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Introduction: The American College of Sports Medicine and American Heart Association recommends resistance training involving 60-70% of 1-repetition maximum (1RM) for 8-12 repetitions on 2 or 3 nonconsecutive days per week for the elderly. The Borg 6-20 scale, Borg category ratio (CR-10) scale, and OMNI scale are used to determine the rating of perceived exertion (RPE) for resistance training. Areas covered: RPE scales for resistance training performed by elderly individuals are described. The RPE has been related to resistance training intensity, and the RPE scale was used to determine the resistance training intensity of elderly or ill individuals. Expert commentary: RPE scales can determine the resistance training intensity of elderly individuals and may be used at home or in nursing homes, if they do not have specific resistance training machines. RPE is simple and useful, and may improve skeletal muscle strength or other health-related issues.

Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) is increasingly used in the treatment of hematologic cancers such as leukemias, lymphomas, and myeloma, and for other hematologic disorders such as primary immunodeficiency, aplastic anemia, and myelodysplasia. Allo-HSCT entails a conditioning regimen of frequent high-dose chemotherapy in combination with total body irradiation, followed by infusion of donor-harvested bone marrow or peripheral blood stem cells. As an aggressive and demanding medical therapy that profoundly impacts patient quality of life (QOL), allo-HSCT is associated with numerous treatment-related physical, psychological, and psychosocial side effects. The procedure can result in decreased respiratory and balance function, skeletal muscle strength, and exercise capacity. Thus, as physical exercise has been shown to positively effect physical and psychosocial function and QOL in allo-HSCT patients, it is a recommended intervention for improving essential functions and offsetting lost exercise capacity after the procedure. Furthermore, recent evidence has shown that physical exercise can influence survival rate and mortality in allo-HSCT patients. This review provides an overview of the current research on the effectiveness of physical exercise for allo-HSCT patients., Competing Interests: Conflicts of Interest The authors of this review declare no conflict of interest.

Objective: This study aimed to investigate the correlation between the face scale and heart rate (HR), exercise load and oxygen uptake (V̇O 2 ) during cardiopulmonary exercise testing. Methods This was a prospective, observational study of face scale rating of perceived exertion (RPE) and HR, exercise load and V̇O 2 during cardiopulmonary exercise testing. A total of 30 healthy college men and 21 healthy college women were included. Subjects performed a cardiopulmonary exercise test with ramps and an increment increase in workload of 20 W/min. We recorded the responses of subjects using a face scale for RPE, HR, exercise load and V̇O 2 every minute during the cardiopulmonary exercise test., Results: In men, there was a significant positive correlation between the face scale RPE and HR (ρ=0.856, p<0.01), exercise load (ρ=0.888, p<0.01) and V̇O 2 (ρ=0.878, p<0.01) during the cardiopulmonary exercise test. Similarly, in women, there was a significant positive correlation between the face scale RPE and HR (ρ=0.885, p<0.01), exercise load (ρ=0.908, p<0.01) and V̇O 2 (ρ=0.895, p<0.01) during the cardiopulmonary exercise tests., Conclusion: The face scale proposed in this study was related to physiological parameters, which suggests that it may be used to determine the intensity of exercise in healthy adults., Competing Interests: Competing interests: None declared.

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.

Older adults who have survived cancer experience significantly more falls compared with healthy adults. Adult cancer survivors may also have a lower balance function than healthy adults. We examined muscle strength and balance function among 19 cancer survivors and 14 healthy subjects. The mean age of the cancer survivors was 51.5 ± 11.2 years; 6 men and 13 women. Cancer diagnoses included breast cancer, retroperitoneal sarcoma, acute leukemia, lung cancer, colorectal cancer, thyroid cancer, Ewing's sarcoma, and tongue cancer. The mean age of healthy subjects was 47.4 ± 14 years; 3 men, 11 women. Muscle strength was assessed using hand grip and knee extensor strength tests. Balance function was evaluated using the Timed Up and Go (TUG) test, and body sway was tested using a force platform. No significant differences were found with respect to right and left grip strength or right and left knee extension strength between the 2 groups. A significantly higher TUG time was observed in cancer survivors than in healthy subjects ( P < .05). With eyes open, the area of the center of pressure was significantly larger in cancer survivors than in healthy subjects ( P < .05). Similarly, the length per area was significantly lower both with eyes open and closed for cancer survivors than for healthy subjects ( P < .05). TUG was significantly correlated with muscle strength in both groups ( P < .05). However, no body sway parameters were related to muscle strength in either group. Cancer survivors had lower balance function that might not have been related to muscle strength. Cancer survivors should be evaluated for balance function as there is a potential for impairment. The findings of this study will be relevant for planning the prevention of falls for cancer survivors.

This study is the first to evaluate the existence and quality of patient-related cancer rehabilitation content on the websites of National Cancer Institute (NCI)-Designated Cancer Centers. In 2016, a team of cancer rehabilitation physicians (physiatrists) conducted an analysis of the patient-related rehabilitation content on the websites of all NCI-Designated Cancer Centers that provide clinical care (N = 62 of 69). The main outcome measures included qualitative rating of the ease of locating descriptions of cancer rehabilitation services on each website, followed by quantitative rating of the quality of the cancer rehabilitation descriptions found. More than 90% of NCI-Designated Cancer Centers providing clinical care did not have an easily identifiable patient-focused description of or link to cancer rehabilitation services on their website. Use of a website's search box and predetermined terms yielded an additional 13 descriptions (21%). Therefore, designers of nearly 70% of the websites evaluated overlooked an opportunity to present a description of cancer rehabilitation services. Moreover, only 8% of the websites included accurate and detailed information that referenced four core rehabilitation services (physiatry and physical, occupational and speech therapy). Further research is needed to confirm the presence of cancer rehabilitation services and evaluate access to these types of services at NCI-Designated Cancer Centers providing clinical care.

