Rehabilitation of the Cancer Patient with a Stroke

Brendan E Conroy, MD, FAAPM&RSenior Stroke Rehabilitation Specialist

CMIOMedStar National Rehabilitation Hospital

Associate Professor Clinical Rehabilitation MedicineMedStar Georgetown University Medical Center

None

Conflicts of Interest

1. Be able to name 3 medicines that are helpful for appetite stimulation

2. Name 3 simple medical interventions that will optimize rehab outcomes (will be in PURPLE TEXT )

3. Be able to chose 3 appropriate antidepressants based on use of drug side effects

4. Be able to describe 3 accommodations that help a cancer patient succeed in inpatient Stroke Rehabilitation

Objectives

53 RHAAM, diagnosed with Pancreatic CA w/liver mets who suffered a large L MCA infarct giving R dominant HP, severe Mixed Aphasia and severe dysphagia, while mid-course in a series of chemotherapy infusions. Chemo was temporarily halted. He was placed on DVT ppx with enoxaparin (40mg daily), but needed to taken off it for Gastrostomy Tube placement, and then developed a large DVT in his involved leg. Enoxaparin was increased to therapeutic dose (1mg/kg BID). He indicated he was having pain on his involved side arm and leg, and he had been placed on Oxycontin

Recent patient

I determined his pain was not well controlled, and he indicated it was very uncomfortable, making him restless and interfering with sleep

Restlessness caused an accidental removal of the GTube Quickly tapered off Oxycontin and started on

Lyrica, which resulted in good improvement in his pain, restlessness and sleep problem

Arrival in Rehab center

SLP determined swallowing was still too impaired for safe oral intake

Gastroenterology consult: We needed him to stay on anticoagulation while having another GTube placed, due to Coagulopathy

Enoxaparin was given very early one morning and he had a new GTube placed that afternoon and received his PM dose of enoxaparin on schedule, without complications!

G-Tube replacement

Discharged to home with his devoted fiancée after an 8 week stay, still w/GTube, needing min/mod assist for ADL, modA for transfers, modA for toileting, unable to ambulate except with therapist, continent of bladder, incontinent of bowel, limited naming skills, but reliable yes/no responses, good pain control, after adding antidepressant to Lyrica, rare need for PRN narcotics

After extensive Caregiver Training of fiancée and a son from previous relationship in: GTube care, transfers, self-care, skin care, etc Equipment: hospital bed, lifting device, high backed

wheelchair, bedside commode Home therapy: Nsng, PT, OT, SLP Follow-up: OP Rehab, Oncology, ongoing

Outcome

Hypercoagulability (brain, breast, colon, lung, ovary, pancreas, prostate)

Vascular obstruction (meningioma) Mechanical obstruction internal external

Vascular aneurysm (lymphoma) Fusiform, not berry

Cardiovascular instability BP unstable arrhythmia

Intracranial mets and Primary tumors can behave like a stroke Posterior fossa

Cancer increases risk of Stroke

Lung Melanoma Kidney Breast Colon Lymphomas

Often multifocal mets Most often in posterior fossa

IT: Primary Brain Tumors (such as Astrocytoma) NEVER metastasize outside the skull

Tumors that give Intracranial Disease most commonly

Stoppage of anticoagulation for a procedure Latent Radiation Vasculitis

After neck or whole brain XRT Months or even years later

Chemotherapeutics rarely cause CVA directly , but do cause nausea, emesis, dehydration, poor nutrition, which increase risk of brain infarct.

