Abeloff's Clinical Oncology, 4th Edition
Part II – Problems Common to Cancer and its Therapy
Section A – Symptom Management and Palliative Care
Chapter 37 – Rehabilitation of Individuals with Cancer
- Samuel Mayer,Kenneth Silver,
N. Lynn Gerber
N. Lynn Gerber
SUMMARY OF KEY POINTS
The National Cancer Institute Dictionary of Cancer Terms defines rehabilitation as “a process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way.” Rehabilitation is critical to improving quality of life (QoL) for cancer survivors, and maintaining dignity for those with terminal illness. Rehabilitation requires several components to be successful.
First, it must be patient-centered—that is, individualized to the patient's needs, desires, and situation. Health care providers always must remember that the patient is the captain of the rehabilitation team. Rehabilitation that fails to respect a patient's wishes will fail altogether. Most problems in rehabilitation occur when there are differences in the team's goals and those of the patient.
Second, it must be goal-oriented. Goals should be meaningful to the patient's QoL. They must be measurable and concrete, so that they are transparent to the patient and the caregivers. Goals also must be achievable. Health care providers must balance realism with hope in counseling patients about their goals.
Third, rehabilitation requires an interdisciplinary team approach. In traditional multidisciplinary medical teams, different health care professionals each individually set goals appropriate to their area of specialization. In interdisciplinary rehabilitation, the team members work toward common goals by fulfilling the responsibilities of not only their particular discipline, but also the added responsibility as a group toward fulfilling the patient's goals. Team members must demonstrate a high degree of communication skills, humility, and commitment.
Finally, rehabilitation also requires the active participation of the patient. Rehabilitation is not something done to an individual; it must be done with the individual. It is not a passive process, and it requires individuals to take responsibility for self-management of their illness. Rehabilitation is largely an educational process for the patient and family members.
The World Health Organization has recently published an International Classification of Functioning, Disability and Health, which is meant to supplement the International Classification of Disease (ICD-10). It lays out a series of definitions that are crucial to understanding the role of rehabilitation in improving QoL. Box 37-1 lists these definitions. In this chapter we will focus on impairments, activity limitations, and participation restrictions seen in cancer patients, and discuss how rehabilitation can ameliorate these disabilities.
WORLD HEALTH ORGANIZATION INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH DEFINITIONS
EPIDEMIOLOGY OF CANCER DISABILITY
As a result of the tremendous progress in prevention, early detection, and treatment of cancer in the last quarter century, there has been a decline in mortality rates from cancer. However, the number of cancer survivors continues to grow, as more people are living longer with cancer because of the new advances in surgery, and in medical and radiation oncology. The result is that increasing numbers of patients face more years with cancer-related disability. Data from the National Health Interview Survey 2002 indicate that 11.3% of patients with cancer have difficulty with activities of daily living (ADLs) as compared with 3.8% of people without cancer in the United States. Among prostate cancer patients, 15% have major difficulties with ADLs; among colon cancer patients, 35% have such difficulty, and the proportion rises to 40% among lung cancer patients.
Even among 5-year cancer survivors, elderly women with a history of cancer had statistically significantly more problems with ADLs than age-matched controls. Focus should be directed away from mere survival toward the preservation and improvement of QoL for these survivors. In Japan, for example, the number of breast cancer survivors with lymphedema, as well as chest wall, axilla, and arm pain is expected to double by 2020.
OUTCOME MEASURES FOR CANCER REHABILITATION
Cancer is a complex, chronic illness whose management requires vigilance and a comprehensive and preventive approach to illness and disability. To accomplish this, a systematic approach to patient evaluation throughout all the phases of the disease process is necessary ( Table 37-1 ).
Table 37-1 -- Phases of Cancer Rehabilitation
1. Evaluation and treatment planning
Pain, anxiety, insomnia
Disruption of daily routines
2. Primary training
Education, acute care
Pain, fatigue, ROM, ↓ ambulation, ADL support
Daily routines, stamina (psychologic social function)
3. Post-treatment, recovery
Education, support, chronic care, healthy lifestyle
Pain, anxiety, depression, mobility, edema, fatigue, neuropathy, insomnia
Work, family, avocation, cosmesis
Same as above; metastatic disease effects
Daily routines, work/play
5. End of life
Pain, asthenia, depression
The major concerns of persons with cancer include their overall health, fitness, fatigue, emotional and social function, and pain, which may vary during different phases of the disease. For example, in the initial staging phase, anxiety and disruption of routines may present the greatest challenges. During the treatment phase, the symptoms of fatigue, nausea, and sleep disruption may be the most significant problems.
In general, patient assessments should be tailored to which signs and symptoms are most likely to be associated with the current phase of the disease. Screening tools should include questions relevant to which problems are important to the patient and family, which are likely to be associated with disabilities and which are remediable or need palliation. Once treatments are initiated the care team must assess whether the treatments are effective and at what cost.
Many outcome measures have been developed for cancer patients and have been validated in this population—some for specific cancers, some for toxicity measures, some for specific age groups. In general, it is appropriate to select measures that are easy to use, standardized, and valid for the population and problems being addressed. The following measures are recommended:
Impairment measures: range of motion, muscle testing (including grip strength), pain indices, fatigue measures, mood/affect
Functional measures/disability measures: mobility (6- or 9-minute walk time), ADLs
Health-related QoL/health status measures: SF36, Karnofsky, Eastern Cooperative Oncology Group (ECOG), Eastern Organization for Research and Treatment of Cancer–Quality of Life Questionnaire (EORTC-QLQ).
Cancer, even when localized to—or arising from—one organ system, causes the loss of body function across many organ systems in individuals. The physician must obtain a comprehensive review of systems when evaluating a cancer patient, because this will help identify impairments to be addressed by the treatment team. Delineating these impairments in individuals is the first step toward ameliorating them; this lies at the core of cancer rehabilitation.
Virtually every cancer patient experiences pain during the course of the illness; it can often become debilitating.   Pain severity correlates closely with function, as demonstrated in one study of 216 Chinese cancer patients with metastatic disease. In that study patients with increasing severity of pain had poorer function, whereas those with mild, well-controlled pain functioned similarly to those without pain. The clinician should distinguish whether the pain is acute in onset or a chronic problem. Often it can be an acute exacerbation heaped upon a chronic underlying pain.
