Central Nervous System Cancer Rehabilitation

Adrian Cristian

• Publisher: Elsevier
• Year: 2018
• ISBN:
  9780323548304
• Topic: Medicine
• Subtopic: Occupational Therapy

Offering a well-rounded overview of CNS cancers and best practices for rehabilitation of the cancer patient, Spinal and Brain Cancer Rehabilitation provides succinct, easy-to-digest coverage for practicing and trainee physiatrists, as well as physical and occupational therapists. This concise resource by Dr. Adrian Cristian begins with an introduction to CNS cancers and progresses to rehabilitation practice, associated symptom management, and palliative care.

• Covers commonly used medical, surgical, and radiation treatments; the continuum of rehabilitative care; safety considerations; cancer fatigue; depression and anxiety; cognitive impairment; and much more.
• Discusses pediatric cancer rehabilitation, cancer pain management, palliative care, and associated symptoms and conditions.
• Consolidates today's available information on this timely topic into one convenient resource.

Chapter 1

Cancer Rehabilitation Continuum of Care and Delivery Models

Jack Fu, MD, and Adrian Cristian, MD, MHCM

Abstract

Persons with cancer of the brain and spinal cord receive rehabilitative care in a variety of settings. These often include hospitals, postacute care facilities such as acute inpatient rehabilitation facilities, long-term healthcare facilities, hospice, outpatient rehabilitation facilities, and the person's home. A truly integrated continuum of cancer care delivers both cancer and rehabilitative services using a treatment plan that provides the right care, at the right place, at the right time by personnel who are well versed in the principles of oncologic rehabilitation. This chapter explores the advantages and challenges to providing rehabilitative care in each of these settings.

Keywords

Cancer rehabilitation; Delivery care models

Introduction

Cancer rehabilitation has been defined as “medical care that should be integrated throughout the oncology care continuum and delivered by trained rehabilitation professionals who have it within their scope of practice to diagnose and treat patients' physical, psychologic, 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.”¹

Persons with cancer often receive their oncologic care in a variety of settings such as acute care hospitals, long-term healthcare facilities, outpatient clinics, and the person's home. This parallels the types of locations where they also receive their rehabilitative care. It is therefore important to have fully integrated oncologic and rehabilitative care across this continuum of care. The fundamental goal of rehabilitation of the person with brain or spinal cord cancer is to maximize function and to improve the quality of life regardless of the setting where they receive their healthcare.

To accomplish this goal, the person should first be evaluated for functional deficits by a rehabilitation specialist. This is meant to establish a baseline functional level and serves as the foundation for an individualized rehabilitation plan of care. The person should subsequently be screened periodically and treated for cancer-related impairments throughout their life across the rehabilitation continuum. The rehabilitative treatments need to be provided by an experienced clinical staff, in the most appropriate setting, and at the most appropriate time in the person's cancer care. The management of functionally relevant impairments should be holistic and person-centered, addressing physical impairments, nutrition, emotional well-being, sexuality, spirituality, and the role of the individual in their family and society.²

The aim of this chapter is to describe the components of the rehabilitative continuum of care and the advantages and challenges faced by each of these components in the provision of rehabilitative services to the person with cancer.

Barriers to the Provision of Rehabilitation Services to Persons With Brain and Spinal Cord Cancer

This current delivery model of rehabilitative care is hindered by several barriers as follows: (1) patients, their families, and medical providers may have a limited knowledge about the benefits of rehabilitation; (2) the families and significant others of persons with cancer are often overwhelmed by the complexity, cost, and limited resources and cannot fit rehabilitation into an already busy schedule; (3) a limited workforce of rehabilitation providers that has the necessary working knowledge and expertise to provide cancer rehabilitation services to persons with brain or spinal cord cancer; (4) a fragmented carryover of a rehabilitation treatment plan across the continuum of care; (5) lack of a coordinated plan of care that incorporates both cancer treatment and rehabilitation; (6) lack of use of standardized rehabilitation clinical protocols and outcome measures across the rehabilitation continuum; (7) lack of standardization of cancer rehabilitation programs across the United States; and (8) limited coverage for rehabilitation services by health insurance companies.^2,3