Background and Purpose: Lower extremity edema, which can be caused by several factors, is often poorly managed with commonly prescribed compression stockings and diuretics. Diuretics are often erroneously given in all forms of edema and may cause problems because their long-term application may induce chronicity of the edema due to disturbance of the renin-angiotensin relationship. Compression therapy, although effective against venous edema, is widely underused., Case Description: A 64-year-old man with a history of hypertension, coronary artery disease, psoriasis, and multiple myeloma was admitted to the hospital for neutropenic fever, right lower extremity (RLE) cellulitis, bilateral lower extremity (BLE) weakness, RLE pain, and significant BLE edema. The patient was referred to a lymphedema-certified therapist to apply lower extremity multilayered compression bandaging and document serial limb circumference measurements., Outcomes: The patient's weight decreased from 94.5 kg on day 1 of compression bandaging to 86.3 kg on day 7. The circumferences of the affected limbs also decreased., Discussion: This case demonstrates the utility of multilayered compression bandaging, typically used in the management of lymphedema, in the control of peripheral edema that is refractory to diuretic therapy.

Objective: To identify the frequency and characteristics of bleeding complications during acute inpatient rehabilitation of hematologic malignancy patients with severe thrombocytopenia., Design: Retrospective descriptive analysis., Setting: Comprehensive cancer center acute inpatient rehabilitation unit., Participants: Consecutive hematologic malignancy patients with a platelet count of less than or equal to 20,000/microliter (μL) on the day of acute inpatient rehabilitation admission from 1/1/2005 through 8/31/2016., Interventions: Medical records were retrospectively analyzed for demographic, laboratory, and medical data. Patients were rehabilitated using the institutional exercise guidelines for thrombocytopenic patients., Main Outcome Measures: Bleeding events noted in the medical record., Results: Out of 135 acute inpatient rehabilitation admissions, 133 unique patients were analyzed with a total of 851 inpatient rehabilitation days. The mean platelet count was 14,000/μL on the day of admission and 22,000/μL over the course of the rehabilitation admission. There were 252 days of inpatient rehabilitation where patients had less than 10,000/μL platelets. A total of 97 bleeding events were documented in 77/135 (57%) admissions. Of the 97 bleeding events, 72 (74%), 14 (14%), and 11 (11%) were considered to be of low, medium, and high severity, respectively. There were 4/97 (4%) bleeding events that were highly likely attributable to physical activity but only 1/4 was considered high severity. Bleeding rates were .09, .08, .17, and .37 for > 20,000, 15-20,000, 10-15,000, and < 10,000/μL mean platelet counts respectively (p = .003). Forty-four percent of patients were transferred back to the primary acute care service with infection being the most common reason for transfer., Conclusions: This study is the first to examine exercise-related bleeding complications during acute inpatient rehabilitation in severely thrombocytopenic hematologic cancer patients. Bleeding rates increased with lower platelet counts. However, using the exercise guidelines for severely thrombocytopenic patients, the risk of severe exercise-related bleeding events was low.

We investigated the difference in relationship between muscle strength and quality of life (QOL)/fatigue in long-term cancer survivors and healthy subjects. Thirty-six cancer survivors and 29 healthy subjects were assessed for body composition and bone status at the calcaneus using the Osteo Sono Assessment Index. Muscle strength was evaluated via handgrip and knee extensor strength. Health-related QOL was assessed using the Medical Outcome Study 36-item Short-Form Health Survey. Fatigue was measured using the brief fatigue inventory. Cancer survivors exhibited lower QOL scores in the physical functioning, physical role function, bodily pain and general health domains (p < .05). Grip and knee extension muscle strength in cancer survivors was positively correlated with the physical function and bodily pain of QOL (p < .05). The usual fatigue subscale score was only significantly higher in cancer survivors than in healthy subjects (p < .05). However, there were no correlations between muscle strength and fatigue in cancer survivors. Our results showed that muscle strength was an important factor for improving QOL in cancer survivors. We believe that the findings of this study will be relevant in the context of planning rehabilitation for cancer survivors., (© 2018 John Wiley & Sons Ltd.)

Neurologic tumors account for over 50% of American acute inpatient rehabilitation facility cancer admissions. WHO Grade IV astrocytoma (also known as glioblastoma multiforme, high grade glioma or GBM) is the most common primary brain tumor in adults and is invariably fatal. The majority of primary brain tumor patients experience neurologic deficits. However, under-referral from oncology to rehabilitation has been reported. This brief narrative review article covers functional, medical and regulatory considerations when rehabilitating brain tumor inpatients., Competing Interests: Conflict of Interest The authors declare that they have no competing interests.

