Frequency, Characteristics, and Risk Factors for Falls at an Inpatient Cancer Rehabilitation Unit.

PURPOSE: Falls in the hospital can lead to adverse events, including injuries. Studies have shown that patients with cancer and those undergoing inpatient rehabilitation (IPR) are at higher risk for falls. Therefore, we measured the frequency, degree of harm, and characteristics of patients who fell in an inpatient cancer rehabilitation unit. METHODS: A retrospective review was conducted on inpatient cancer rehabilitation patients admitted from January 2012 to February 2016. Fall frequency, degree of harm, fall circumstances, cancer type, patient's fall risk score on the basis of the MD Anderson Cancer Center Adult Inpatient Fall Risk Assessment Tool (MAIFRAT), length of stay, and risk factors were evaluated for patients. RESULTS: There were 72 out of 1,571 unique individual falls (4.6%), with a falls incidence of 3.76 falls per 1,000 patient-days. Most fallers (86%) suffered no harm. Risk factors for falls included presence of patient-controlled analgesia pump (P = .03), pump such as insulin or wound vacuum-assisted closure (P < .01), nasogastric, gastric, or chest tube (P = .05), and higher MAIFRAT score (P < .01). The fallers were younger (62 v 66; P = .04), had a longer IPR stay (13 v 9; P = .03), and had a lower Charlson comorbidity index (6 v 8; P < .01). CONCLUSION: The frequency and degree of harm for falls in the IPR unit were less than previous studies, which suggests that mobilization for these patients with cancer is safe. The presence of certain medical devices may contribute to fall risk, and more research is needed to better prevent falls in this higher-risk subgroup.

Frequency of Sarcopenia, Sarcopenic Obesity, and Changes in Physical Function in Surgical Oncology Patients Referred for Prehabilitation.

PURPOSE: Sarcopenia and suboptimal performance status are associated with postoperative complications and morbidity in cancer patients. Prehabilitation has emerged as an approach to improve fitness and muscle strength in patients preoperatively. We sought to describe the frequency of sarcopenia and sarcopenic obesity (SO) in a cohort of cancer patients referred for prehabilitation and the association between body composition and physical function. METHODS: In this retrospective review of 99 consecutive cancer patients referred for prehabilitation prior to intended oncologic surgery, prehabilitation included physical medicine and rehabilitation (PM&R) physician evaluation of function and physical therapy for individualized home-based exercise. Sarcopenic A was defined using sex-adjusted norms of skeletal muscle (SKM), measured using the sliceOmatic software (TomoVision, 2012) on computed tomography images at baseline. Sarcopenic B was defined by abnormal SKM and physical function. SO was defined as sarcopenia with BMI ≥ 25. Six-minute walk test (6MWT), 5 times sit-to-stand (5×STS), and grip strength were obtained at consultation (baseline) and at preoperative follow-up (if available). RESULTS: Forty-nine patients (49%) were Sarcopenic A, 28 (28%) SO, and 38 (38%) Sarcopenic B. Age was negatively correlated with SKM (P = .0436). There were no significant associations between Sarcopenic A/B or SO with baseline or changes in physical function. Assessed by sex, Sarcopenic A females had low 5×STS (P = .04) and Sarcopenic B females had low GS (P = .037). Sarcopenic B males had low preoperative GS (P = .026). 6MWT and grip strength at baseline were lower than age- and sex-related norms (both P < .001). Preoperatively, 6MWT distance and 5×STS time improved (both P < .001). Functional improvement in the sarcopenic and nonsarcopenic patients did not differ according to sex. CONCLUSIONS: In this cohort of prehabilitation surgical oncology patients, frequencies of sarcopenia and SO were high, and baseline physical function was abnormal but improved significantly regardless of body composition. These findings suggest that patients have considerable prehabilitation needs and are capable of improving with comprehensive care.

Postacute Care in Cancer Rehabilitation.

