- Email: [email protected]
Poster 27: Stroke-Like Migraine Attacks After Radiation Therapy: A Case Report
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Poster 25 Knowledge and Exercise Adherence After a Multidisciplinary Osteoporosis and Prevention Program: A Retrospective Review. Lisa M. Ruppert, MD (NYPH University Hospitals of Columbia and Cornell, Manhattan, NY); Michael D. Stubblefield, MD. Disclosures: L. M. Ruppert, Proctor and Gamble, unrestricted educational grant, Research grants Objective: To establish whether a short multidisciplinary program emphasizing education and home exercise can produce a significant improvement in exercise adherence and knowledge of osteoporosis in cancer patients with diagnosis of osteopenia/osteoporosis. Design: Retrospective review. Setting: Tertiary care cancer center. Participants: 31 individuals with the diagnosis of cancer and osteopenia/osteoporosis based on T scores, deemed able to safely and effectively participate in a group exercise program. Interventions: Four 30-minute lectures over 4 consecutive weeks given by a physiatrist, physical therapist, endocrinologist, and dietician, followed by a 60-minute exercise class lead by a physical therapist. The course is followed by a review and reevaluation 2 weeks after the last class. A binder containing lecture notes and illustrated instructions on exercises was given at first class. Main Outcome Measures: Subjective questionnaires, pre/post test to assess knowledge, pre/post Berg balance scale, pre/post assessment of body mechanics (sit-to-stand/ supine-to-sit/supported sit/picking up an object). Results: 20 participants completed the course. Mean pretest score 55.6 with SD 20.3, mean posttest score 81.8 with SD 16.1. Mean Berg on intake 52 with SD 36, mean Berg on discharge 54 with SD 3. 6 participants showed no change in their Berg scores. Mean score on body mechanics at intake 3.9 with SD 2, and mean on discharge 8.7 with SD 1.7. 14/30 participants reported a regular exercise program (at least 3-4⫻/wk) at intake, and 17/20 participants who completed the course reported a regular exercise program. 6/7 participants who have received 3-month follow-ups reported performing regular exercise, consisting of the exercises provided in the course. Three-month follow-ups are currently ongoing. Conclusions: A short multidisciplinary program emphasizing education and home exercise can produce improvement in exercise adherence and knowledge in cancer patients with osteopenia/osteoporosis. Keywords: Rehabilitation, Cancer, Osteoporosis, Exercise.
Poster 26 Opioids Used for Pain Management in Patients Who Had Undergone Internal Hemipelvectomy (IH) Versus External Hemipelvectomy (EH). Ying Guo, MD (The University of Texas M. D. Ander-
POSTER PRESENTATIONS
son Cancer Center, Houston, TX); Eduardo Bruera; Lynn Palmer, PhD. Disclosures: Y. Guo, None. Objective: Opioids are frequently used postoperatively for patients who underwent hemipelvectomy. The objective of this study is to compare the opioids used for pain management in patients undergoing an IH versus EH. Design: Retrospective chart review. Setting: Tertiary care cancer center. Participants: Charts from 30 patients who underwent IH and 30 patients who underwent EH during 1993-2005 were reviewed. Interventions: N/A. Main Outcome Measures: Information collected included demographic data; tumor diagnosis and treatment received; morphine equivalent dose (MED) upon discharge, postoperative hospital length of stay (LOS); and patients’ functional independence measure (FIM) score for gait upon discharge. We compared differences between the IH and EH groups using the Wilcoxon rank sum test, 2 test, and Fisher’s exact test. Results: The mean age (range) for IH was 47 (8-80) and 44 (12-75) for EH group. The male gender was 22/30 (73%) for IH and 15/30 (50%) for EH groups. Preoperative chemotherapy and radiation treatments were similar between IH and EH groups (P ⫽ .11 and .37, respectively). The median MED (mg/day) upon discharge required for EH was significantly higher than that required for IH group (150 vs 45, P ⫽ .032). The mean (range) hospital LOS for patients who underwent EH was significantly longer than that for patients who underwent IH (37 vs 19, P ⫽ .0035). At the time of discharge, a significantly higher percentage of IH patients were able to ambulate without another person’s assistance (14/30 (47%) vs 5/30 (17%) in EH patient group, P ⫽ .0125). Conclusions: Internal hemipelvectomy with limb salvage seems to be advantageous over external hemipelvectomy, with less opioid use, shorter hospital LOS and better shortterm functional recovery. Keywords: Pain, Cancer, Opioids, Rehabilitation.