Studies have reported that the load intensity of Resistance training is related to the rating of perceived exertion scale in healthy subjects. The aim of our column was to evaluate current evidence regarding the relationship between the rating of perceived exertion scale and the load intensity of resistance training., Competing Interests: Conflict of Interest: None Disclosure Statement: I have nothing to disclose

Background and Objectives: Total pelvic exenteration are performed in patients with locally advanced or recurrent pelvic malignances. Many patients have prolong hospital length of stay (LOS), but risk factors are not clearly identified., Methods: From 2002 through 2012, 100 consecutive patients undergoing pelvic exenteration were retrospectively reviewed. A general linear model was used to examine risk factors for prolonged hospital LOS., Results: Among the 100 patients, 51 had gastrointestinal cancer, 14 had genitourinary cancer, 31 had gynecologic cancer, and 4 had sarcoma. Perioperative complications included infection (n = 44), anastomotic leak/fistula (n = 6), wound or flap dehiscence (n = 11), and ileus or bowel obstruction (n = 30). The median (Interquartile range (IQR)) hospital LOS was 15 days (10-21.5 days). On multivariate regression analysis, hospital LOS was significantly prolonged by underweight status, genitourinary cancer or sarcoma diagnosis, ≥2 infections, anastomotic leak/fistula, requiring rehabilitation consult and admission, and ≥2 consultations (P = 0.05)., Conclusion: In patients undergoing pelvic exenteration, prolonged hospital LOS is associated with underweight status, genitourinary cancer or sarcoma diagnosis, more than one infection, anastomotic leak/fistula, requiring rehabilitation consult and admission, and more than one consultation. Further study is needed to assess whether minimizing these risk factors can improve hospital LOS in these patients., (© 2017 Wiley Periodicals, Inc.)

Objective: The aim of the study was to describe the mobility outcomes of neurofibromatosis (NF) patients who received acute inpatient rehabilitation., Design: This is a retrospective study of 62 consecutive neurofibromatosis patients of any age who received physical medicine and rehabilitation consultations at a comprehensive cancer center. Postoperative, inpatient rehabilitation admission and discharge functional independence measures (FIM scores) of transfers and gait and length of hospital stay were obtained from 37 patients who were transferred to inpatient rehabilitation (acute rehabilitation) and 25 who had an alternative disposition (consultation only)., Results: Mean age was 34 yrs. Both groups had similar postoperative FIM transfer and gait scores; however, at approximately postoperative day 10, the consultation only group was discharged with median FIM of 5 (supervision level) as compared with the acute rehabilitation group FIM of 4 (P = 0.000). The acute rehabilitation group had improved mobility FIM scores from postoperative to rehabilitation admission and again from rehabilitation admission to discharge (P < 0.0001). At discharge, the acute rehabilitation group ambulated a significantly longer distance (500 f. vs. 300 ft) (P = 0.04). The median length of hospital stay for the acute rehabilitation and consultation only groups was 20 and 10 days, respectively (P = 0.004)., Conclusions: Acute inpatient rehabilitation leads to improvement in mobility-associated FIM scores for neurofibromatosis patients minimizing caregiver needs at home.

The field of cancer rehabilitation and prehabilitation has grown significantly over the past decade. Advancements in early detection and treatment have resulted in a growing number of cancer survivors in the United States (US), expected to reach 26 million by 2040. 1 Health care professional graduate education is trying to catch up with anticipated clinical demand by increasing the number of cancer rehabilitation fellowship training programs and introducing rehabilitation/prehabilitation concepts earlier in training. Numerous national organizations have issued guidelines for cancer rehabilitation research and posttreatment cancer health care. As treatment modalities evolve, so too must research on side-effects and multisystem management over the continuum of care. Current research strategies address different cancer types with a broad focus on timing of interventions, cost effectiveness, efficacy of rehabilitation, and improving screening and assessment tools. A collaborative, interdisciplinary research model is paramount to deepen impact and broaden reach. Policy supports could advance cancer survivorship and rehabilitative care. Funding to advance evidence-based practices for distress screening, psychosocial support, survivorship care planning, and rehabilitation services remains critical. Current social policies and health care access protections must be expanded to best serve the growing number of cancer survivors in the US. Equitable health care access, health care experience and health care outcomes remain a critical area for research and policy supports. The cost of cancer treatment requires significant reform to ensure access to all. Rehabilitation services are elements of standards of care for many neurological, cardiovascular and orthopedic diagnoses, but currently are not standard for actual or potential dysfunctions among cancer survivors. Both the disease process and the variety of therapeutic modalities increase risks of dysfunction, impairments, poor survival, and diminished quality of life. Rehabilitation focuses on optimizing quality of life and maximizing function throughout the continuum of cancer care. Health care professionals are urged to integrate high quality interdisciplinary care to promote collaboration and dissemination of knowledge which will yield better care for cancer survivors. Prehabilitation has the potential to play key roles in reducing or eliminating many cancer-related impairments and disabilities.

