delivery model, all four centers reported inpatient consult teams and outpatient rehabilitation. Outpatient experience included electrodiagnosis, botulin toxin, and ultrasound-guided injections. Three of the four programs also reported the presence of an acute inpatient cancer rehabilitation service. A number of clinical rotations are available at each of the four programs with considerable variation. Comprehensive educational efforts are present in all programs with varying expectations for research.

Electrodiagnosis in Cancer Rehabilitation.

With numerous advancements in early detection and multimodal therapy, cancer has become a chronic disease. As the number of cancer survivors continues to increase, physiatrists and other neuromuscular disease specialists are more likely to encounter individuals with residual impairments, disabilities, and/or handicaps resulting from cancer or related treatments. The patient with cancer is especially prone to injury directed at the peripheral nervous system at multiple anatomic levels. Electrodiagnosis is an invaluable tool in the evaluation of neuromuscular disorders in this patient population.

Electrophysiological features of taxane-induced polyneuropathy in patients with breast cancer.

Fifty-five patients with breast cancer were analyzed for electrophysiological characteristics of taxane-induced polyneuropathy. Based on the electrodiagnostic criteria, sensory motor polyneuropathy was found in 67% (37/55) of patients ranging between mild degree and moderate to severe degree. The polyneuropathy is predominantly axonal with three unique features: (1) frequent asymmetry, (2) high sural and radial sensory amplitude ratio in patients with mild polyneuropathy, and (3) slow conduction velocity seen only at the common entrapment sites, such as the carpal tunnel. The severity of polyneuropathy correlated positively with the cumulative dose received. Our study supports the clinical utility of electrodiagnostic study in both diagnosis and monitoring of taxane-induced polyneuropathy.

Electrodiagnosis in cancer treatment and rehabilitation.

As cancer patients are living longer and the number of cancer survivors increases, more secondary complications related to cancer and its treatments are being recognized. A large number of neuromuscular processes, stemming from cancer itself, from secondary metabolic effects, from paraneoplastic syndromes, from preexisting conditions, or from adverse effects related to cancer treatments, can affect the peripheral nervous system at any level. Electrodiagnostic tools such as nerve conduction studies and needle electromyography are uniquely suited to assess the function of the peripheral nervous system and are valuable tools in confirming and defining neuromuscular dysfunction and in helping guide oncologic and physiatric treatment and prognosis for the cancer rehabilitation patient.

NCCN task force report: management of neuropathy in cancer.

Neuropathy is a common, often debilitating complication of cancer and its treatment. Effective management of this disorder depends on early diagnosis and an understanding of its underlying causes in the individual patient. In January 2009, NCCN gathered a multidisciplinary group to review the literature and discuss intervention strategies currently available to patients as well as areas that require research efforts. The task force, which comprised experts in anesthesiology, medical oncology, neurology, neuro-oncology, neurophysiology, nursing, pain management, and rehabilitation, was charged with the goal of outlining recommendations for the possible prevention, diagnosis, and management of neuropathy. This report documents the proceedings of this meeting with a general background on neuropathy and neuropathy in oncology, followed by discussions on challenges and research issues, evaluation criteria, and management of different symptoms associated with this disorder.

The role of botulinum toxin type A in the radiation fibrosis syndrome: a preliminary report.

OBJECTIVE: To describe the use of botulinum toxin type A (BTX-A) in radiation fibrosis syndrome (RFS). DESIGN: Retrospective case series. SETTING: A large tertiary care cancer center. PARTICIPANTS: Twenty-three consecutive patients treated for sequelae of RFS with BTX-A. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A description of the components of RFS thought to benefit from BTX-A injections and the patient's self-report of benefit from those injections. RESULTS: The sequelae of RFS for which BTX-A injection was thought to be indicated include radiation-induced cervical dystonia in 18 (78%), trigeminal nerve or cervical plexus neuralgia in 10 (43%), trismus in 7 (30%), migraine in 3 (13%), and thoracic pain in 1 (4%) patient. Most (87%) patients self-reported benefit from the injections. CONCLUSIONS: Initial clinical experience with the use of BTX-A as adjunctive treatment for select neuromuscular and musculoskeletal complications of RFS in a variety of cancer patients has been encouraging. Well-designed prospective studies are needed to clarify the potential beneficial role of BTX-A in specific sequelae of RFS.

Neuromuscular complications of cancer and cancer treatments.

Death rates related to cancer have steadily decreased over the past few decades, and as a result, the number of survivors has exponentially increased. Increasingly, more and more secondary complications caused by cancer and its treatments are being recognized. Neuromuscular complications related to the underlying cancer itself, or caused by associated treatments, such as chemotherapy and radiation therapy, are common but are likely underreported. While neurologic involvement can occur in both the central and peripheral nervous systems at any level, this article focuses on the effects of cancer on the peripheral nervous system.