Cancer therapeutics can lead to Stroke

Take good care of typical CVA Risk Factors BP Diabetes Hyperlipidemia Atrial Fibrillation Monitor for Hypercoagulability

Monitor D-dimer Maintain hydration

CRITICAL Maintain nutrition

CRITICAL

Prevention of CVA in Cancer patients

Fatigue Pain Need to undergo XRT and/or chemo

If these can be delayed until inpatient rehab phase completed, it facilitates rehab

If no delay is possible, schedule therapy sessions prior to Oncology Tx each day

Risk of pathological fracture Bone scan most helpful in predicting this risk

Depression, +/- anxiety Anorexia Insomnia

Problems during Rehab of Cancer/Stroke patient

Alter therapy schedule, w/at least 1 hour break between Tx sessions

Make sure they are sleeping Make sure they are hydrated Make sure they are eating Treat depression Encourage napping Make sure XRT and/or Chemo sessions are in late

afternoons, after therapy sessions for that day

Fatigue

Helpful Meds: Trazodone Mirtazepine (Remeron) Melatonin

Zolpidem (Ambien)

Problematic meds: Benzodiazepines Anti-psychotics

Amnesogenic, decrease respiratory drive, depressing, cause confusion

Poor Sleep

Psychology consultation! Helpful Meds:

Buspirone Fluoxetine Escitalopram, not citalopram Mirtazepine Bupropion (clonazepam)

Problematic meds: Most other benzodiazepines narcotics

Anxiety

Give in the early evening, 7-8PM May cause some lethargy first couple days Not helpful for learning capacity in general I use olanzepine, quetiapine for agitation I use very small dose of clonazepam (0.25mg)

for severe anxiety I will NOT use haloperidol, thorazine,

diazepam, alprazolam (too sedating, reduce learning capacity)

Use of Psychotropic meds

Good medications for bone and deep tissue, aching pain, and post-op pain

Cause less interference with rehab if given in long acting formulations Oxycontin, MSContin

With breakthrough Pain PRNs Oxycodone, Morphine IR

Try to use the same active ingredient for LA and IR formulations

Pain - Narcotics

Great for localized pain, minimize side effects Diclofenac gel/ Diclofenac patch Lidoderm patch Myoflex gel (counter-irritant) Hot/Cold modalities

Moist heat Quick onset and offset Very comforting and very effective

Icing Takes 15-20 minutes to kick in and uncomfortable but effects last longer

Topical Pain treatments

Burning, tingling, lancinating pain Central Post-Stroke Pain Syndrome

A.k.a. Thalamic Pain; or, Syndrome of Dejerine-Roussy Complex Regional Pain syndromes Gabalins are highly effective

Gabapentin has more side-effects Pregabalin has much less side effects, but is less often covered

by insurance TCAs Fluoxetine Vascular Surgical wound neuropathies

Lidoderm great if limited painful area Can’t be used on damaged skin

Narcotics much less effective

Neuropathic pain

NSAIDs highly effective Joint injections also very helpful Always check for pathological fractures

Bone and Joint Pain

Adequate nutrition and fluid intake for good rehab is essential

Appetite stimulants Megestrol Tetrahydrocannabinol (THC)(“Weed”) Dronabinol (THC derivative) Mirtazepine

Gastrostomy Tube Doesn’t prevent the patient from pleasure eating Assures adequate nutrition, fluids and medication Can be temporary

Anorexia/Cachexia

Typically under-treated in cancer Psychology/Psychiatry interventions very helpful Most antidepressants are useful

Try to use the side effects to patient’s advantage E.g.:

trazodone for poor sleep mirtazepine for depressed patient with anorexia and

poor sleep fluoxetine for lethargic patient with neuropathic pain

and/or anxiety

Depression

Rehab during End of Life therapy Can decrease helplessness Optimize sense of self-worth Minimize burden on caregivers Minimize depression improve the quality of final weeks/days

Treatable Cancer Rehab is just as effective for people with cancer as

those without Although progress is somewhat slower

Applications of Rehab

Rehabilitation therapies improve quality of life Discharge to home Minimize burden of care on caregivers Although slower rate of improvement, CVA

survivors with Cancer can have similar outcomes to CVA survivors without cancer (US figures) 65-70% discharge to home 80% ambulate within one year 60% return to living independently

Outcomes

“DNR” does not mean “Do Not Rehabilitate”

REMEMBER!

2005 Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline; Stroke, 2005; 36: e100-e143; Duncan, Zorowitz, et al (entire contents available online)

Important Cancer Rehabilitation authors Lynn Gerber Michael Stubblefield Andrea Cheville

References

Thank-you very much!

Any questions?