Objective: To determine the frequency of venous thromboembolism, possible predictors, and the association between venous thromboembolism and Functional Independence Measure (FIM) scores and length of stay among cancer patients admitted to the inpatient rehabilitation unit at a cancer centre., Design: Retrospective analysis of patients admitted to acute inpatient rehabilitation from September 2011 to June 2013. Subject/patients: Cancer patients in the acute inpatient rehabilitation unit within a tertiary cancer centre., Methods: International Classification of Diseases (ICD-9) codes identified deep vein thrombosis, pulmonary embolism, and inferior vena cava filter., Results: Venous thromboembolism occurred in 32/611 patients (5.2%): 23/611 (3.8%) during the course of hospitalization before admission to rehabilitation, and 9/611 patients (1.5%) during rehabilitation. Patients with lower extremity oedema at admission (p = 0.0218) had a higher chance of subsequently developing venous thromboembolism. Patients with venous thromboembolism during rehabilitation had a significantly lower FIM transfer score at admission to rehabilitation (p = 0.0247), a longer length of stay in rehabilitation (p = 0.0013) and overall hospitalization (p = 0.0580)., Conclusion: Cancer patients with low FIM transfer scores and lower extremity oedema are at higher risk of venous thromboembolism. Patients with these clinical findings at admission may require measures for more aggressive surveillance for the presence of venous thromboembolism. Patients with venous thromboembolism had an increased length of stay in rehabilitation, but ultimately did not have significant differences in FIM score changes.

Background: Cancer survivors often have unmet needs, and cancer rehabilitation is becoming an integral part of the continuum of care. Understanding the needs and satisfaction of patients undergoing cancer rehabilitation is important for the development of effective programs., Objective: To determine the overall perception of acute inpatient cancer rehabilitation usefulness., Design: Prospective study., Setting: Acute inpatient cancer rehabilitation unit at a National Cancer Institute (NCI) Comprehensive Cancer Center., Participants: Patients admitted to the acute inpatient cancer rehabilitation unit from September 2014 to July 2015 were approached, and 200 patients enrolled with completed surveys., Methods: Patients meeting study criteria were asked to complete a survey about their perception of the rehabilitation received; their attitudes and beliefs on their condition, treatment, functional independence; and their attitudes and beliefs on obtaining health information and psychosocial issues., Main Outcome Measures: Functional Independence Measure (FIM) scores, FIM efficiency, and results from an anonymous survey with a 22-item Likert-type scale at the end of patients' rehabilitation stay were analyzed., Results: Of 327 patients admitted, 239 patients (73%) were approached, and 200 patients (84%) were enrolled with completed surveys. Patients agreed or strongly agreed that rehabilitation helped with improving physical function (n = 193, 97%), regaining physical independence (n = 181, 91%), and preparing to deal with self-care tasks (n = 183, 94%). Patients agreed that rehabilitation improved hope (n = 187, 94%), mood (n = 176, 84%), anxiety (n = 180, 90%), and spirituality (n = 182, 94%). FIM score improvements (from admission to discharge) and FIM efficiency (change in FIM score / length of stay) were significant in all functional domains. Overall, respondents believed that their rehabilitation stay was extremely good (n = 128, 64%) or very good (n = 60, 30%)., Conclusions: Patients perceived their rehabilitation stay as beneficial in multiple respects. Significant improvements in FIM measurements were also found., Level of Evidence: IV., (Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the feasibility and necessity of endoscopic thyroidectomy with central lymph node dissection via the combined breast and trans-oral approaches., Methods: Six patients with papillary thyroid carcinoma who underwent endoscopic total thyroidectomy with central node dissection via combined breast and trans-oral approaches from November 2014 to January 2015 in Zhongshan Hospital, Xiamen University, were analyzed., Results: After completion of endoscopic central lymph node dissection via the traditional breast approach, eight pieces of lymph nodes could still be dissected via the trans-oral approach. Two of these eight pieces were positive for thyroid cancer metastasis., Conclusions: It is advisable to perform endoscopic central lymph node dissection for thyroid carcinoma via the breast approach combined with the trans-oral approach.

Cancer inpatients commonly suffer from impairments that can prohibit safe discharge home from the acute care inpatient medical service and thus require transfer to a postacute inpatient rehabilitation facility. It has been demonstrated in multiple studies that cancer rehabilitation inpatients are able to make statistically significant functional improvements and at a similar pace as their noncancer counterparts. Medical fragility and reimbursement regulations are concerns that affect acceptance and triage of cancer rehabilitation inpatients. Strategies to rehabilitate these challenging patients include considering risk factors for medical complications, consult-based inpatient rehabilitation, and improved communication and coordination with oncology teams., (Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Because of their expertise, physiatrists provide disability insurance assistance for cancer survivors. In this brief report, we perform a descriptive retrospective analysis of all new (354) outpatient physiatry consultations from January 1, 2009, to December 31, 2013, at a National Cancer Institute Comprehensive Cancer Center. Disability and/or work accommodations were brought up at some point with the physiatrist during the duration of their care for 131 (37%) of 354 patients. More than 90% of the discussions took place during the first visit. Of those patients who had a documented disability/employment discussion, 58 (44.3%) of 131 patients were originally referred for disability assistance specifically, and 58 (44.3%) of 131 also had disability insurance paperwork completed by the physiatrist. Outcomes of initial physiatry disability insurance assistance were 45 (77.6%) of 58 approved/renewed, 5 (8.6%) of 58 denied, and 8 (13.8%) of 58 unknown/died during the disability application process. The median form size was 33 (SD, 25.95) items. This study is the first of its kind and provides an initial look at work-related discussions and support with disability insurance paperwork as a specific intervention provided by physiatrists at a cancer center. The results are compelling and demonstrate that physiatrists frequently provide these interventions. These interventions take considerable time and effort but are generally successful.