Acute care is usually associated with disease progression, treatments for cancer, and medical comorbidities. Patients with cancer may develop sudden functional deficits that require rehabilitation. Some of these patients benefit from acute rehabilitation, others benefit from subacute rehabilitation. After acute rehabilitation, continuous care for these patients has not been well described. Three studies are presented to demonstrate that cancer rehabilitation is a continuous process. Rehabilitation professionals should know how to detect fall risk, monitor symptoms, and render symptom management. Patients with cancer often require rehabilitation services during their entire disease trajectory.

An Analysis of Inpatient Rehabilitation Approval Among Private Insurance Carriers at a Cancer Center.

BACKGROUND: Acute inpatient rehabilitation is often used by cancer patients to assist with discharge home and/or preparation for further treatment. Private insurance patients often require approval before transfer to acute inpatient rehabilitation. OBJECTIVE: To analyze the approval rate of private insurance carriers for acute inpatient cancer rehabilitation. DESIGN: Retrospective analysis. SETTING: Tertiary referral-based cancer center. PATIENTS: A total of 96 consecutive patients with private insurance who had acute inpatient rehabilitation authorization requests made between April 1, 2014, and September 17, 2014. INTERVENTION: Patient cases were assessed by a physiatrist, deemed clinically appropriate for acute inpatient rehabilitation, and submitted to private insurance payers for an approval request. RESULTS: In all, 84 of 96 requests (87%) for private insurance authorization for inpatient rehabilitation transfer were approved. Of the 96 cases, 14 cases (14.6%) were initially denied. Nine of 96 (9.4%) progressed to a peer-to-peer appeal, of which only 2 of 9 (11.1%) resulted in approval for inpatient rehabilitation transfer (P = .222). The insurance carriers represented were designated as insurance A (46 patients, 48%), insurance B (18 patients, 19%), insurance C (12 patients, 13%), and other insurances (20, 21%). Two of 46 insurance A requests were initially denied, as compared to 7 of 18 for insurance B, 0 of 12 for insurance C, and 4 of 20 for other insurances (P = .001). Patients with insurance B (P = .002, odds ratio = 14) and other insurances (P = .062, odds ratio = 5.50) were more likely to be denied inpatient rehabilitation approval compared to patients with insurance A. No significant difference between mean Functional Independence Measure scores for approved and denied patients were found for transfers (P = .239) and mobility (P = .129), respectively. CONCLUSION: Access to acute inpatient rehabilitation is unfortunately limited by insurers rather than clinical indicators. Future multicenter studies and universally accepted guidelines regarding inpatient rehabilitation criteria are needed.

Inpatient cancer rehabilitation: the experience of a national comprehensive cancer center.

OBJECTIVE: Cancer rehabilitation is an important but often underutilized treatment in the comprehensive care of the cancer patient. Cancer patients have varying levels of access to rehabilitation services. Acute inpatient, inpatient consultation-based, and outpatient-based cancer rehabilitation services have been described in the literature. We will discuss acute inpatient cancer rehabilitation and some of its outcomes at the University of Texas MD Anderson Cancer Center in Houston, TX, which is the only national comprehensive cancer center to have its own acute inpatient rehabilitation unit dedicated solely to cancer patients. DESIGN: We retrospectively reviewed the inpatient medical records of consecutive inpatients admitted to the acute inpatient cancer rehabilitation unit from September 2008 to August 2009 for the following information: patient age, sex, primary tumor type, rehabilitation diagnoses, length of stay, discharge destination, and payer source. RESULTS: From September 2008 to August 2009, the physical medicine and rehabilitation service at MD Anderson Cancer Center had 1098 inpatient consultations, of which 427 patients were admitted to the inpatient rehabilitation unit with a mean length of stay of 11 days. Of the 427 patients, 73 (17%) were patients with primary neurologic-based tumor, 71 (16%) were patients with hematologic-based tumors, 48 (11%) were sarcoma patients, 35 (8%) were gastrointestinal tumor patients, 27 (6%) were head and neck tumor patients, 25 (6%) were prostate and bladder cancer patients, 24 (6%) were lung cancer patients, 22 (5%) were melanoma patients, 20 (5%) were breast cancer patients, 15 (4%) were renal cancer patients, 14 (3%) were gynecologic cancer patients, and 53 (12%) were patients with other types of cancer. Of the 427 patients admitted to acute inpatient rehabilitation at MD Anderson Cancer Center, 324 (76%) were discharged home, 72 (17%) went back to acute care service, 15 (4%) were sent to a skilled nursing facility, 9 (2%) were discharged to palliative care, and 5 (1%) were discharged to a long-term acute care facility. CONCLUSIONS: An active inpatient rehabilitation unit within a national comprehensive cancer center receives referrals from patients with a wide variety of tumor types and is able to successfully discharge home 76% of its patients.