Poster 27 Stroke-Like Migraine Attacks After Radiation Therapy: A Case Report. Cara Prideaux, MD (Mayo Clinic Rochester, Rochester, MN); Disclosures: C. Prideaux, None. Patients or Programs: A 45-year-old right-hand-dominant woman with recurrent stroke-like migraine attacks after radiation treatment (SMART syndrome). Program Description: The patient has a history of left temporoparietal grade III astrocytoma treated with resection and subsequent external beam radiation therapy and chemotherapy in 1995. As a result of the resection, she had chronic, mild aphasia and right hemiparesis. However, she was independent in mobility and ADLs. She presented with her sixth
PM&R
episode of transient left hemispheric dysfunction since the initial diagnosis/treatment. Prior episodes lasted days to weeks and all resulted in full recovery back to baseline level of functioning. Clinical findings include worsening rightsided weakness and aphasia, right facial weakness, right homonomous hemianopsia, dysarthria and dysphagia. She also typically experiences left-sided headache without aura. MRI findings during these episodes show abnormal contrast enhancement involving the left posterior frontoparietal region without T2 signal changes or residual/recurrent tumor and without conforming to any specific vascular territory. MRA shows no significant pathology. EEG shows slowing over the left temporal region without epileptiform abnormalities. Repeated neuroimaging following complete recovery reveals resolution of the MRI abnormalities. Setting: Inpatient adult rehabilitation center. Results: Following full medical and neurological evaluations, she transitioned to inpatient rehabilitation where her symptoms gradually resolved over a 4-week period back to her previous baseline. Discussion: SMART syndrome has been previously recognized in the literature. Diagnostic criteria include: remote history of external beam cranial irradiation without evidence of residual or recurrent tumor; prolonged, reversible signs and symptoms of unilateral hemispheric dysfunction; transient, diffuse unilateral cortical gadolinium enhancement on MRI within a previous radiation field; not attributed to another disorder. Both neurological symptoms and neuroimaging findings return to baseline. Conclusions: Recognition of this syndrome can provide reassurance to the patient, family, and health-care providers and help avoid some unnecessary and potentially dangerous invasive diagnostic tests. Keywords: Rehabilitation, Brain tumors, MRI scans, Radiation therapy.
Poster 28 Terminal Malignant Fibrous Histiocytoma with Spinal Metastasis and Incomplete Paraplegia. Bed Rest or Ambulate? A Case Report. Pramod Kumar, MD (Montefiore Medical Center, Bronx, NY); Svetlana Trounina, MD. Disclosures: P. Kumar, None. Patients or Programs: A 51-year-man with metastatic malignant fibrous histiocytoma. Program Description: A 51-year-old man was diagnosed with malignant fibrous histiocytoma involving the right tibia in 2001. Post surgery he underwent radiation and chemotherapy and remained asymptomatic until 2007 when he developed severe low back pain following a jump on a trampoline. Furthermore, patient was complaining of hip pain, weakness of both lower extremities, and numbness of the right thigh. Diagnostic work-up including radiographs and MRI of spine/pelvis revealed extensive metastatic disease involving ribs, liver, hips, pelvis and spine with cord compression at T5 and L2. Patient underwent T5 excision of
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mass/ tumor T4-T6 stabilization, L2 laminectomy and decompression. Perioperative hospital course was complicated by DVT in right leg. In addition, patient had atrial fibrillation and was treated with Coumadin. Upon admission to rehab, physical examination showed muscle strength of grade 3/5 in both hip flexors, 3/5 in both knee flexors and extensors, 3/5 right ankle and 5/5 left ankle. Sensations were decreased over right L1 and L2 dermatomes. Lower extremity reflexes were not elicitable. Patient underwent 3 hours of physical and occupational therapy every day maintaining spinal and fall precautions. Setting: Tertiary care hospital. Results: Patient achieved significant improvement in his ability to ambulate and perform activities of daily living. While on admission he required maximum assistance with transfers and was able to stand for few minutes, at time of discharge he was able to ambulate and do activities with minimal assistance. Discussion: Malignant fibrous histiocytoma is the most common soft tissue sarcoma occurring in late adult life. Spinal metastatic involvement is often a debilitating and terminal event in this disease. Maintaining mobility and functional independence goes a long way in preventing rapid functional deterioration and associated comorbidities. Inpatient acute rehabilitation offers an excellent opportunity for these patients to regain their quality of life in the shortest possible time. Conclusions: Even in terminal malignancy with spinal metastasis and incomplete paraplegia, aggressive rehabilitation is preferred over bed rest. Keywords: Rehabilitation, Spine, Malignant fibrous histiocytoma, Metastasis.