Background: Pancytopenia, immunosuppression, and other factors may place patients with multiple myeloma at risk for medical complications. These patients often require inpatient rehabilitation. No previous studies have looked at risk factors for return to the primary acute care service of this patient population., Objective: To determine the percentage of and factors associated with return to the primary acute care service of multiple myeloma rehabilitation inpatients., Design: Retrospective review., Setting: Acute inpatient rehabilitation unit within a National Cancer Institute Comprehensive Cancer Center., Participants: All patients with multiple myeloma admitted to the inpatient rehabilitation unit between March 1, 2004, and February 28, 2015., Main Outcome Measures: Return to the primary acute care service was analyzed with demographic information, multiple myeloma characteristics, medications, laboratory values, and hospital admission characteristics., Results: One hundred forty-three inpatient rehabilitation admissions were found during the study period. After we removed multiple admissions of the same patients and planned transfers to the primary acute care service, 122 admissions were analyzed. Thirty-two (26%) patients transferred back to the primary acute care service for unplanned reasons. Multivariate analysis revealed male gender and thrombocytopenia as significantly associated with return to the primary acute care service. The median survival of patients who transferred back to the inpatient primary acute care service was 180 days versus 550 days for those who did not (P < .001)., Conclusion: Because of their medical fragility, clinicians caring for rehabilitation inpatients with multiple myeloma should maintain close contact with the primary oncology service. Factors associated with an increased risk of transfer back to the primary acute care service include male gender and thrombocytopenia., Level of Evidence: IV., (Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To solicit expert opinions and develop consensus around the research that is needed to improve cancer rehabilitation for older adults., Design: Delphi methods provided a structured process to elicit and prioritize research questions from national experts., Setting: National, Web-based survey., Participants: Members (N=32) of the American Congress of Rehabilitation Medicine completed at least 1 of 3 investigator-developed surveys., Interventions: Not applicable., Main Outcome Measures: In the first survey, participants identified up to 5 research questions that needed to be answered to improve cancer rehabilitation for older adults. In 2 subsequent surveys, participants viewed the compilation of questions, rated the importance of each question, and identified the 5 most important questions. This generated priority scores for each question. Consensus scores were created to describe the degree of agreement around the priority of each question., Results: Highest priority research concerns the epidemiology and measurement of function and disability in older adult cancer survivors; the effects of cancer rehabilitation interventions on falls, disability, participation, survival, costs, quality of care, and health care utilization; and testing models of care that facilitate referrals from oncology to rehabilitation providers as part of coordinated, multicomponent care., Conclusions: A multipronged approach is needed to fill these gaps, including targeted funding opportunities developed with an advisory panel of cancer rehabilitation experts, development of a research network to facilitate novel collaborations and grant proposals, and coordinated efforts of clinical groups to advocate for funding, practice change, and policy change., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

As cancer evolves from a terminal illness to a chronic medical condition, so too does the view of clinical services. Palliative care and physical medicine and rehabilitation (PM&R) will increase in acceptance because they provide a valuable resource. The overarching theme is improving cancer-related symptoms or treatment-related side effects, improving patient health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision making. Managing symptom burden may improve therapy participation/performance. PM&R and palliative care departments are well-equipped to develop patient-centered care protocols, and could play an important role in developing a universal measure of performance status., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Paraneoplastic stiff person syndrome is a rare, but debilitating, manifestation of cancer, characterized by painful extremities, truncal and facial spasms. The resultant functional impairment may necessitate comprehensive rehabilitation and symptom management. This case series describes the acute inpatient rehabilitation courses of 2 patients at different tertiary care referral cancer rehabilitation programmes, including work-up and diagnosis, medical management of symptoms, and functional outcomes. Both patients had a reduction in symptom burden and an improvement in motor function as a result of multidisciplinary acute inpatient rehabilitation.

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., (Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Fatigue is a ubiquitous and an extremely distressing symptom among patients with brain tumors (BT), particularly those with high-grade gliomas. The pathophysiology of cancer-related fatigue (CRF) in the context of patients with BT is multifactorial and complex, involving biological, behavioral, medical and social factors. The etiology of CRF in the general oncology population is pointing to the role of inflammatory cytokines as a key factor in the genesis of CRF, but this research is currently limited in the setting of BT. CRF should be screened, assessed and managed according to clinical practice guidelines. Fatigue has recently emerged as a strong, independent prognostic factor for survival that provides incremental prognostic value to the traditional markers of prognosis in recurrent high-grade gliomas. Therefore, strategies to treat fatigue warrant investigation, not only to improve the QOL of a group of patients with often limited life expectancy, but also possibly to optimize survival.

Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their respective roles in comprehensive oncology care, and highlights how these services can contribute complementary components of essential quality care. An understanding of how cancer rehabilitation and palliative care are aligned in goal setting, but distinct in approach may help facilitate earlier integration of both into the oncology care continuum-supporting efforts to improve physical, psychological, cognitive, functional, and quality of life outcomes in patients and survivors.