The etiology of pain in cancer patients is myriad and frequently has multifactorial causation. The pain may be visceral (arising from internal organs), somatic (from soft tissue, muscles, and/or bones), or neuropathic (from the central or peripheral nervous system). Visceral pain tends to be poorly localized. It is often described as “deep” and “cramping.” Somatic pain, on the other hand, is usually well localized. It is often characterized as “sharp” or “stabbing,” and is frequently worsened by weight bearing or movement. There is often point tenderness on examination. Neuropathic pain tends to radiate along dermatomal or peripheral nerve distributions. Patients frequently describe “burning” or “pins and needles.” The pain tends to be unrelenting. There may be associated allodynia (pain with light stroking).
Pain often produces psychological distress in patients, which in turn exacerbates the pain. Tishelman and colleagues studied symptoms among 400 patients newly diagnosed with inoperable lung cancer and reported that pain, breathing, and fatigue caused the most distress. They concluded, “Breathing and pain appeared to function as icons representing threats associated with lung carcinoma.” Thus, pain may cause the patient to fear disease progression and impending death.
Sadly, pain is often inadequately treated in cancer patients. As many as 50% to 80 % of nonhospice cancer patients receive inadequate analgesia. Yet pain can be well controlled in more than three-quarters of cancer patients using multimodal treatment, according to one study of 2118 patients. Treatments can include opioids, adjuvant medications,   complementary therapy, physical modalities, exercise, behavior management, injections, implantable opiate pumps, radiation therapy, and surgery.
Cancer-related fatigue (CRF) is a “persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning.” (National Comprehensive Cancer Network [NCCN],http://www.nccn.org; American Cancer Society, http://www.cancer.org). This has been expanded to include concepts of “overwhelming and sustained exhaustion and decreased capacity for physical and mental work…not relieved by rest.” In addition, fatigue has been shown to affect negatively one's economic status, and social and emotional status.
CRF is correlated to treatment intensity and can last well past completion of treatment. As many as 75% of cancer patients have CRF. The likelihood of developing fatigue is increased with any cancer-related treatment (surgical, chemotherapeutic, or radiotherapeutic) and is also more likely to occur with comorbidities (e.g., hepatic, cardiac, renal, pulmonary) and other conditions (e.g., insomnia, inactivity, chronic pain, mood disorders). Fatigue may persist beyond the treatment period.
Treatment is frequently directed at varying the treatment protocol when possible and providing treatment holidays (Practice Guidelines NCCN for Cancer-Related Fatigue. http://www.nccn.org). It has been shown that improving quality of sleep is helpful, but increasing the amount of “rest” is not effective in reducing the symptoms of CRF. Careful attention to comorbidities and their treatment will reduce CRF. Treatment of depression and chronic pain has been shown to improve symptoms. Exercise has been shown to mitigate fatigue.
Delirium and Cognitive Dysfunction
Delirium is a mental state in which a person is confused, disoriented, and not able to think or remember clearly. The incidence in studies of advanced cancer patients ranges from 20% to 86%.Delirium may be reversible in 50% of the cases with proper identification and management. Delirium in cancer usually has multifactorial etiology. Accurate assessment is critical for effective treatment. Direct involvement of the central nervous system by primary or metastatic tumors, especially with resultant cerebral edema, is the most readily apparent cause. However, distant tumor cytokine production may also play a role. Liver metastasis may also elevate serum toxins, causing a metabolic delirium. Risk factors for the development of delirium in bone marrow transplant patients before transplantation include lower cognitive functioning, lower physical functioning, and higher blood urea nitrogen, alkaline phosphatase, and magnesium levels.
Medications certainly play a large role in the development of delirium. In a study of 216 hospitalized cancer patients, corticosteroids, opioids, and benzodiazepines were most frequently associated with delirium. A variety of other medications may also contribute: anticholinergics, anticonvulsants, antihistamines, dopamine agonists, metoclopramide, and selective serotonin reuptake inhibitors. A number of chemotherapy agents have also been implicated: methotrexate, isofamide, fluorouracil, vincristine, bleomycin, carmustine, cisplatin, and procarbazine. It is also important to remember that abrupt withdrawal of certain medications can cause delirium; these include benzodiazepines and muscle relaxants (especially Baclofen).
The clinician must also consider metabolic causes. Fever and sepsis often produce acute delirium. Dehydration and uremia frequently contribute. Electrolyte abnormalities—increased and decreased levels of sodium, calcium, and magnesium—are often associated with cognitive dysfunction. Hypoxia and hypoglycemia are additional possibilities that can be easily assessed.
Delirium may present as either a hypoactive or a hyperactive state. In hypoactive cases, dehydration frequently contributes to delirium. In hyperactive states, medication side effects (especially opioids and corticosteroids) and liver failure are often culprits.
Management of delirium should always start with nonpharmacologic interventions. Family involvement may decrease anxiety and provide familiar surroundings. If family is unavailable to supervise the patient, a sitter may be necessary. Calm, simple communication should be used. Environmental changes should be used to minimize distractions (noise, lights, simultaneous conversations). Physical restraints tend to worsen the situation and should only be applied in extreme situations. The clinician should discontinue the use of unneeded medical devices such as intravenous lines and urinary catheters.
Pharmacologic intervention can be of help when there is agitation or hallucination. Haloperidol is considered to be the major tranquilizer of first choice. Newer antipsychotics such as olanzapine may be helpful as well. Benzodiazepines are effective when there are convulsions or in cases of alcohol or sedative withdrawal, but they often worsen confusion in other causes of delirium. Methylphenidate has been used successfully in a small study (in cancer patients with hypoactive delirium (psychomotor retardation).
Receiving a cancer diagnosis is stressful and frightening for most individuals. Initially patients may experience symptoms of shock, disbelief, denial, or despair as they struggle to accept and incorporate the reality of the diagnosis. Patients may also experience a variety of normal fears throughout their treatment course, including fears of disability, loss of societal roles, loss of control, loss of desirability, abandonment, and death. Overall, however, most patients cope successfully with cancer diagnosis and treatment and experience good long-term psychologic adjustment. Many patients even describe positive changes in their lives related to their diagnosis, including positive changes in self-perception, interpersonal relationships, priorities, and goals.
Although most patients cope well, a significant number do experience serious mood disorders. The average estimates of the prevalence of depression among cancer patients are from 15% to 25%. The importance of correctly diagnosing and treating depression is underlined by research showing that depression is associated with poor compliance with medical care, longer hospitalizations, and higher mortality rates in patients with chronic illnesses.
