to assess impairments and basic function include manual muscle testing, grip dynamometry, range of motion, limb girths, up and go test (15), timed walking, single foot balance, tandem walking (16), modified sit-and-reach test (for flexibility), and stand and sit test (for strength) (17). Karnofsky (Table 44-2) and Eastern Cooperative Oncology Group (ECOG) scales have been employed by oncologists as a measure of performance status, less so for functional outcome; hence, these measures are of uncertain value in rehabilitation. Some questionnairebased tools developed for oncology patients incorporate both functional and quality-of-life measures. Examples include the Functional Assessment of Cancer Therapy (FACT), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTCQ), Cancer Rehabilitation Evaluation System (CARES), and Functional Living Index-Cancer (FLIC). The 36-Item Short Form Health Survey (SF-36), a health status instrument, has also been applied to the cancer population (18, 19, 20).
TABLE 44.1 Estimated New Cancer Cases and Deaths by Sex, United States, 2008 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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TABLE 44.2 Karnofsky Scale | ||||||||||||||
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for surveillance of symptoms and function, both at critical points in care (e.g., in association with surgery) and over an extended period of time. One study of individuals with advanced breast cancer and remediable disabling impairments found that outpatients were markedly less likely than inpatients to receive rehabilitation services (31). This suggests the need for improved rehabilitation systems for outpatients and perhaps especially for those with advanced disease. Home health care may be needed if mobility is a significant obstacle to treatment.
Hematologic profile: hemoglobin less than 7.5 g, platelets less than 20,000, white blood cell count less than 3,000
Metastatic bone disease (see the section “Bony Metastatic Disease”)
Compression of a hollow viscous (bowel, bladder, or ureter), vessel, or spinal cord
Fluid accumulation in the pleura, pericardium, abdomen, or retroperitoneum associated with persistent pain, dyspnea, or problems with mobility
CNS depression or coma, or increased intracranial pressure
Hypokalemia/hyperkalemia, hyponatremia, or hypocalcemia/hypercalcemia
Orthostatic hypotension
Heart rate in excess of 110 beats/min or ventricular arrhythmia
Fever greater than 101°F
always be possible, and that in most cases 33% to 50% pain reduction is clinically meaningful (37). Factors associated with difficulty attaining adequate pain control include neuropathic quality, psychologic distress, history of addiction, and impaired cognition (35).
TABLE 44.3 Pharmacologic Management of Pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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metabolic causes have been excluded. Myoclonus related to opioid use may respond to baclofen, benzodiazepines, dantrolene, or valproate (35). While tolerance of a particular opioid may develop, reduced cross tolerance between different agents makes rotation of opioid drugs an effective way of avoiding escalating dosage requirements and the resulting side effects (35).
management involves collaboration among physiatry, orthopedic surgery, medical and radiation oncology, with care goals that encompass systemic disease management, pain control, skeletal stabilization, and rehabilitation.
TABLE 44.4 Fracture Risk (>8 Points High Risk) | ||||||||||||||||||||||||
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No significant neurological involvement
Involvement of bone without collapse or instability
Major neurological impairment without significant bone involvement
Vertebral collapse without neurologic impairment
Vertebral collapse with neurologic impairment
TABLE 44.5 Interventions for Fatigue | ||||||||||||||||||||||||||||||||||||||||||
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identified the greatest statistically significant impact in studies limited to a specific disease population such as breast cancer with less effect demonstrated when patients with heterogeneous diagnoses were recruited (78). Even when exercise interventions do not directly reduce fatigue scores, they nonetheless play an important role in the management of CRF by stemming the cycle of deconditioning that occurs as patients with CRF reduce their activity.