Background/aims: To determine if there is a relationship between patient symptoms and functional improvement on inpatient rehabilitation., Methods: Retrospective review of medical records at an American tertiary referral-based cancer center of all patients admitted to an inpatient rehabilitation unit between 3/1/2013-5/20/2013. Main outcome measures included the Edmonton Symptom and Assessment Scale (ESAS) and Functional Independence Measure (FIM)., Findings: The medical records for 71 unique cancer rehabilitation inpatients were analyzed. Statistical analysis of total admission ESAS on total FIM change found no significant relationships. The symptom burden of the patients was mild. Patients demonstrated statistically significant improvements in function and symptoms during inpatient rehabilitation. The mean change in total FIM and total ESAS were an increase of 19.20 and decrease of 7.41 respectively. Statistically significant changes occurred in fatigue, sleep, pain, and anxiety., Conclusion: Both symptom and functional scores improved significantly during inpatient rehabilitation. However, no significant relationships were found between symptoms at admission and improvement in FIM.

The purpose of this paper is to review the evidence for the role of physical rehabilitation in stem cell transplantation patients. We will also review the literature and discuss professional experiences on how rehabilitation can play a role in stem cell transplant care and survivorship. Hematopoietic stem cell transplantation (HCT) is a procedure that has evolved substantially over the years to help treat multiple conditions, particularly hematologic malignancies. HCT can be very stressful on the body and can leave patients weakened and sometimes quite debilitated. Supportive care measures have advanced to improve the quality of life and overall survival of HCT survivors. One key component of improved supportive care is gaining increased attention, and that is physical medicine and rehabilitation. Its role in HCT survivorship care is expanding, and new insight and research within the discipline have focused on fatigue, inflammation, exercise, and the development of structured rehabilitation programs to improve the musculoskeletal sequelae of transplantation. This literature review has demonstrated the utility of physical rehabilitation in HCT, its impact on cancer-related fatigue, and to outline the current state of the literature on these topics. The paper delves into a background of HCT. Cancer-related fatigue in HCT is then discussed and summarized, and the role that exercise plays in modifying such fatigue is outlined. We then outline the models and the impact that physical rehabilitation may play in HCT recipients.

Introduction: The sural/radial nerve amplitude ratio (SRAR) is the quotient of the sensory nerve action potential (SNAP) amplitudes (Amp) of the sural and the superficial radial nerve. It has been hypothesized that this ratio can be used for the detection of early axonal loss, because the sural SNAP amplitude will decrease first, thereby also decreasing the SRAR value., Objectives: To determine the sensitivity and specificity of SRAR, age-adjusted sural and radial SNAP Amp in the diagnosis of axonal sensory polyneuropathy in cancer patients., Design: Retrospective review., Setting: Comprehensive cancer center., Patients: One hundred and ninety one EMG reports from January 2001 to December 2005., Methods: The independent variable is the diagnosis of axonal sensory polyneuropathy in the EMG reports that is based on multiple tests., Main Outcome Measurements: We assessed the agreement between classifications of axonal sensory polyneuropathy made using the current 'gold standard' and the proposed method that is based on patients' age-adjusted radial and sural SNAP amplitude; an SRAR being above or below the normal value (0.21)., Results: We found that the sensitivities for age-adjusted radial SNAP Amp, age-adjusted sural SNAP Amp, and SRAR were 33%, 64%, 56% respectively; the specificities were 85%, 70%, 77% respectively., Conclusions: SRAR is neither the most sensitive, nor the most specific in the diagnosis of axonal sensory polyneuropathy.

Objective: To evaluate the functional improvement of rehabilitation inpatients with paraneoplastic cerebellar degeneration., Design: Retrospective review., Setting: Referral-based hospitals., Participants: Cancer rehabilitation inpatients (N=7) admitted to 3 different cancer centers with a diagnosis of paraneoplastic cerebellar degeneration., Intervention: Medical records were retrospectively analyzed for demographic, laboratory, medical, and functional data., Main Outcome Measure: FIM., Results: All 7 patients were white women (median age, 62y). Primary cancers included ovarian carcinoma (n=2), small cell lung cancer (n=2), uterine carcinoma (n=2), and invasive ductal breast carcinoma (n=1). Mean admission total FIM score was 61±23.97. Mean discharge total FIM score was 73.6±29.35. The mean change in total FIM score was 12.6 (P=.0018). The mean length of rehabilitation stay was 17.1 days. The mean total FIM efficiency was .73. Of the 7 patients, 5 (71%) were discharged home, 1 (14%) was discharged to a nursing home, and 1 (14%) was transferred to the primary acute care service., Conclusions: To our knowledge, this is the first study to demonstrate the functional performance of a group of rehabilitation inpatients with paraneoplastic cerebellar degeneration. Despite the poor neurologic prognosis associated with this syndrome, these patients made significant functional improvements in inpatient rehabilitation. When appropriate, inpatient rehabilitation should be considered. Further studies with larger sample sizes are needed., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Demonstrate the inpatient rehabilitation potential of cerebellopontine angle epidermoid cyst patients. Due to their location, symptoms may present with a complex combination of headache, cerebellar dysfunction, and cranial nerve deficits affecting functional status., Methods: This report describes the cases of 3 patients with cerebellopontine angle epidermoid cysts who underwent neurosurgical resection followed by inpatient rehabilitation. All 3 patients experienced gait instability and cranial nerve deficits before surgery, and 2 of the patients had mild cognitive deficits. A customized rehabilitation program for these patients can address these deficits., Results: Each patient showed demonstrable gains in function with inpatient rehabilitation and good outcomes at discharge., Conclusion: When rehabilitating epidermoid cyst patients, the clinician must be aware of a higher likelihood of cranial neuropathies, need for increased psychosocial support, and the need for more vigilant long term medical monitoring to detect recurrence.