Anxiety is quite common in cancer patients and may be related to poorly controlled pain, abnormal metabolic states, or medication side effects. They may also develop post-traumatic stress disorder in response to cancer diagnosis and treatment. Post-traumatic stress disorder is an anxiety disorder that develops after an extremely stressful event, such as the development of a life-threatening illness. Within 5 years of diagnosis, between 10% and 15% of cancer survivors may meet criteria for post-traumatic stress disorder.
A wide variety of impairments of nervous system function may result from cancer, either by direct effect at the primary or metastatic tumor site or secondarily as a consequence of surgical or radiation treatments. These impairments, regardless of the tumor's location, extent, or type, may significantly affect the individual's physical, social, vocational, and emotional capabilities. Important differences exist between the management of patients with cancer of the central nervous system and those with other types of acquired neurologic disability. Rehabilitation strategies must consider progressive, sometimes rapid, functional decline, toxic effects of cancer treatments, tumor recurrence, CRF, medical fragility, insurance and workplace discrimination, and psychologic and family issues associated with an often terminal disease. The interdisciplinary rehabilitation team is best equipped to handle the complexities of restorative care in these situations, and meet the patient's and family's goals of maximizing functional recovery and preserving QoL.
Tumors affecting brain tissue are either primary or metastatic in origin, with metastatic lesions composing roughly 50% of all intracranial tumors. Brain metastases occur in 20% to 40% of patients with cancer and their frequency has increased in recent years, probably as a result of improved detection and treatment. Lung, breast, and skin (melanoma) are the commonest sources of brain metastases, and in as many as 15% of patients the primary site remains unknown. In those with metastatic brain tumors, studies demonstrate that the three strongest prognostic factors are physical performance status, response to steroids, and evidence of systemic disease. Brain tumors vary widely in aggressiveness and prognosis. To what extent tumor type or location has an impact on rehabilitation outcomes is not clear. However, one study found a tendency for greater gains for meningiomas and patients with left hemispheric lesions. Brain tumor patients receiving inpatient acute rehabilitation show similar gains between those with metastatic origin and primary brain tumor. However, functional gains were superior on initial presentation to rehabilitation as compared with those with recurrence of the cancer.Brain tumor patients have been found in some studies to have shorter lengths of stay on acute rehabilitation units as compared with other noncancerous brain disorders, possibly as a result of higher initial levels of functional independence on admission, fewer behavioral issues, better social support, and expedited discharge planning due to cancer-related prognostic factors. Despite increases in survival rates of patients with primary brain tumors and advances in treatment, survival is limited for many and must be considered with regard to the timing, duration, and types of rehabilitation interventions.Statistics show the mean survival for glioblastoma multiforme patients with optimal treatment is about 1 year, and that patients with brain metastases assessed as having the best prognosis survive only a mean of 7.1 months.
Most patients with brain cancer have multiple impairments, depending on tumor location and size, and in those who have undergone surgery, the volume of tissue excised. In a study of patients with brain tumor undergoing acute rehabilitation, the most common neurologic deficits included impaired cognition (80%), weakness (78%), and visual-perceptual dysfunction (53%). Rehabilitation efforts for brain cancer patients should focus on the patient's neurologic and functional status, coexisting medical problems, and tolerance of physical activity. As with patients with stroke or traumatic brain injury, goal setting should be appropriate to the individual's physical, cognitive, and behavioral status, and include early planning for postacute rehabilitation care.
Specific rehabilitation measures for patients with brain cancer-related disability emphasize early attention to mobilization, including bed mobility, transfer training, and ambulation or wheelchair skills. Those patients presenting with unilateral leg weakness will benefit from a physical therapist assisting with progressive gait and balance training, and when necessary using an assistive device appropriate for the degree of stability required (single-point cane, four-pronged cane, or walker). Provision of an ankle-foot orthosis to control weakness and/or spasticity of ankle musculature is often needed. The risk of limb contracture—especially in ankle plantar flexion, wrist and finger flexion, and shoulder adduction and internal rotation—is increased in patients with weakness, particularly spastic hemiplegia. Early and regular stretching programs, along with appropriate limb positioning and supportive devices such as Multi Podus (LEEDER Group Inc., Miami, FL) boots are critical. Glenohumeral support and position in bed and wheelchair, the latter involving a lap table or arm trough, is key to preventing hemiparetic shoulder pain. A flaccid or significantly subluxed glenohumeral joint may require a humeral cuff or sling-type arm support, used judiciously so as to not promote a contracture in internal rotation and adduction. For individuals limited by unilateral arm weakness, an occupational therapist can provide adaptive equipment such as reachers, sock donners, or elastic shoelaces.
Additionally, attention should be given to other potential complications of reduced mobility including deep venous thrombosis and skin breakdown. Awareness among physicians of the risk of thromboembolism in brain tumor surgery patients may be insufficient, highlighting the need to be vigilant in prophylaxis for deep venous thromboses. Seizures represent the most frequent medical problem encountered during rehabilitation for brain tumor patients, occurring in about 20% to 40% of patients with brain metastases. Anticonvulsants are appropriate in patients with documented seizures and probably for short-term use perioperatively, but prophylactic use of these agents in patients with tumor but without seizures is generally not recommended.
Paraplegia and Tetraplegia
Injuries to the spinal cord may be secondary to either traumatic or nontraumatic causes. Cancer-related spinal cord injury (SCI) incidence may actually exceed that from trauma and represents the most frequent type of nontraumatic SCI. Symptoms consistent with SCI occur as a result of metastasis in as many as 5% of all cancer patients. Symptoms such as weakness, sensory loss, and bladder and bowel sphincter dysfunction can be a consequence of either tumor compression on, or invasion of, the spinal cord or its vasculature, spinal instability from bony invasion, or secondary to the cancer therapy itself (radiation or surgery). Spinal metastases occur more commonly in the thoracic spine (70%), followed by the lumbosacral (20%) and cervical (10%) spine, and most often originate from primary tumors of breast (15%), lungs (10%), and prostate (10%). Lymphoma, myeloma, and primaries of unknown origin also metastasize to the spine, each accounting for around 10% of cases. The majority (95%) of metastatic spine involvement is extradural, arising from a vertebral body. Primary tumors of the spinal cord such as meningiomas, neurofibromas, and gliomas are relatively rare. Spinal cord metastases produce a clinical syndrome characterized initially by pain in 90% of cases, followed by weakness, sensory loss, and sphincter dysfunction. Weakness is present in 74% to 76% of patients, autonomic dysfunction in 52% to 57%, and sensory loss in 51% to 53%. Pain alone may persist for a month or more (average 6 weeks) before significant neurologic changes develop. Acute onset of back or neck pain in a patient with cancer should be considered as spinal metastasis until proven otherwise.