Inpatient rehabilitation improved functional status in asthenic patients with solid and hematologic malignancies.

OBJECTIVE: The aim of this study was to compare functional outcomes in asthenic patients with hematologic malignancies with those of asthenic patients with solid tumors after inpatient rehabilitation. We hypothesized that asthenic patients with hematologic malignancies are less likely than patients with solid tumors to make functional improvement after rehabilitation. DESIGN: The records of 60 asthenic cancer patients (30 consecutive patients with solid tumors and 30 consecutive patients with hematologic malignancies) who underwent inpatient rehabilitation at a comprehensive cancer center between October 2005 and October 2007 were retrospectively reviewed. Patients with focal neurologic deficits were excluded. All patients admitted to the inpatient rehabilitation unit received 3 hrs of more of therapy per weekday. The main outcomes included total, motor, and cognitive Functional Independence Measure (FIM) scores, hospital and rehabilitation length of stay, and FIM efficiency. RESULTS: The mean total FIM score significantly improved in patients with solid tumors (mean, 15; range, -6 to 38) and in patients with hematologic malignancies (mean, 17; range, -3 to 27); however, between-group differences in FIM scores were not significant (P = 0.31). The solid tumor patients were significantly older than the hematologic malignancy patients (71 ± 11 vs. 64 ± 12 yrs; P = 0.02), but the mean rehabilitation lengths of stay were the same for each group (9.5 days; P = 0.82). The mean FIM efficiency in the hematologic malignancy group was higher than that of the solid tumor group (1.9 vs.1.4; P = 0.049). CONCLUSIONS: Asthenic patients with solid tumors or hematologic malignancies could benefit from inpatient rehabilitation and make significant functional gain.

Comparison of functional outcomes in low- and high-grade astrocytoma rehabilitation inpatients.

OBJECTIVES: To compare inpatient rehabilitation outcomes between patients with low- and high-grade astrocytoma. DESIGN: A retrospective review of medical records for patients admitted from September 1, 1996, to June 30, 2008, to the inpatient rehabilitation unit at a tertiary care cancer center. A high-grade (21 of 443 patients) and low-grade astrocytoma (21 of 24 patients) group were matched on three of five criteria in the order of importance: area of brain involvement (divided into left cerebral, right cerebral, midline and/or bilateral cerebral, and infratentorial), single vs. multiple intracranial neurosurgical procedures, age (within 10 yrs), period of rehabilitation admission (within 3 yrs), and sex. Descriptive statistics were used to compare demographic data and scores in four categories (total, activities of daily living, mobility, and cognition) from the patients' functional independence measure assessment. RESULTS: No significant (P > 0.05) differences were found in demographics or efficiency between the two groups. The high-grade group had significantly (P < 0.05) higher total gain and longer stay in inpatient rehabilitation (mean +/- standard deviation, 21.7 +/- 10.1 vs. 13.0 +/- 9.3 and 13 +/- 7.1 day vs. 9 +/- 6.2 days, respectively) than did the low-grade astrocytoma group. CONCLUSIONS: Compared with patients with low-grade astrocytoma, patients with high-grade astrocytoma had higher total functional independence measure gain but also longer lengths of stay. Functional independence measure efficiencies were comparable between the two groups. Our results parallel those of previous rehabilitation outcome studies comparing patients with brain tumors with patients with brain injuries of other etiologies. Larger matched studies are needed for this patient population.

Low back pain in adult female caregivers of children with physical disabilities.