Poster 29 The Effects of a Brief Relaxation Program on Heart Rate Variability in Cancer Patients. Arash Asher, MD (Cedars-Sinai Medical Center, Los Angeles, CA); Ying Guo, MD; Lynn Palmer, PhD. Disclosures: A. Asher, None. Objective: (1) To characterize the physiologic changes of the autonomic nervous system, demonstrated by heart rate variability (HRV) high frequency (HF) spectral analysis, before and after a 15-minute, one-time, guided relaxation program for cancer patients. (2) To assess whether changes of HRV correlates with subjective feeling for anxiety, based on the Edmonton Symptom Assessment Scale (ESAS), and the summed ESAS score. Design: Before and after study. Setting: University of Texas, MD Anderson Cancer Center. Participants: 20 patients with any current or past cancer diagnosis and normal cognition were recruited for the study. Interventions: The ECG electrodes were attached. After 15 minutes of supine resting, a 5-minute period of heart rate variability was recorded (HRVbefore). The patient then began the brief relaxation program via recorded audio. Another 5-minute period of HRV was then recorded (HRVafter). The
Poster 25 Knowledge and Exercise Adherence After a Multidisciplinary Osteoporosis and Prevention Program: A Retrospective Review. Lisa M. Ruppert, MD (NYPH University Hospitals of Columbia and Cornell, Manhattan, NY); Michael D. Stubblefield, MD. Disclosures: L. M. Ruppert, Proctor and Gamble, unrestricted educational grant, Research grants Objective: To establish whether a short multidisciplinary program emphasizing education and home exercise can produce a significant improvement in exercise adherence and knowledge of osteoporosis in cancer patients with diagnosis of osteopenia/osteoporosis. Design: Retrospective review. Setting: Tertiary care cancer center. Participants: 31 individuals with the diagnosis of cancer and osteopenia/osteoporosis based on T scores, deemed able to safely and effectively participate in a group exercise program. Interventions: Four 30-minute lectures over 4 consecutive weeks given by a physiatrist, physical therapist, endocrinologist, and dietician, followed by a 60-minute exercise class lead by a physical therapist. The course is followed by a review and reevaluation 2 weeks after the last class. A binder containing lecture notes and illustrated instructions on exercises was given at first class. Main Outcome Measures: Subjective questionnaires, pre/post test to assess knowledge, pre/post Berg balance scale, pre/post assessment of body mechanics (sit-to-stand/ supine-to-sit/supported sit/picking up an object). Results: 20 participants completed the course. Mean pretest score 55.6 with SD 20.3, mean posttest score 81.8 with SD 16.1. Mean Berg on intake 52 with SD 36, mean Berg on discharge 54 with SD 3. 6 participants showed no change in their Berg scores. Mean score on body mechanics at intake 3.9 with SD 2, and mean on discharge 8.7 with SD 1.7. 14/30 participants reported a regular exercise program (at least 3-4⫻/wk) at intake, and 17/20 participants who completed the course reported a regular exercise program. 6/7 participants who have received 3-month follow-ups reported performing regular exercise, consisting of the exercises provided in the course. Three-month follow-ups are currently ongoing. Conclusions: A short multidisciplinary program emphasizing education and home exercise can produce improvement in exercise adherence and knowledge in cancer patients with osteopenia/osteoporosis. Keywords: Rehabilitation, Cancer, Osteoporosis, Exercise.