Positive results have been demonstrated following rehabilitation for individuals with disability from spinal cord tumors, with significant functional gains measured after inpatient rehabilitation.   For patients who retained some motor or sensory function, those with the most neurologic deficits were found to benefit most from inpatient rehabilitation. Factors that have been identified as better prognostic indicators for survival after inpatient rehabilitation include lymphoma, myeloma, breast and kidney tumor types, SCI as the presenting symptom, slow progression rate of neurologic symptoms, combined surgery and radiation treatments, partial bowel control, and partial independence with transfers on admission.
As with traumatic injuries, dysfunction resulting from spinal cord tumor may be classified according to the level of motor and sensory impairment as well as the completeness of the involvement. However, nontraumatic SCI, which includes cancer etiology, differs from traumatic involvement. For spine tumor patients, McKinley and associates found less severe neurologic impairment, greater likelihood of presenting with paraplegia than tetraplegia, and greater frequency of motor incomplete lesions than complete lesions.
Medical complications associated with recent SCI are common, potentially life-threatening, and require a vigilant and knowledgeable hospital staff. Comprehensive SCI care includes attention to ventilatory ability in those with high spinal levels of injury, and management of pain, autonomic dysreflexia, pulmonary and urinary tract infections, thromboembolic disease, bowel and bladder dysfunction, decubitus ulcers, limb contractures, and spasticity. Certain measures instituted immediately after onset of spinal cord dysfunction remain standards of acute care in this patient population. Prophylaxis for lower-extremity venous thromboses with low-molecular-weight heparin should be immediately initiated unless otherwise medically contraindicated, and continued for at least the duration of the rehabilitation phase, and in cases of plegia or severe paresis, for a total of 3 months. Other areas of management that should be instituted early for those with loss of thoracic musculature include incentive spirometry and chest physiotherapy. Initiation of intermittent bladder catheterization every 4 to 6 hours when daily bladder volumes are less than 2 liters should be routine treatment, as well as instituting a bowel program with daily or every other day suppository or digital stimulation. Other key measures in early spinal cord care include prevention of skin breakdown in body areas commonly at risk (occiput, sacrum, greater trochanter, heels, and ischial tuberosities) including turning in bed every 2 hours, specialized pressure relief bed and wheelchair mattresses, and heel protectors. Additionally, at least daily limb range of motion should be initiated immediately after onset of the SCI. Patients with severe spinal cord dysfunction above T6 level are prone to developing autonomic dysreflexia—a significant increase in blood pressure above baseline, as a result of vasoconstriction from splanchnic sympathetic nerve stimulation by noxious stimuli below the level of the spinal lesion. If blood pressure remains significantly elevated, pharmacologic measures and intensive monitoring may be required.
Speech, Swallowing, and Nutrition
Disorders of speech and swallowing may be the result of direct tumor invasion of the oral cavity, larynx, pharynx, esophagus, or adjacent structures; secondary to surgical or radiation treatments; or consequent to cancers of the nervous system that affect pharyngeal or laryngeal control. Head and neck cancers constitute about 3% to 5% of all malignancies. Preservation of swallowing, having a natural airway, and intact speech are critical components that influence QoL in head and neck cancer patients. Among these, swallowing has been shown to have the largest impact on global QoL.
Head and neck cancer and its treatment often results in major effects on nutrition, swallowing, and communication function. Depending on the tumor location, surgical excision and repair often impairs key articulatory, deglutitory, or airway-protective structures causing difficulty in speaking, transporting food, and maintaining a healthy airway. For example, deeply infiltrative cancerous lesions of the tongue requiring more than 50% tissue resection significantly impair speech and swallowing. In one study, some surgical patients, depending on the extent of tissue resection, achieved functional swallowing and eating within 3 months of surgery, whereas for others significant impairment remained for as long as 9 months postoperatively.
Postsurgical nutrition is initially via nonoral means (percutaneous endoscopic gastrostomy or nasogastric feeding tubes). However, prompt and early evaluation of oropharyngeal function is required before oral intake is resumed. The physical examination should include the neck, mouth, oropharynx, and larynx, and related neurologic function. As soon as feasible following surgery, oral-motor exercises are initiated with speech-language pathology focusing on strength, range of motion, and sensory awareness of the involved structures. Dysphagia assessment and treatment typically begin with a radiographic evaluation defining the nature of the patient's swallow dysfunction, with attention to alterations of the local anatomy. A videofluorographic swallowing study is particularly useful for identifying aspiration risk and for empirically testing therapeutic and compensatory techniques to eliminate food entry into the airway and promote successful and timely passage into the esophagus.
Swallowing strategies focus on prevention of aspiration and the efficiency and completeness of moving the food bolus through the oral, pharyngeal, and esophageal segments. Common interventions include modifying food texture, such as thickening liquids or blenderizing solid food, and/or altering head posture and swallowing behaviors. The latter may include techniques such as chin tuck to prevent laryngeal penetration, head rotation to reduce retention in the piriform sinus, enforced double or effortful swallows to reduced pharyngeal residue, or supraglottic swallow to optimize vocal fold closure and airway clearance.
In the majority of head and neck cancer patients, impaired vocal communication occurs at some point during treatment. It is important to keep in mind that multiple conditions other than total laryngectomy can result in deficient phonation in cancer patients. These include copious secretions, localized edema, fibrosis and scarring, presence of a tracheostomy, glossectomy, loss of oral mobility from local tumor or trismus, and neurogenic pharyngeal or laryngeal paralysis. The patient with total laryngectomy lacks a source of voice production and must replace laryngeal function with an artificial larynx (electrolarynx), esophageal speech, or tracheoesophageal puncture voice restoration with a prosthetic surgical device.