The Continuum of Care for Oncologic Rehabilitation

Dietz classified cancer rehabilitation using four distinct roles: preventive, restorative, supportive, and palliative.⁴ These fundamental roles can be applied and used to guide rehabilitative treatment from time of diagnosis, through acute cancer treatment and survivorship, and in the advanced stages of cancer. Preventive rehabilitation begins at the time of diagnosis when preexisting impairments are identified and treated. It is also an opportunity to optimize the individual's level of physical and mental fitness using exercise, nutrition, and psychosocial interventions. Restorative rehabilitation focuses on maximizing the person's level of function by addressing their impairments. For example, a person with cancer affecting the spinal cord and paralysis of the extremities would benefit from acute inpatient rehabilitation to address the corresponding deficits. Supportive rehabilitation focuses on improving self-care and mobility and maximizing function in persons with progressing cancer. Palliative rehabilitation aims to improve the level of function of the person with cancer in the advanced stages of the disease by managing symptoms such as pain and fatigue and addressing physical impairments that can limit function. It can also be used to minimize the risk of developing potentially preventable conditions such as pressure ulcers and contractures.

Acute Hospitalization

During the acute hospitalization period, the person with cancer often moves from one setting to another depending on their underlying condition and medical stability. It is not uncommon to have the person be admitted through the emergency room and spend time on a medical and/or surgical floor and/or in an intensive care unit in one hospitalization. As a result they can become deconditioned very quickly due to prolonged bed rest and use of steroid medications.

The goals of rehabilitation in this setting include the following: (1) minimize the deleterious effects of prolonged immobilization; (2) maximize patient safety (i.e., minimize risk of falls, development of aspiration pneumonia, pressure ulcers, contractures, and medication side effects); (3) maximize level of function for activities of daily living; (4) mobilize the patient if they are able to ambulate; (5) maximize nutritional intake; (6) educate the person and their significant others about cancer-related physical impairments; (7) address psychosocial stressors; and (8) assist the primary treatment team with discharge recommendations to the most appropriate setting.

The physiatrist has a significant role in the coordination of rehabilitative services during an acute hospitalization. Through close communication with members of the rehabilitation team and referring physicians, the physiatrist can address the physical impairments of the person with cancer of the brain and spinal cord. In addition, he/she can make recommendations for discharge to the most appropriate setting for the patient. Rehabilitative services are typically provided at the bed side or in an inpatient gym in the institution. Under-referral of cancer patients to rehabilitation has been a chronic problem for the cancer rehabilitation specialty^5–7 and has also been noted in the inpatient setting specifically.^8,9 A recent Italian study by Pace et al. evaluated the rehabilitation referrals of brain tumors patients. Only 12.8% received inpatient rehabilitation, 3.1% received intensive outpatient rehabilitation, and 11.8% received traditional outpatient rehabilitation.¹⁰ Like traditional brain injury populations, neurologic deficits can include hemiplegia, spasticity, aphasia, dysphagia, ataxia, cognitive deficits, bowel/bladder dysfunction, visual symptoms including diplopia and dysarthria. Given that 75% of brain tumor patients have 3 or more neurologic deficits and 39% have more than 5 neurologic deficits, these low referral rates to rehabilitation for this patient group appear grossly inadequate.¹¹ Some referring oncology services have been shown to lack understanding of what rehabilitation does and fail to identify impairments that rehabilitation can help treat.^12–14

A consult-based inpatient cancer rehabilitation program has been used at the Mayo Clinic–Rochester called the Cancer Adaptation Team (CAT) and MD Anderson Cancer Center called the Mobile Team. The CAT consists of a nurse, physiatrist, physical therapists, occupational therapist, social worker, nutritionist, and chaplain who meet daily to coordinate rehabilitation care.¹⁵ The MD Anderson Mobile Team enabled patients to receive up to 1 h of physical and 1 h of occupational therapy daily while still on the acute care service and met weekly. The idea was to provide a mobile acute inpatient rehabilitation type program for cancer patients. These rehabilitation models allow more intensive coordinated team-based rehabilitation led by a physiatrist while the patient is still on the acute care oncology service. The services have been particularly useful for medical fragile hematologic cancer patients but could also be used in a neurologic tumor population. Barriers to this model of consult-based rehabilitation include the Prospective Payment System and therapy resource availability.¹⁶

The challenges of providing rehabilitative services in this setting include the following: (1) rapid changes in the person's medical condition; (2) lack of knowledge about the role of physiatry and rehabilitation among oncologists and other healthcare providers involved in the person's care; (3) delay in the identification and initiation of rehabilitative services; and (4) gaps in communication between the oncology and rehabilitation teams.

Postacute Care

Postacute rehabilitative care is most commonly provided in acute inpatient rehabilitation facilities (IRFs) as well as subacute and skilled nursing facilities. Common challenges to the provision of rehabilitative services in these settings include the following: (1) the rehabilitation plan not fully integrated into the oncology treatment plan; (2) significant variability in the type of rehabilitative services available in each of these ...