Poster 26 Opioids Used for Pain Management in Patients Who Had Undergone Internal Hemipelvectomy (IH) Versus External Hemipelvectomy (EH). Ying Guo, MD (The University of Texas M. D. Ander-
POSTER PRESENTATIONS
son Cancer Center, Houston, TX); Eduardo Bruera; Lynn Palmer, PhD. Disclosures: Y. Guo, None. Objective: Opioids are frequently used postoperatively for patients who underwent hemipelvectomy. The objective of this study is to compare the opioids used for pain management in patients undergoing an IH versus EH. Design: Retrospective chart review. Setting: Tertiary care cancer center. Participants: Charts from 30 patients who underwent IH and 30 patients who underwent EH during 1993-2005 were reviewed. Interventions: N/A. Main Outcome Measures: Information collected included demographic data; tumor diagnosis and treatment received; morphine equivalent dose (MED) upon discharge, postoperative hospital length of stay (LOS); and patients’ functional independence measure (FIM) score for gait upon discharge. We compared differences between the IH and EH groups using the Wilcoxon rank sum test, 2 test, and Fisher’s exact test. Results: The mean age (range) for IH was 47 (8-80) and 44 (12-75) for EH group. The male gender was 22/30 (73%) for IH and 15/30 (50%) for EH groups. Preoperative chemotherapy and radiation treatments were similar between IH and EH groups (P ⫽ .11 and .37, respectively). The median MED (mg/day) upon discharge required for EH was significantly higher than that required for IH group (150 vs 45, P ⫽ .032). The mean (range) hospital LOS for patients who underwent EH was significantly longer than that for patients who underwent IH (37 vs 19, P ⫽ .0035). At the time of discharge, a significantly higher percentage of IH patients were able to ambulate without another person’s assistance (14/30 (47%) vs 5/30 (17%) in EH patient group, P ⫽ .0125). Conclusions: Internal hemipelvectomy with limb salvage seems to be advantageous over external hemipelvectomy, with less opioid use, shorter hospital LOS and better shortterm functional recovery. Keywords: Pain, Cancer, Opioids, Rehabilitation.
Poster 27 Stroke-Like Migraine Attacks After Radiation Therapy: A Case Report. Cara Prideaux, MD (Mayo Clinic Rochester, Rochester, MN); Disclosures: C. Prideaux, None. Patients or Programs: A 45-year-old right-hand-dominant woman with recurrent stroke-like migraine attacks after radiation treatment (SMART syndrome). Program Description: The patient has a history of left temporoparietal grade III astrocytoma treated with resection and subsequent external beam radiation therapy and chemotherapy in 1995. As a result of the resection, she had chronic, mild aphasia and right hemiparesis. However, she was independent in mobility and ADLs. She presented with her sixth
PM&R
episode of transient left hemispheric dysfunction since the initial diagnosis/treatment. Prior episodes lasted days to weeks and all resulted in full recovery back to baseline level of functioning. Clinical findings include worsening rightsided weakness and aphasia, right facial weakness, right homonomous hemianopsia, dysarthria and dysphagia. She also typically experiences left-sided headache without aura. MRI findings during these episodes show abnormal contrast enhancement involving the left posterior frontoparietal region without T2 signal changes or residual/recurrent tumor and without conforming to any specific vascular territory. MRA shows no significant pathology. EEG shows slowing over the left temporal region without epileptiform abnormalities. Repeated neuroimaging following complete recovery reveals resolution of the MRI abnormalities. Setting: Inpatient adult rehabilitation center. Results: Following full medical and neurological evaluations, she transitioned to inpatient rehabilitation where her symptoms gradually resolved over a 4-week period back to her previous baseline. Discussion: SMART syndrome has been previously recognized in the literature. Diagnostic criteria include: remote history of external beam cranial irradiation without evidence of residual or recurrent tumor; prolonged, reversible signs and symptoms of unilateral hemispheric dysfunction; transient, diffuse unilateral cortical gadolinium enhancement on MRI within a previous radiation field; not attributed to another disorder. Both neurological symptoms and neuroimaging findings return to baseline. Conclusions: Recognition of this syndrome can provide reassurance to the patient, family, and health-care providers and help avoid some unnecessary and potentially dangerous invasive diagnostic tests. Keywords: Rehabilitation, Brain tumors, MRI scans, Radiation therapy.
