LETTER TO THE EDITOR
RE: CANCER REHABILITATION EDUCATION DURING PHYSICAL MEDICINE AND REHABILITATION RESIDENCY
To the Editor: The recent article published in 2014 at the American Journal of Physical Medicine & Rehabilitation by Raj et al.1 raised important points regarding cancer rehabilitation training during physical medicine and rehabilitation (PM&R) residency. The study reveals the importance of cancer rehabilitation training for future physiatrists and the need for improving the experiences on this field during residency training. By consulting PM&R residency directors, it is also pointed out that many PM&R residency programs still do not have dedicated oncology rehabilitation faculty and, unfortunately, are not planning to get this faculty in the near future. This is one of the most important published studies showing descriptive information from a residency program regarding characteristics of the education and experiences of physiatrists in cancer rehabilitation. Once longer life expectancy combined with the growth of the cancer survival rate has raised the number of people living with physical impairments as a result of cancer treatment, it is a pleasure reading the study of Raj et al.1 Similarly, in Brazil, current improvements in health care often lead to early cancer diagnosis, increasing the number of long-term functional impairments after cancer diagnosis. Therefore, the reviewers also agree that it is urgent to have better cancer rehabilitation training for future physiatrists. With all of this in mind, since 2009, the rehabilitation residency program of School of Medicine of University of Sa˜o Paulo (FMUSP), under the supervision of Prof Linamara Rizzo Battistella, promotes a teaching program in cancer rehabilitation. The focus has been on the importance of proper cancer rehabilitation training for future physiatrists, and the Cancer Institute of University of Sa˜o Paulo (ICESP) currently receives PM&R residents from the FMUSP rehabilitation residency program. There are approximately ten resident physicians per year enrolled in this program, and the reviewers would like to use this opportunity to share some thoughts based on this rehabilitation teaching experience, showing the aspects the reviewers consider as the strongest points on this rehabilitation training. ICESP is one of the leading cancer treatment centers in Brazil. It was planned concerning the need for cancer support from active treatment to survivorship, rehabilitative, and palliative needs. The institute is linked to the School of Medicine of University of Sa˜o Paulo (FMUSP) and receives more than 10,000 new patients per year. From January to August 2014, the ICESP rehabilitation department received 441 new patients. Seventy-two percent of all patients were women, and 28% were men. Patients aged 41 to 65 yrs were the most prevalent age
group, corresponding to 63% of all patients, followed by 22% who were 66 to 85 yrs old, 13% who were 18 to 40 yrs old, and 7% who were 86 yrs or older. Their diagnoses were as follows: breast (57%), head and neck (9%), hematologic (7%), brain (5%), gastrointestinal (4%), prostate (3%), gynecologic (3%), skin (3%), endocrinologic (2%), soft tissue sarcoma (2%), lungs (2%), and bone sarcomas (1%). The leading impairment complaints are pain (29%) and rangeof-motion limitation (29%), followed by lymphedema (13%), hemiparesis (6%), fatigue (5%), strength loss (3%), gait alteration (2%), deconditioning (1%), brain injury (1%), balance disorders (1%), dyspnea (1%), immobility (1%), amputations (1%), functional impairment (1%), dysphagia (1%), spinal cord injury (1%), postchemotherapy neuropathy (1%), and others (1%). PM&R internship on oncologic rehabilitation is 1Y2 mos long. The integrated rehabilitation efforts planned for prevention of incapacities and maximizing functional independence start on clinical and surgery wards and intensive care units. Residents provide supervised interconsultations, having the opportunity to discuss and share their doubts and points of view with all clinics involved in cancer care. This is important especially for planning rehabilitation priorities during acute treatment phase, when there is certainly a need to discuss with other clinics about the best care pathway. Integrating rehabilitation intervention within the oncology office practice allows a comprehensive, coordinated follow-up cancer care.2,3 They can also participate in physiatrist inpatient or outpatient consultations and follow the activities from a multiprofessional team composed of physiotherapists, occupational therapists, speech therapists, and other rehabilitation health professionals. The reviewers certainly know that an internship 1Y2 mos long is not enough to get a complete training in cancer rehabilitation. Nevertheless, this in-depth cancer rehabilitation program allows future physiatrists to learn the particularities of functional impairment related to cancer in all stages of disease. Moreover, the residents can learn the main functional impairments and disabilities of cancer patients: lymphedema, cancer-related fatigue, pain, acupuncture medicine, fracture risk of bone metastasis, spasticity, neurogenic bladder, dysphagia, physical fitness and physical activity prescription to cancer patients, asthenia, chemotherapy-induced peripheral neuropathy, vasomotor symptoms and polymyalgia after hormone suppression, and paraplegia after spine metastasis, among others. This residency program provides a unique opportunity for physiatrists to experiment specialty care that focuses on an individual as a whole, as it relates to function and quality-of-life. During these 2 mos, they have also approximately four to six didactic lectures allocated toward this cancer rehabilitation training. All of these activities are supervised by a teaching faculty physiatrist. Currently, there are five physicians engaged at this teaching activity. Letter to the Editor
www.ajpmr.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
e35
As a matter of conclusion, the reviewers strongly believe that cancer rehabilitation should be one of the competencies of PM&R residency training. Considering the functional impairments as a result of cancer and its treatment, it is extremely important that the rehabilitation physician becomes familiar with the functional diagnosis of cancer patients and ready for prescribing the best rehabilitation strategies for them, improving their functional prognosis and quality-of-life. Cancer rehabilitation education should take into account the different needs for rehabilitation during active treatment, survivorship, and palliative phases. Further research in this field will help to establish oncologic rehabilitation faculty during PM&R residency training. Studies such as that of Raj et al.1 corroborate this teaching protocol and encourage the field to continue this experience.