Objective: To assess the frequency and risk factors for return to the primary acute care service among patients with lymphoma undergoing inpatient rehabilitation., Design: Retrospective study., Setting: Tertiary referral-based cancer center., Patients: All patients with a history of lymphoma admitted to an inpatient rehabilitation between October 1, 2003, and January 30, 2013., Main Outcome Measures: Items analyzed from patient records included return to the primary acute care service with demographic information, lymphoma characteristics, medications, hospital admission characteristics, and laboratory values., Results: A total of 143 unique patient admissions were analyzed, and 54 of these 143 lymphoma inpatient rehabilitation admissions (38%) returned to the primary acute care service. However, 16 of 54 (30%) returned because they needed additional chemotherapy. Excluding patients who returned to the primary acute care service for chemotherapy, statistically significant or approaching statistically significant factors (P < .10) associated with return to the primary acute care service included a creatinine level ≥ 1.3 mg/dL (P = .0002), male gender (P = .001), history of hematopoietic stem cell transplantation (P = .0355), and presence of an intravenous antifungal agent (P = .0717). Of the patients transferred back to the primary acute care service, 13 of 38 (34%) were discharged directly home, 10 of 38 (26%) died in the hospital, 7 of 38 (18%) were transferred to a subacute rehabilitation facility, and 4 of 38 (11%) were transferred to inpatient rehabilitation., Conclusions: When excluding patients who returned for chemotherapy, patients with lymphoma who were male, had undergone hematopoietic stem cell transplantation, and had a creatinine level ≥ 1.3 mg/dL demonstrated increased risk for return to the primary acute care service., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to assess the frequency and reasons for return to the primary acute care service among patients with leukemia undergoing inpatient rehabilitation., Design: This is a retrospective study of all patients with leukemia, myelodysplastic syndrome, aplastic anemia, or myelofibrosis admitted to inpatient rehabilitation at a tertiary referral-based cancer center between January 1, 2005, and April 10, 2012. Items analyzed from patient records included return to the primary acute care service with demographic information, leukemia characteristics, medications, hospital admission characteristics, and laboratory values., Results: Two hundred twenty-five patients were admitted a total of 255 times. Ninety-three (37%) of the 255 leukemia inpatient rehabilitation admissions returned to the primary acute care service. Eighteen (19%) and 42 (45%) of the 93 patients died in the hospital and were discharged home, respectively. Statistically significant factors (P < 0.05) associated with return to the primary acute care service include peripheral blast percentage and the presence of an antifungal agent on the day of the inpatient rehabilitation transfer. Using additional two factors (platelet count and the presence of an antiviral agent, both P < 0.11), the Return to Primary-Leukemia Index was formulated., Conclusions: Patients with leukemia with the presence of circulating peripheral blasts and/or an antifungal agent may be at increased risk for return to the primary acute care service. The Return to Primary-Leukemia Index should be tested in prospective studies to determine its usefulness.

Objective: To assess rehabilitation inpatient risk of return to primary (RTP) service in patients with bone marrow transplant (BMT)., Design: Retrospective review., Setting: Inpatient rehabilitation unit within a tertiary referral-based cancer center., Participants: All patients with BMT (131) who were admitted a total of 147 times to inpatient rehabilitation between January 1, 2002, and April 30, 2010., Interventions: None., Main Outcome Measures: We analyzed RTP service and demographic information, cancer characteristics, medications, hospital admission characteristics, and laboratory values., Results: A total of 61 (41%) of 147 of BMT admissions were transferred from the inpatient rehabilitation unit back to the primary service. Of those transferred back, 23 (38%) of 61 died after being transferred back to the primary service. Significant or near-significant relationships were found for a platelet count of <43,000 per microliter (P<.01); a creatinine level of >0.9 milligrams/deciliter (P<.01); the presence of an antiviral agent (P=.0501); the presence of an antibacterial agent (P=.0519); the presence of an antifungal agent (P<.05); and leukemia, lymphoma, or multiple myeloma diagnosis (P<.05). Using 5 of these factors, the RTP-BMT index was formulated to determine the likelihood of return to the primary team., Conclusions: Patients with BMT have a high rate of transfer from the inpatient rehabilitation unit back to the primary service. The RTP-BMT index score can be a useful tool to help clinicians predict the likelihood of return to the primary acute care service., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To study the immune tolerance induced by bone marrow cell transplantation combined with short-term use of cyclophosphamide after pancreatic transplantation in diabetic rats., Methods: Type I diabetes mellitus was induced in BN rats with streptozotocin (STZ) intraperitoneal injection at a single dose of 45 mg/kg. Pancreatic transplantations were performed with the SD rats as donors and the diabetic BN rats as recipients. Twenty BN rats with type I diabetes mellitus were randomly divided into four groups. The BN rats in Group I received pancreas transplantations only. The BN rats in Group II received intraperitoneal injection of 150 mg/kg cyclophosphamide on the first day after pancreas transplantations. The BN rats in Group 11 received injection of 2.0 x 10(8) donors' bone marrow cells via the portal vein during the pancreas transplantations. The BN rats in Group IV received injection 2.0 x 10(8) donors' bone marrow cells via the portal vein during the pancreas transplantations and an intraperitoneal injection of 150 mg/kg cyclophosphamide on the first day after pancreas transplantations. The blood glucose of the rats was measured after transplantations. The graft functional survival time (GFST) was recorded. Peripheral blood was obtained two weeks after the transplantations to prepare single cell suspension for detecting chimera formation rate and the level of Vbeta11+ T cell by flow cytometry., Results: The average GFST of group IV was (18 +/- 2.2) d, significantly longer than those of group I (7.8 +/- 1.2) d, group II (8.2 +/- 1.6) d, and group III (8.8 +/- l.4) d (P < 0.05). The rats in group IV had significant lower level of Vbeta11+ T cells (2.5 +/- 0.3)% than those in the other groups (P < 0.05). Donors' bone marrow-derived cells could be detected in the peripheral blood of diabetic rats in group IV, with a chimeric rate of (10.0 +/- 2.3)%. No donors' bone marrow-derived cells were detected in the rats in other groups., Conclusion: Bone marrow cell transplantation combined with short-term use of cyclophosphamide promote chimerism formation and induce immune tolerance in rats with pancreatic transplantations, which prolongs pancreatic graft functional survival time.