Poster 28 Terminal Malignant Fibrous Histiocytoma with Spinal Metastasis and Incomplete Paraplegia. Bed Rest or Ambulate? A Case Report. Pramod Kumar, MD (Montefiore Medical Center, Bronx, NY); Svetlana Trounina, MD. Disclosures: P. Kumar, None. Patients or Programs: A 51-year-man with metastatic malignant fibrous histiocytoma. Program Description: A 51-year-old man was diagnosed with malignant fibrous histiocytoma involving the right tibia in 2001. Post surgery he underwent radiation and chemotherapy and remained asymptomatic until 2007 when he developed severe low back pain following a jump on a trampoline. Furthermore, patient was complaining of hip pain, weakness of both lower extremities, and numbness of the right thigh. Diagnostic work-up including radiographs and MRI of spine/pelvis revealed extensive metastatic disease involving ribs, liver, hips, pelvis and spine with cord compression at T5 and L2. Patient underwent T5 excision of
Vol. 1, Iss. 9S, 2009
S115
mass/ tumor T4-T6 stabilization, L2 laminectomy and decompression. Perioperative hospital course was complicated by DVT in right leg. In addition, patient had atrial fibrillation and was treated with Coumadin. Upon admission to rehab, physical examination showed muscle strength of grade 3/5 in both hip flexors, 3/5 in both knee flexors and extensors, 3/5 right ankle and 5/5 left ankle. Sensations were decreased over right L1 and L2 dermatomes. Lower extremity reflexes were not elicitable. Patient underwent 3 hours of physical and occupational therapy every day maintaining spinal and fall precautions. Setting: Tertiary care hospital. Results: Patient achieved significant improvement in his ability to ambulate and perform activities of daily living. While on admission he required maximum assistance with transfers and was able to stand for few minutes, at time of discharge he was able to ambulate and do activities with minimal assistance. Discussion: Malignant fibrous histiocytoma is the most common soft tissue sarcoma occurring in late adult life. Spinal metastatic involvement is often a debilitating and terminal event in this disease. Maintaining mobility and functional independence goes a long way in preventing rapid functional deterioration and associated comorbidities. Inpatient acute rehabilitation offers an excellent opportunity for these patients to regain their quality of life in the shortest possible time. Conclusions: Even in terminal malignancy with spinal metastasis and incomplete paraplegia, aggressive rehabilitation is preferred over bed rest. Keywords: Rehabilitation, Spine, Malignant fibrous histiocytoma, Metastasis.
Poster 29 The Effects of a Brief Relaxation Program on Heart Rate Variability in Cancer Patients. Arash Asher, MD (Cedars-Sinai Medical Center, Los Angeles, CA); Ying Guo, MD; Lynn Palmer, PhD. Disclosures: A. Asher, None. Objective: (1) To characterize the physiologic changes of the autonomic nervous system, demonstrated by heart rate variability (HRV) high frequency (HF) spectral analysis, before and after a 15-minute, one-time, guided relaxation program for cancer patients. (2) To assess whether changes of HRV correlates with subjective feeling for anxiety, based on the Edmonton Symptom Assessment Scale (ESAS), and the summed ESAS score. Design: Before and after study. Setting: University of Texas, MD Anderson Cancer Center. Participants: 20 patients with any current or past cancer diagnosis and normal cognition were recruited for the study. Interventions: The ECG electrodes were attached. After 15 minutes of supine resting, a 5-minute period of heart rate variability was recorded (HRVbefore). The patient then began the brief relaxation program via recorded audio. Another 5-minute period of HRV was then recorded (HRVafter). The