Bone Tumors, Amputation, Bony Metastases
In 2007, about 2370 new cases of cancer of the bones and joints will be diagnosed. Skeletal tumors account for less than 0.2% of all cancers. Soft-tissue and bony sarcomas are managed with amputation or limb-sparing procedures. Limb salvage procedures are increasing in frequency and are associated with long-term survival, local recurrence rates, and QoL equivalent to those of amputations, largely made possible by improved surgical techniques that preserve unaffected tissue, advances in endoprosthetic design and durability, soft-tissue reconstructive procedures, and radiation and chemotherapy effectiveness in controlling local and distal spread.
Rehabilitation after limb-sparing procedures depends on the extent of soft-tissue and bony resection, and because of combined tumor resection, skeletal reconstruction, and soft-tissue and muscle transfers, may be more intensive than that following amputation. The planning process begins preoperatively, with the rehabilitation specialists providing evaluation of the individual's functional level before surgery and then projecting what the probable functional needs will be postoperatively. This includes instruction on mobility aids, orthotics for joint stabilization, as well as strengthening and endurance exercises in collaboration with the treating surgeon. The possible need for long-term limb bracing should be discussed if sacrifice of major nerves or muscles is required. Complex limb reconstruction requires an astute team to assess for possible complications during the recovery process. The majority of microsurgical complications occur within the first 24 to 36 hours after surgery, but that period may extend to as long as 1 or more weeks when the patient begins initial mobilization of the extremity after a period of bedrest. Complications may include arterial or venous microvascular thrombosis, hematoma, or flap dehiscence during ambulation. Splinting and wound dressing must be done with care to avoid problems associated with pressure on the flap. Although various strategies are used in mobilizing patients following reconstruction of the lower extremity, they often require a period of strict bedrest (as long as 7–10 days) to allow wound healing, control edema, and maintain limb alignment, followed by several days of dangling the extremity for short intervals. If this has been successfully achieved, physical therapy can begin with toe-touch ambulation with an assistive device such as a crutch or walker. Upright activity progresses to partial and full weight bearing depending on the patient's strength and degree of wound healing. After adequate healing has occurred, a pressure garment should be fitted so as to prevent or lessen the onset of lymphedema.
Other lower limb-sparing procedures undertaken in this population may involve wide excision of portions of muscle, typically involving hip adductors, quadriceps, hamstrings, and gastrocnemius muscles. Leg elevation, active range-of-motion exercises, and compression garments to control edema are instituted as part a rehabilitation program following these procedures. Approximately 15% to 20% of sarcomas arise in the upper extremities, and are generally smaller in size and associated with better survival than those in the lower extremities, with whole muscle groups only rarely removed.  However, major resections of tumors of the shoulder region can present significant challenges to the rehabilitation team, depending on the extent of tissue loss and neurologic involvement. Upper-extremity reconstructive procedures often require a sling or shoulder harness for support, with the goal to develop adequate strength and function of the hand and control edema through the use of low-stretch bandages. Early rehabilitation should avoid humeral motion, and range of motion after acute healing should not exceed 90 degrees of abduction, with adduction not permitted. To minimize contracture formation of the digits, the hand should be placed in a functional position with the wrist dorsiflexed at 30 degrees, the metacarpophalangeal joints flexed at 70 to 90 degrees, the interphalangeal joints extended, and the thumb abducted. The salvaged limb becomes for the long term non–weight bearing and nonlifting. A shoulder mold can be fashioned that allows a more cosmetic clothing fit. For soft-tissue sarcomas involving the forearm extensor muscles or radial nerve removal, a cock-up splint to maintain wrist extension or a brace that incorporates a dynamic outrigger to substitute for weak or absent finger extension may be prescribed.
Tumor amputees differ from dysvascular and traumatic amputees in several important ways. Fatigue, anemia, nausea, and toxic effects of chemotherapy may diminish functional capacity. Wound healing may be delayed over irradiated areas and skin less tolerant of prosthetic wear. Cancer amputees typically have shorter residual limbs so as to obtain tumor-free margins. It is more common in this population to have more proximal sites of amputation, in that the primary pathology is often located at proximal sites, such as forequarter or shoulder disarticulation in the upper limbs or hemipelvectomy in the lowers. Weight loss, muscle atrophy, and residual volume shifts, particularly during chemotherapy, may prolong the wait for a definitively fitted prosthesis. In these cases, the use of flexible, adjustable sockets to permit continued prosthetic wear and training has proven beneficial for patients with early postoperative fluctuations in stump size.  
If amputation is required the most functional level should be selected, allowing for as much residual limb length without sacrificing tumor control. For instance, a very short above-knee amputation can be accommodated with a prosthesis and is more energy efficient and functional than a more proximal hip disarticulation. Similarly, prosthetists are able to effectively fit short below-knee and below-elbow stumps, functionally superior to their above-elbow and above-knee counterparts. Otherwise the rehabilitation of tumor amputees is similar to that for other patients, including the use of a multidisciplinary team, preoperative education for the family and patient about what to expect at different stages of preprosthetic and prosthetic training, and early initiation of exercises to improve strength and stamina. Rehabilitation often commences in the operating room when it is recommended that an immediate postoperative rigid dressing be fitted to the residual limb. Early use of rigid stump dressings have been shown in some studies to reduce time to delivery of the first definitive prosthesis, control stump edema and pain, reduce phantom limb sensation, help shape the residual limb, and speed incision healing. Otherwise stump shrinker socks or elastic wraps are applied to control the shape of the residual limb. Proper positioning both in bed and in the wheelchair is necessary to prevent contracture formation and reduce edema in the residual limb, along with range-of-motion exercises and judicious use of splinting. Management of postoperative pain is critical, often requiring narcotics for the initial period. Desensitization techniques can help prepare the stump for acceptance of the prosthetic socket. Preprosthetic training includes upper-body strengthening and endurance exercises, and should include unipedal walking with appropriate assistive devices until weight bearing through the prosthetic leg is advised. The timing of fabrication of a permanent prosthesis will depend on the type and extent of the surgery as well as the status of other concurrent medical management, including chemotherapy.
The vast majority of skeletal cancer is of metastatic origin, with breast cancer being the most common primary source in women and prostate cancer in men. Other common primaries that metastasize to bone include lung, renal, and thyroid cancers. The vertebrae, pelvis, femur, ribs, and skull are the most frequently involved sites of bone metastases, with the axial skeleton and the lower extremities, particularly the hip region, affected most frequently. One or more of the following problems may occur with bone metastasis: pain, hypercalcemia, pathologic fractures, myelosuppression, and spinal cord and/or nerve root compression with subsequent progressive immobility.