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.

Purpose: The significance of HER-2/neu results obtained by immunohistochemical analyses (IHC) which are neither negative nor strongly positive is controversial. The incidence of fluorescence in situ hybridization (FISH) positivity in these tumors is small and the implication is that these borderline results represent laboratory misclassification. We analyzed the tumor characteristics of these HER-2/neu borderline tumors to determine if they represent a unique tumor type., Methods: HER-2/neu status was determined by image analysis (IA) of IHC sections in 669 cases of invasive breast cancer. Borderline cases were reflexed to FISH to determine gene status. HER-2/neu results were compared to tumor morphology and other tumor markers., Results: HER-2/neu was negative, borderline and positive in 69.5, 15.8, and 14.6% of cases, respectively. HER-2/neu amplification was present in 17.3% of borderline cases. The borderline group is significantly different from the HER-2/neu positive group for all parameters studied except Ki-67. Compared to the HER-2/neu negative group, the borderline group showed a significantly higher HER-2/neu gene copy number and a trend towards lower progesterone receptor expression (p=0.058). Compared to the HER-2/neu negative group, the HER-2/neu borderline/FISH-negative group showed significantly lower PR expression. Compared to the HER-2/neu positive group, the HER-2/neu borderline/FISH positive group showed significant differences with multiple parameters., Conclusion: Borderline HER-2/neu tumors are a unique tumor type and do not represent laboratory imprecision. Hormone receptor alterations are associated with early changes in HER-2/neu expression. While IA is capable of detecting these changes, current FISH methodology is not.

Objective: To summarize surgery experience and efficiency of laparoscopic excision of choledochal cyst and reconstruction of biliary tract and to analyze the treatments administered during intra and post-operation of the biliary reconstruction., Methods: We enrolled 48 cases of video-guided laparoscopic intraoperative cholangiography, cholecystectomy, choledochocele resection, Roux-en-Y hepaticojejunostomy with an anti-reflux valve from August, 2001 to October, 2003. Their operative procedures and aims were retrospectively analyzed., Results: Forty-four out of 48 patients successfully underwent laparoscopy and recovered soon. Only 4 cases were transformed to open operation. The post-operation complications were found in 4 cases., Conclusion: Video-guided laparoscopic excision of choledochal cyst, biliary tract reconstruction and Roux-en-Y hepaticojejunostomy are an effective method of treatment with advantages of minimal injury, less bleeding, and sooner recovery.

Purpose: We developed a real-time, quantitative, methylation sensitive polymerase chain reaction (PCR) protocol to analyze hypermethylation of the CpG islands in the promoter region of the pi class glutathione-S-transferase gene GSTP1 in prostate cancer tissue., Materials and Methods: A total of 21 prostate cancer and 72 benign prostate hyperplasia (BPH) tissue samples were analyzed. Genomic DNA was digested with restriction enzyme, followed by real-time quantitative PCR amplification. Cycle threshold values were used to determine whether cancer genome was present in these tissues. A cutoff cycle threshold value of 35 was arbitrarily assigned. Samples with a cycle threshold of 35 or less were considered positive for prostate cancer. Conventional nested PCR was also performed for comparison., Results: The mean cycle threshold values plus or minus standard deviation in prostate cancer and BPH cases were 30.12 +/- 2.88 and 37.77 +/- 2.72, respectively. All prostate cancer samples analyzed showed positive results, while 5 of the 72 BPH samples tested positive. Conventional nested PCR data indicated that 19 of 21 prostate cancer cases were positive for the methylation change, while 71 of 72 BPH cases tested negative. The test limitations of real-time PCR and the nested PCR protocols were determined to be 0.048 and 0.64 ng. DNA, respectively., Conclusions: We established a novel protocol for detecting the methylation change in the 5' regulatory sequence flanking the GSTP1 gene. The sensitivity of this protocol was superior to that of conventional nested PCR. The data also suggest that this novel protocol may accurately discriminate prostate carcinoma from BPH.