BACKGROUND: Low back pain (LBP) in occupational settings has been studied extensively. There are fewer studies on LBP in domestic settings, especially in an informal caregiving setting. OBJECTIVES: To compare the prevalence of LBP in adult female primary caregivers of children with physical disabilities who need assistance with transfers (eg, moving from a bed to a wheelchair) with the prevalence of LBP in adult female primary caregivers of children with nondisabling medical illnesses and to evaluate the factors associated with LBP. DESIGN: A 15-minute, self-administered, cross-sectional survey. SETTING: University-based clinics. Subjects Ninety consecutive adult female caregivers of children presenting to a pediatric physical medicine and rehabilitation clinic and 23 consecutive adult female caregivers of children presenting to a pediatric endocrine clinic were studied. General exclusionary criteria included the following: male sex, a history of back surgery or fracture, the caregiver was younger than 18 years old at the time of the completion of the questionnaire, or the caregiver was caring for any child younger than 2 years old. Caregivers visiting the pediatric endocrine clinic were excluded if they were caring for 1 or more children needing assistance with transfers. MAIN OUTCOME MEASURES: The dependent variable was the presence of LBP. The independent variables were mood, work status, amount of lifting at work, physical functioning of the child, demographic variables of the caregiver, and demographic variables of the child. RESULTS: The prevalence of having LBP (71.1%) in the physical medicine and rehabilitation group is higher than the prevalence (43.5%) in the endocrine clinic group (odds ratio, 3.2; 95% confidence interval, 1.25-8.21). The prevalence of having LBP (80.3%) when the child required physical assistance with transfers was significantly higher than the prevalence (40.5%) when the child did not require physical assistance with transfers (odds ratio, 2.56; 95% confidence interval, 2.56-14.0). Forward multiple logistic regression showed that the factors related to LBP in the caregiver were the transferability of the child, mood of the caregiver, and a history of LBP in the caregiver. CONCLUSIONS: The prevalence of LBP is higher in caregivers of children needing assistance with transfers. This increased prevalence is associated with the transferability of the child and mood of the caregiver. Results of this study suggest that physical and psychological factors both contribute to the presence of nonoccupational LBP.

Physical functioning in female caregivers of children with physical disabilities compared with female caregivers of children with a chronic medical condition.

OBJECTIVES: To evaluate if physical functioning is different in female caregivers of children with physical disabilities compared with female caregivers of children with nondisabling medical illnesses, and to investigate the factors associated with functioning level. DESIGN: Cross-sectional survey. SETTING: University-based clinics. PATIENTS: Ninety consecutive female caregivers of children presenting to a pediatric physical medicine and rehabilitation (PM&R) clinic, and 23 presenting to a pediatric endocrine clinic. INTERVENTION: Fifteen-minute self-administered survey. MAIN OUTCOME MEASURES: The dependent variable measured was physical functioning (physical functioning subscale of the Short Form-36). Independent variables measured were the average back pain severity over the last week (100-mm visual analog scale), mood (using the Center for Epidemiologic Studies-Depression Scale), work status, amount of lifting at work, caregiver demographics, child demographics, and the physical functioning ability of the child (measured using the WeeFIM scale). RESULTS: The mean (SD) physical functioning score of caregivers of children in the pediatric PM&R clinic was 80.6 (21.9), which was less than the score of 90.2 (17.6) for caregivers in the pediatric endocrine clinic (mean difference, 9.6; 95% confidence interval, -0.9 to -18.4). The physical functioning score of 77.7 (22.9) in caregivers of PM&R clinic children with a WeeFIM scale score of 1 to 4 was significantly worse than the 90.5 (14.8) in female caregivers of children with a WeeFIM score of 5 to 7 (mean difference, 12.8; 95% confidence interval, -2.0 to -23.6). This decrease is associated with the average pain severity, mood, and total length of time of back pain in the previous 12 months. Regression analysis shows that pain severity and caregiver mood are significantly related to the physical functioning status of the caregiver. CONCLUSIONS: Physical functioning is decreased in female caregivers of children with a physical disability. This decrease is associated with caregiver pain severity and mood.