Bone metastases are a frequent source of cancer-related physical impairment that requires the active involvement of the rehabilitation team. Challenges for the treating team arise when metastatic bone lesions produce severe pain that limits function or imposes risks of fracture during therapeutic exercise or mobility. Factors that inform the therapeutic approach will include the degree of associated pain, lesion location, response to radiation therapy, neurologic compromise, and the presence or risk of fracture. The type of metastasis (lytic versus blastic) is also important, with lytic lesions considered more prone to fracture. The incidence of pathologic fracture among all tumor types is about 8%, with breast carcinoma responsible for the majority of these. Sixty percent of all long bone fractures involve the femur, with most of these involving the proximal portion. Patients who are deemed at risk for a pathologic fracture should be made non–weight bearing to the affected structure, pending surgical consultation.
Rehabilitation for this patient population focuses on removal of weight bearing or immobilizing compromised bone through the provision of assistive devices and orthoses, strength and balance training, and modification of the patient's environment. Whenever possible, bedrest should be avoided, because it adds to general debility and further functional loss, as well as increasing the risks of hypercalcemia and thromboembolic disease. Depending on the severity and location of the lesion, mobility restrictions can range from non–weight bearing to weight bearing as tolerated. For complete non–weight bearing restrictions, assistive devices in the form of walkers or bilateral crutches are typically necessary. Single-point canes are used for patients with minimal balance deficits and smaller lesion size, but patients with larger, more symptomatic lesions should be advanced to a forearm (Lofstrandt)-type crutch, which permits a greater degree of weight support. It is critical to first rule out the coexistence of upper-extremity lytic lesions before prescribing assistive devices that require weight support through the arms. Bracing may reduce risk or symptoms of a pathologic fracture involving the upper extremities, and can facilitate use of the arms in functional activities. Those individuals with upper-limb lesions should be taught to minimize torsion and weight loading, and may benefit from an arm sling or humeral cuff support. In the spine, Jewett bracing to prevent spinal flexion, or a custom-molded clam-shell design to give stability in all directions can be prescribed. When more rigid bracing is not tolerated secondary to poor skin tolerance or discomfort, a thoracolumbar corset provides limited support and pain relief. Spinal bracing should extend several segments above and below the involved area of the spine.
Cancer patients suffering from pathologic fractures and associated functional deficits have been shown to make significant gains when admitted to an inpatient rehabilitation hospital unit. It should be recognized that rehabilitation of patients with skeletal metastases has many inherent risks, and strategies to exercise these patients remain largely theoretical because of a lack of empiric data. However, the alternative to rehabilitation therapies is often bedrest, which carries its own set of potential complications, including muscle contractures, weakness and atrophy, osteoporosis, orthostatic hypotension, pressure sores, pulmonary infection, and increased risk of thromboembolic disease.
Soft-Tissue Impairments Associated with Cancer Diagnoses
Cancer and or its treatments can cause significant soft-tissue abnormalities. One of the most frequently observed is lymphedema, extremity swelling that results from disruption of the lymphatics following axillary or groin dissection. The prevalence of this in breast cancer patients has been reported to be 200,000 (10%), or generally between 15% and 30%. In the ALMANAC study, the relative risks of any lymphedema and sensory loss for the sentinel lymph node biopsy group compared with the standard axillary treatment group at 12 months were less, as were drain usage, length of hospital stay, and time to resumption of normal day-to-day activities after surgery. Overall patient-recorded QoL and arm functioning scores were statistically significantly better in the sentinel lymph node biopsy group. Although the prevalence of limb edema is high following standard treatment, the treatment options for managing this have improved. The use of manual lymph drainage and compression garments is effective in controlling edema. When applied early in the course of treatment, before the development of significant volume increase (e.g., >250 mL increase in the arm), lymphedema can almost be reversed.
The second, frequently seen soft-tissue complication of cancer treatment is frequently radiation induced. In the brain this causes gliosis, in the lung and gastrointestinal tract, fibrosis. Each is associated with significant inflammatory reaction and subsequent scarring. In the musculoskeletal system, muscle, fascia, and tendon all respond in a similar fashion. Long-term sequelae include fibrosis and contracture, eventually resulting in loss of muscle mass. This process is associated with vascular permeability and inflammation and release of proinflammatory cytokines (interleukins, transforming growth factor-β) and continues well past cessation of the radiation therapy. The use of antifibrotic agents in the treatment of this problem has shown promise.
Allogeneic bone marrow transplantation has prolonged life for many with hematologic malignancies. One of the complications of this procedure has been the rejection by the host of the transplanted, immunocompetent engrafted cells, called graft versus host disease. The immunologic reaction is often quite brisk, resulting in organ damage (fibrosis) to lung, liver, gastrointestinal tract, and notably skin and soft tissue. In the chronic form of graft versus host disease, limb edema, peau d'orange, fasciitis, and enthesitis can occur, resulting in significant loss of joint motion. There may be subsequent muscle atrophy secondary to disuse and associated loss of upper- and lower-extremity mobility.
Bladder and Bowel Management
Loss of bladder or bowel control in cancer patients is often multifactorial and can be secondary to neurogenic causes, such as with brain or spinal cord tumors, can result from nonsurgical or surgical cancer therapies, or can occur as a direct effect of gastrointestinal or genitourinary tumors. Incontinence in this population may also be related to immobilization in bed, side effects of pharmacologic management, or diminished alertness and communication skills. This condition encompasses both medical consequences and QoL issues. Medical sequelae of loss of bladder and bowel function include renal infection and stone formation, skin ulceration, autonomic dysreflexia, fecal impaction, hemorrhoids, diverticulosis, and rectal prolapse. Loss of self-esteem, depression, and social isolation may develop. Incontinence after stroke, for instance, has been shown to be a strong predictor of mortality, dependency, and need for institutional care. It is incumbent on the treating team to properly assess patients with fecal or urine incontinence and institute a management plan.
The formulation of a bowel management program should take into account the limitations of the patient's functional mobility and self-care skills, available family support and resources, and concurrent medical problems. Patient and family need to be educated on the long-term management of bowel dysfunction including the rationale, goals, and techniques of bowel management. This should include instruction in the safe use of assistive devices for bowel emptying, efficient and effective techniques for bowel emptying, and the importance of timing, regularity, and positioning in bowel evacuation.