REFERENCES 1. Raj VS, Balouch J, Norton JH: Cancer rehabilitation education during physical medicine and rehabilitation residency: Preliminary data regarding the quality and quantity of experiences. Am J Phys Med Rehabil 2014;93:445Y52 2. Gamble GL, Gerber LH, Spill GR, et al: The future of cancer rehabilitation: Emerging subspecialty. Am J Phys Med Rehabil 2011;90(suppl 1):S76Y87
e36
Letter to the Editor
3. Neumann V, Gutenbrunner C, Fialka-Moser V, et al: Interdisciplinary team working in physical and rehabilitation medicine. J Rehabil Med 2010;42:4Y8 Gustavo Carneiro Ferra˜o, MD Institute of Physical Medicine and Rehabilitation School of Medicine, University of Sa˜o Paulo Sa˜o Paulo, Brazil Rebeca Boltes Cecatto, PhD, MD Rehabilitation Department Cancer Institute School of Medicine University of Sa˜o Paulo Sa˜o Paulo, Brazil Christina May Moran de Brito, PhD, MD Rehabilitation Department Cancer Institute School of Medicine University of Sa˜o Paulo and Hospital Sı´rio-Libaneˆs Sa˜o Paulo, Brazil Linamara Rizzo Battistella, MD School of Medicine, University of Sa˜o Paulo and Legal Medicine Department Institute of Physical Medicine and Rehabilitation Sa˜o Paulo, Brazil DOI: 10.1097/PHM.0000000000000276
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
RE: CANCER REHABILITATION EDUCATION DURING PHYSICAL MEDICINE AND REHABILITATION RESIDENCY
To the Editor: The recent article published in 2014 at the American Journal of Physical Medicine & Rehabilitation by Raj et al.1 raised important points regarding cancer rehabilitation training during physical medicine and rehabilitation (PM&R) residency. The study reveals the importance of cancer rehabilitation training for future physiatrists and the need for improving the experiences on this field during residency training. By consulting PM&R residency directors, it is also pointed out that many PM&R residency programs still do not have dedicated oncology rehabilitation faculty and, unfortunately, are not planning to get this faculty in the near future. This is one of the most important published studies showing descriptive information from a residency program regarding characteristics of the education and experiences of physiatrists in cancer rehabilitation. Once longer life expectancy combined with the growth of the cancer survival rate has raised the number of people living with physical impairments as a result of cancer treatment, it is a pleasure reading the study of Raj et al.1 Similarly, in Brazil, current improvements in health care often lead to early cancer diagnosis, increasing the number of long-term functional impairments after cancer diagnosis. Therefore, the reviewers also agree that it is urgent to have better cancer rehabilitation training for future physiatrists. With all of this in mind, since 2009, the rehabilitation residency program of School of Medicine of University of Sa˜o Paulo (FMUSP), under the supervision of Prof Linamara Rizzo Battistella, promotes a teaching program in cancer rehabilitation. The focus has been on the importance of proper cancer rehabilitation training for future physiatrists, and the Cancer Institute of University of Sa˜o Paulo (ICESP) currently receives PM&R residents from the FMUSP rehabilitation residency program. There are approximately ten resident physicians per year enrolled in this program, and the reviewers would like to use this opportunity to share some thoughts based on this rehabilitation teaching experience, showing the aspects the reviewers consider as the strongest points on this rehabilitation training. ICESP is one of the leading cancer treatment centers in Brazil. It was planned concerning the need for cancer support from active treatment to survivorship, rehabilitative, and palliative needs. The institute is linked to the School of Medicine of University of Sa˜o Paulo (FMUSP) and receives more than 10,000 new patients per year. From January to August 2014, the ICESP rehabilitation department received 441 new patients. Seventy-two percent of all patients were women, and 28% were men. Patients aged 41 to 65 yrs were the most prevalent age