Barriers to rehabilitation of patients with extremity sarcomas.

The treatment of most extremity bone or soft tissue sarcomas involves either limb salvage surgery with adjuvant chemoradiation therapy or amputation. The rehabilitation of patients with extremity sarcomas is challenging, and the approach differs depending on the choice of surgical procedure as well as potential-associated medical complications. Early, interdisciplinary rehabilitation involvement is helpful in lessening the impact of expected impairments and disability. There is a lack of evidence examining specific rehabilitation interventions in this patient population. Functional outcomes and quality of life studies suggest overall similar findings between limb salvage patients and amputees, but with differences in various subscales. Rehabilitation interventions are therefore individualized; based on the assessment of medical limitations, functional goals and expectations, and modification of environmental factors. Overcoming medical and oncologic barriers to rehabilitation; as well as psychological, structural, cultural, political, and economic barriers; can serve to lessen the degree of disability.

Cardiopulmonary rehabilitation and cancer rehabilitation. 3. Cancer rehabilitation.

UNLABELLED: This self-directed learning module highlights the treatment and rehabilitation of patients with cancer. It is part of the study guide on cardiac, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article reviews medical and rehabilitation issues in patients with various types of cancer. Cases were selected to allow discussion of problems seen in both younger and older patient populations. Identification of common sequelae of cancer and cancer treatments, associated rehabilitation challenges, and appropriate interventions are included. OVERALL ARTICLE OBJECTIVE: To summarize the medical and rehabilitation issues in patients with various types of cancer.

Upper-extremity pain disorders in breast cancer.

UNLABELLED: Upper-extremity pain is a common and debilitating problem for patients with breast cancer. Although there is considerable literature describing symptoms, little is available on the specific disorders responsible for pain and debility in these patients. Cervical radiculopathy, brachial plexopathy, neuropathy, rotator cuff tendonitis, adhesive capsulitis, epicondylitis, postmastectomy syndrome, swelling, and bone metastases are among the common disorders responsible for upper-extremity pain in breast cancer patients. OVERALL ARTICLE OBJECTIVE: To discuss common upper-extremity pain disorders in patients with breast cancer.

Small-Fiber Neuropathy Associated with Capecitabine (Xeloda)-induced Hand-foot Syndrome: A Case Report.

Hand-foot syndrome commonly results from treatment with capecitabine and is associated with pain, dysesthesias, paresthesias, and temperature intolerance. The cause of these symptoms in hand-foot syndrome has not been determined. We present the clinical, electrophysiologic, and biopsy data from a patient with capecitabine-induced hand-foot syndrome as supporting evidence implicating small-fiber neuropathy as the cause of these neuropathic symptoms. A patient with stage 4 breast cancer who develops capecitabine-induced hand-foot syndrome is referred for clinical and electrophysiologic testing. Intraepidermal nerve fiber density is assessed. Clinical evaluation demonstrates markedly decreased pain and temperature sensation with preserved strength, proprioception, and light touch. Standard electrodiagnostic testing is normal. The assessment of epidermal nerve fiber density demonstrates marked small-fiber loss both proximally and distally. In conclusion, small-fiber neuropathy is a likely cause of the neuropathic symptoms encountered in capecitabine-induced hand-foot syndrome. Similar clinical, electrophysiologic, and pathologic assessments are needed to confirm this finding in larger populations.

Delayed postanoxic encephalopathy: a case report and literature review.

Delayed postanoxic encephalopathy is a rare condition in which patients appear to make a complete clinical recovery after an episode of anoxia or hypoxia but then develop a relapse characterized by apathy, confusion, agitation, and/or progressive neurologic deficits. The incidence of delayed postanoxic encephalopathy is unclear but has been reported to range from less than 1 to 28 per 1000 in patients who have suffered hypoxic or anoxic events. The exact pathogenesis remains unknown. We describe a case of an independently living 51-year-old woman admitted to an inpatient rehabilitation unit 11 days after a respiratory arrest. At admission, she exhibited cognitive and visual deficits that were relatively mild but prevented a safe return to independent living. Two days later, she developed the sudden onset and rapid worsening of parkinsonian symptoms and excruciating bilateral lower-extremity pain. The pain was intractable, and over the next 2 days she progressed to being unable to walk or perform her activities of daily living without maximum assistance. A diagnosis of delayed postanoxic encephalopathy was made, and the patient responded to a trial of carbidopa and levodopa as well as redirection of her physical and occupational therapy programs. This case illustrates the unusual presentation of delayed postanoxic encephalopathy during inpatient rehabilitation and suggests that this condition should be considered if patients who have suffered an anoxic or hypoxic event show a sudden neurologic deterioration.