Any destructive lesion or process above the conus medularis can lead to an upper motor neuron bowel pattern of dysfunction, characterized by fecal distention of the colon, overactive segmental peristalsis, underactive propulsive persistalsis, and a hyperactive holding reflex with spastic external anal sphincter constriction. The latter requires a mechanical (i.e., digital stimulation) or chemical (i.e., bisocodyl suppository) aid to trigger a reflex defecation. A lesion at the level of the conus medullaris, cauda equina, or inferior splanchnic or pudendal nerves affects the parasympathetic and somatic pudendal cell bodies. This condition results in a lower motor neuron lesion characterized by colonic slowing, constipation, fecal incontinence, and difficulty with emptying. In such patients routine manual clearance of stool from the rectum may be necessary. Inactivity and debility associated with hospitalization for cancer management promotes the supine position, which inhibits effective bowel evacuation. Hospitalized cancer patients should also be placed on a consistent timed emptying program based on stimulating regular bowel evacuation, and where appropriate, the use of stool softeners, bulk-forming agents, and/or natural stimulants such as senna. Stimulation of the rectocolic reflex using manual stimulation and/or bisocodyl or glycerine suppository may induce bowel movement on a regimen basis. Taking advantage of the gastrocolic reflex with planning defecation after meals is also useful. Overactive intestinal motility with frequent stooling and/or diarrhea may require judicious use of medications to decrease peristalsis.
Management of bladder incontinence in cancer patients follows many of the same principles outlined previously for managing bowel incontinence. The patient should be taught to take responsibility wherever feasible for understanding and directing his or her bladder program. Patients with cancer involving bladder outlet obstruction such as with prostate cancer are at added risk of incomplete emptying, urinary stasis, hydronephrosis, and urinary tract infection. Certain commonly encountered medications may impair bladder control and function, including sedatives, muscle relaxants, opiates, calcium channel blockers, and antihistamines.
Voiding disorders in cancer patients may be a result of neurologic conditions, such as spinal cord tumor involvement, myelopathic consequences of radiation therapy, brain tumor, or lesions affecting sacral or pelvic nerve structures. Spinal cord lesions at suprasacral levels result in bladder dysfunction characterized by detrusor hyperreflexia and uncoordinated micturition with detrusor-sphincter dyssynergia. Tumors involving more caudal spinal regions including the conus medullaris, cauda equina, and S2 to S4 peripheral nerves will cause variable loss of parasympathetic and somatic nerve function, resulting in areflexia and loss of external sphincter function. Suprapontine lesions due to brain tumors may lead to uninhibited bladder contractions possibly secondary to loss of cerebral cortex inhibition at the sacral micturition center. Voiding dysfunction may also be classified functionally as failure to store urine due to bladder hyperreflexia, or insufficient sphincter outlet control, or due to failure to empty because of bladder hypo- or areflexia, or from inadequate sphincter opening ( Table 37-2 ).
Table 37-2 -- Functional Classification of Voiding Dysfunction and Management Options
Sexual function can be very important to cancer patients, yet it is seldom discussed by the patient and physician. In breast cancer, treatment often produces side effects of fatigue, nausea, diminished vaginal lubrication, not to mention the significant body image changes from mastectomy. A meta-analysis of 36 studies of sexuality in testicular cancer patients showed that problems were largely related to ejaculatory dysfunction, but, fortunately, rates of decreased sexual desire were low and may improve with time. Erectile dysfunction is a common side effect of prostatectomy, and of hormonal and radiation therapy for prostate carcinoma. Colorectal cancer surgeries often lead to sexual dysfunction in men. Not surprisingly, gynecologic cancers often produce changes in vaginal sensation, structure, and lubrication. On a positive note, however, of cancer patients who received brief sexual counseling, 63.5% reported improvement.
With their multitudes of possible impairments, it is not surprising that many individuals with cancer have significant limitations in their activities. These limitations include reduced mobility and limited ability to perform ADLs. These often result from neurologic or orthopedic impairments but may also be related to fatigue. Communication and socialization skills may be negatively affected by cognitive deficits, by impairment of speech, or by depression and anxiety.
Activities of Daily Living
Basic ADLs include feeding, dressing, hygiene, and toileting. These ADLs are virtually universal to human dignity across world cultures. Impairments of upper-limb function play an obvious role in limiting performance of ADLs, but other impairments also can impede these functions. Cognition is critical to sequencing, awareness, and carryover in the performance of ADLs. Pain and fatigue can also limit the individual's ability to complete these tasks. Lower-limb impairments can limit standing and transferring, making it difficult to carry out dressing, hygiene, and toileting.
When individuals become disabled enough to require assistance with these skills, the burden generally falls on caregivers. In one study of 483 cancer patients at varying stages of their disease course, 18.9% had unmet needs in their ADLs as a result of lack of a suitable caregiver. Among advanced-stage cancer patients the percentage of caregivers with a high level of psychologic distress varies from 41% to 62% directly depending upon the functional status of the patient.
Rehabilitation efforts, particularly with the involvement of occupational therapy, can significantly reduce this burden on caregivers and enhance the QoL for cancer patients with disabling impairments.Addressing functional loss from impairments of the upper limb, such as chemotherapy-related peripheral neuropathy of the hand or radiation-induced brachial plexopathy, can substantially improve performance of ADLs. To improve feeding independence among cancer patients with upper-limb neurologic dysfunction, Chinese researchers used positioning, feeding aid supports, and upper-limb supports, and significantly improved function over a 3-week treatment intervention. Use of simple adaptive aids, such as a swivel fork, can enhance function tremendously. Home-based occupational therapy interventions produce a high level of patient and caregiver satisfaction, reducing burden of care.
Exercise for Cancer Patients
Patients with cancer diagnoses suffer from a variety of symptoms attributable to direct effects of tumor and/or their treatments. Some of the treatments—surgical, chemotherapeutic, radiotherapeutic, or biologic—can cause immediate and remote effects.
Typically the treatment substantially affects the neuromusculoskeletal system, resulting in functional loss and fatigue. The latter is reported to be one of the most distressing symptoms.  