group, corresponding to 63% of all patients, followed by 22% who were 66 to 85 yrs old, 13% who were 18 to 40 yrs old, and 7% who were 86 yrs or older. Their diagnoses were as follows: breast (57%), head and neck (9%), hematologic (7%), brain (5%), gastrointestinal (4%), prostate (3%), gynecologic (3%), skin (3%), endocrinologic (2%), soft tissue sarcoma (2%), lungs (2%), and bone sarcomas (1%). The leading impairment complaints are pain (29%) and rangeof-motion limitation (29%), followed by lymphedema (13%), hemiparesis (6%), fatigue (5%), strength loss (3%), gait alteration (2%), deconditioning (1%), brain injury (1%), balance disorders (1%), dyspnea (1%), immobility (1%), amputations (1%), functional impairment (1%), dysphagia (1%), spinal cord injury (1%), postchemotherapy neuropathy (1%), and others (1%). PM&R internship on oncologic rehabilitation is 1Y2 mos long. The integrated rehabilitation efforts planned for prevention of incapacities and maximizing functional independence start on clinical and surgery wards and intensive care units. Residents provide supervised interconsultations, having the opportunity to discuss and share their doubts and points of view with all clinics involved in cancer care. This is important especially for planning rehabilitation priorities during acute treatment phase, when there is certainly a need to discuss with other clinics about the best care pathway. Integrating rehabilitation intervention within the oncology office practice allows a comprehensive, coordinated follow-up cancer care.2,3 They can also participate in physiatrist inpatient or outpatient consultations and follow the activities from a multiprofessional team composed of physiotherapists, occupational therapists, speech therapists, and other rehabilitation health professionals. The reviewers certainly know that an internship 1Y2 mos long is not enough to get a complete training in cancer rehabilitation. Nevertheless, this in-depth cancer rehabilitation program allows future physiatrists to learn the particularities of functional impairment related to cancer in all stages of disease. Moreover, the residents can learn the main functional impairments and disabilities of cancer patients: lymphedema, cancer-related fatigue, pain, acupuncture medicine, fracture risk of bone metastasis, spasticity, neurogenic bladder, dysphagia, physical fitness and physical activity prescription to cancer patients, asthenia, chemotherapy-induced peripheral neuropathy, vasomotor symptoms and polymyalgia after hormone suppression, and paraplegia after spine metastasis, among others. This residency program provides a unique opportunity for physiatrists to experiment specialty care that focuses on an individual as a whole, as it relates to function and quality-of-life. During these 2 mos, they have also approximately four to six didactic lectures allocated toward this cancer rehabilitation training. All of these activities are supervised by a teaching faculty physiatrist. Currently, there are five physicians engaged at this teaching activity. Letter to the Editor
www.ajpmr.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
e35
As a matter of conclusion, the reviewers strongly believe that cancer rehabilitation should be one of the competencies of PM&R residency training. Considering the functional impairments as a result of cancer and its treatment, it is extremely important that the rehabilitation physician becomes familiar with the functional diagnosis of cancer patients and ready for prescribing the best rehabilitation strategies for them, improving their functional prognosis and quality-of-life. Cancer rehabilitation education should take into account the different needs for rehabilitation during active treatment, survivorship, and palliative phases. Further research in this field will help to establish oncologic rehabilitation faculty during PM&R residency training. Studies such as that of Raj et al.1 corroborate this teaching protocol and encourage the field to continue this experience.
REFERENCES 1. Raj VS, Balouch J, Norton JH: Cancer rehabilitation education during physical medicine and rehabilitation residency: Preliminary data regarding the quality and quantity of experiences. Am J Phys Med Rehabil 2014;93:445Y52 2. Gamble GL, Gerber LH, Spill GR, et al: The future of cancer rehabilitation: Emerging subspecialty. Am J Phys Med Rehabil 2011;90(suppl 1):S76Y87
e36
Letter to the Editor
3. Neumann V, Gutenbrunner C, Fialka-Moser V, et al: Interdisciplinary team working in physical and rehabilitation medicine. J Rehabil Med 2010;42:4Y8 Gustavo Carneiro Ferra˜o, MD Institute of Physical Medicine and Rehabilitation School of Medicine, University of Sa˜o Paulo Sa˜o Paulo, Brazil Rebeca Boltes Cecatto, PhD, MD Rehabilitation Department Cancer Institute School of Medicine University of Sa˜o Paulo Sa˜o Paulo, Brazil Christina May Moran de Brito, PhD, MD Rehabilitation Department Cancer Institute School of Medicine University of Sa˜o Paulo and Hospital Sı´rio-Libaneˆs Sa˜o Paulo, Brazil Linamara Rizzo Battistella, MD School of Medicine, University of Sa˜o Paulo and Legal Medicine Department Institute of Physical Medicine and Rehabilitation Sa˜o Paulo, Brazil DOI: 10.1097/PHM.0000000000000276
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