Exercise is one of the most effective strategies for symptoms associated with cancer fatigue, sleep disruption, and abnormalities of mood, physical function, and QoL. Rigorous meta-analyses, however, caution that these studies are subject to significant methodologic problems, such as small sample sizes, diverse forms of exercise, nonrepresentative samples (e.g., few African Americans and Hispanics; few advanced cancers, many breast cancer studies). Another significant methodologic problem is that the instruments used to measure fatigue, mood, and QoL are subjective, relatively insensitive, and inconsistent in measuring intensity, impact on daily routines, or state of satisfaction or well-being. This makes study comparability difficult. Nonetheless, meta-analyses suggest that for adults with a variety of cancer diagnoses and receiving a variety of exercise interventions, exercise improves physical function, QoL, and cardiorespiratory fitness, and decreases CRF. The great majority of these studies use aerobic exercise, using ergometry and walking programs, and occasionally, aquatic therapies.
Strengthening protocols, though not contraindicated, have not been thoroughly evaluated.
Contraindications for exercise include: thrombocytopenia (<50,000 platelets/μL, no resistive exercise; <20,000 platelets/μL, only ADLs and light activity); anemia (<8 g ADLs only; 8–10 g, light exercise as tolerated); bony metastatic disease (25% to 50% cortical involvement in long bone, partial weight bearing, avoid lifting; 0 to 25%, full weight bearing, no high-impact sports); pulmonary (50% to 75% forced expiratory volume in 1 second or carbon monoxide diffusing capacity, no aerobic exercise); cardiac (low ejection fraction or arrhythmia, consult cardiology; electrolytes (Na below 130 mEq/L, K below 3 mEq/L [correct the hypokalemia], Ca above 6 mEq/L [correct the hypercalcemia], no exercise). Relative contraindications are for tachycardia greater than 100 beats per minute and temperature of >99.5°F or >37.5°C.
Physical modalities may be used to control pain and improve range of motion, thus leading to better mobility. Most physical modalities have not been well studied in cancer patients because of the concern of exacerbating an underlying malignancy. Those that are generally believed to be safe include cryotherapy, biofeedback, iontophoresis (transdermal delivery of medication by electrical current), transcutaneous electrical nerve stimulation (TENS), and massage. Electrical stimulation, regardless of how it is delivered, is generally not done directly over a tumor site. The same is true for massage therapy and superficial heat. Deep heat (e.g., ultrasound and phonophoresis) is usually contraindicated in cancer patients. Spinal traction is contraindicated in those patients with spinal metastases or with significant osteoporosis.
Durable Medical Equipment
Durable medical equipment provides an important tool in improving the activity level of cancer patients. Durable medical equipment includes hospital beds, canes, walkers, wheelchairs, and motorized scooters. These can greatly enhance mobility when properly prescribed and when the patient is properly trained in their use. Wheelchairs should be individually fitted, because the wrong size can lead to skin breakdown or make accessibility difficult, if it is too wide.
Oxygen tanks and supplies are also considered durable medical equipment. Oxygen supplementation can enhance endurance and cognition, and reduce dyspnea in patients with hypoxia due to lung cancers or metastases.
Participation refers to the roles an individual plays in society. These roles can include family and social relationships as well as vocational and avocational pursuits, and they often require modes of transportation to accomplish. Cancer patients are often restricted in many of these functions.
Family and Social Relationships
Cancer can often draw a family together; however, it just as often leads to significant distress for families. Caregiver and patient coping styles significantly influence the level of strain in families.Support groups can also be helpful, yet fewer than half of patients receive information about them, even in a large tertiary oncology center. In one study of 121 cancer patients, caregiver QoL was significantly correlated to the social/family and functional dimensions of the patients’ QoL; physical and emotional dimensions did not correlate. Early, though, caregivers undergo significant psychosocial stress. There are also significant economic burdens on families. Indeed cost considerations play a large role in patient decision making regarding cancer treatment, especially among the poor.
Work disability following cancer diagnosis is a common occurrence. Short and coworkers conducted phone interviews of 1433 cancer survivors at 1 to 5 years after diagnosis. More than half had quit work during their first year after cancer diagnosis, but fortunately three-quarters of those returned to work subsequently. A projected 13% had indefinite work disability. Survivors of central nervous system, head and neck, and stage IV blood and lymph malignancies had the highest risk of quitting work.
Fortunately U.S. laws in recent years have provided more protection to the cancer survivor returning to work. These include the Americans with Disabilities Act, Family and Medical Leave Act, and the Health Information and Portability Act. Nevertheless, a great deal of barriers still stand in the way of gainful employment for cancer survivors with disability. These include ignorance of both employers and cancer survivors of their rights, discrimination, and limits on pre-existing conditions in health insurance benefits.
Little is known about which medical impairments have the greatest impact on employability. Undoubtedly, cognitive and communication deficits play a large role, as evidenced by the high work disability rates among survivors of central nervous system and head and neck malignancy. Fatigue and pain are also likely to limit work participation. Spelten and colleagues studied 235 cancer survivors in the Netherlands. Fatigue levels strongly predicted inability to return to work.
Participation in Recreation
Recreation is much more than fun and games; it is critical to physical and mental well-being. Fatigue, pain, weakness, depression, and other impairments will limit cancer survivors’ participation in avocational pursuits. Health care providers and family members should encourage recreational activity for those with cancer. The benefits include improvements in fitness, musculoskeletal problems, immune system function, cognition and sleep. Physical activity reduces the risk of cardiovascular and cerebrovascular disease, as well as diabetes mellitus. It is also reduces the risk for several common cancers, which is relevant to cancer survivors who are already at risk for new primary cancers. One study looked at 97 European youngsters attending a summer camp for adolescents living with cancer and diabetes. Significant improvements were seen in self-esteem, self-efficacy, and anxiety. Adults benefit as well. For example, Tai Chi Chuan, an Asian mind-body practice, has been shown to have beneficial effects on cancer survivors in 11 small studies.
Cancer patients may be limited in their ability to drive, fly, or take public transportation. They may not have caregivers available to help with transporting them. This can become a major barrier to cancer treatment, which often involves frequent medical visits. Some patients forgo recommended treatments because of lack of adequate transportation. Thus, it behooves physicians to explore with cancer patients any limits to their ability to get transportation.
Physicians are often leery to allow patients to drive while using opioids. However, Galski and associates showed that patients on chronic, stable, opioid analgesic therapy are safe to drive. Patients with cerebral dysfunction due to tumor, paraneoplastic effects, or treatment side effects should be evaluated for driving safety before allowing them to return to the road. There are well-defined off-road driver evaluation tools available.
Air travel might be problematic for patients with brain tumors. There have been case reports of cerebral edema and hemorrhage, although it is unclear how frequently these events occur.
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