The Case for Cancer Rehabilitation In Pakistan: What We Know and What we need to Do? Dr Farooq Azam Rathore Assistant Professor, Rehabilitation Medicine CMH Lahore Medical College, Lahore

Comprehensive rehabilitation care is needed Many barriers are involved  Significant numbers of rehabilitation problems were found that could be improved by rehabilitation care Comprehensive rehabilitation care is needed Many barriers are involved Lehmann JF, DeLisa JA, Warren CG, deLateur BJ, Bryant PL, Nicholson CG. Cancer rehabilitation: assessment of need, development, and evaluation of a model of care. Arch Phys Med Rehabil. 1978 Sep;59(9):410-9.

Objectives To report the effectiveness of cancer rehabilitation programs in improving the outcomes and Quality of Life (QOL) in cancer patients. To describe the current status of cancer rehabilitation in Pakistan and to compare it with the situation in developed countries of the world. To emphasize the need to develop dedicated cancer rehabilitation services for cancer patients in Pakistan.

Research methodology

Literature search Medline, Google scholar, Science Direct, Springerlink, OVID Gray literature ( Reports, thesis and dissertations) Key words (Boolean search) Cancer, oncology, tumour, malignancy, rehabilitation, oncology unit, rehabilitation service, Pakistan, developing country, multi-disciplinary, team work, team meeting, coordination, physiotherapy, occupational therapy, speech therapy, orthotics, nursing care, complications, cost, length of stay, outcomes, quality of life, assessment

Source and data extraction No published local data or guidelines Experience of Cancer Rehabilitation Services, Rusk Institute of Rehabilitation Medicine, NY, USA Discussion/ input from colleagues and subject matter experts USA UK Canada Bangladesh

Results

Cancer statistics in Pakistan Two cancer registries 150 000 new cancer cases each year 60 - 80% of the patients will die each year. 21 dedicated hospitals and 50 general hospitals with facilities to treat cancer 125 trained oncologists Lack of awareness among public Aasim Yousaf. Cancer Care in Pakistan .Jpn J Clin Oncol 2013;43(8)771–775

Improved functional outcome Reduced rate of complications Good scientific evidence that cancer rehabilitation and a multi-disciplinary team approach results in Improved functional outcome Reduced rate of complications Reduced length of stay (LOS) Better discharge rate to home Better overall survival and QOL Raj VS, Lofton L. Rehabilitation and treatment of spinal cord tumors. J Spinal Cord Med. 2013 ;36(1):4-11. Shin KY, Guo Y, Konzen B, Fu J, Yadav R, Bruera E. Inpatient cancer rehabilitation: the experience of a national comprehensive cancer center. Am J Phys Med Rehabil. 2011 May;90(5 Suppl 1):S63-8.

Cancer patients benefit as much as non-cancer patients in undergoing a rehabilitation programme. More patients should be admitted to such programmes and these programmes should be better structured and refined. Tay SS, Ng YS, Lim PA. Functional outcomes of cancer patients in an inpatient rehabilitation setting. Ann Acad Med Singapore. 2009 ;38(3):197-201.

Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation Marciniak CM, Sliwa JA, Spill G, Heinemann AW, Semik PE. Functional outcome following rehabilitation of the cancer patient. Arch Phys Med Rehabil. 1996 ;77(1):54-7.

Effectiveness of Cancer Rehabilitation Prostate Cancer Breast Cancer Neoplastic spinal cord compression Bone cancers Hematologic malignancies Brain Tumours

How Cancer Rehabilitation helps ? Lymphoedema and radiation induced Brahial plexopathy Brain injury Rehabilitation Spinal Cord Injury Rehabilitation Amputee Rehabilitation Deconditioning Acute and chronic Pain management Chemotherapy induced Polyneuropathy

Cancer Rehabilitation Services in the developed World Variable availability – US & Europe Continuum of care and integrated service Multidisciplinary team approach to author Rehabilitation Med Physician – team leader

Multidisciplinary team approach

Cancer Rehabilitation Service –Team members Social Worker/ Social service officer Physiatrist Occupational Therapist Rehab Nurse Psychologist Speech & Language Pathologist Physical Therapist Orthotist Post-Stroke Rehabilitation Fact Sheet http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm#professionals

Ground realities in Pakistan Little understanding of the concept of rehabilitation Innovative idea – Criticism and antagonism Man power shortage Dedicated space and bed allocation Funding Rathore MFA, Rashid P, Butt AW, Malik AA, Gill ZA, Haig AJ. Epidemiology of spinal cord injuries in the 2005 Pakistan earthquake. Spinal Cord 2007; 45: 658–663 Rathore FA, Malik T, Waheed A. Pitfalls in stroke rehabilitation – A Pakistani perspective. Pak Armed Forces Med J 2009;2: 56-61

Cancer Rehabilitation in Pakistan: The current scenario

Cancer Rehabilitation The current scenario No or late referrals Fragmented rehabilitation care No coordination, team work or team meeting Questionable pain management No patient and care givers education No rehab follow up plan

How to develop cancer rehabilitation Service?

Levels of care in Cancer rehab services In-patient consult In-patient MDT Out-patient

Cancer Rehabilitation Service Dedicated team and day Referrals cases only Team evaluation Disability assessment (ICF model )

Disability assessment

Cancer Rehabilitation Service Outdoor service Dedicated team and day Referrals cases only Team evaluation Disability assessment (ICF model ) Documentation Goal setting

Indoor Cancer Rehab Ward/Beds Set goals at the admission Multidisciplinary team (MDT) meetings Comprehensive and intensive rehabilitation protocols Patient and care givers education Discharge planning

Overcoming the barriers in Pakistan Mass awareness programs for public and health care providers CPC’s Case presentations Seminars Workshops Writing in newspapers and local medical journals

Overcoming the barriers in Pakistan Capacity building and training of team members Structured and standardized training programs Short term courses Clinical attachments Coordination with colleagues abroad

Overcoming the barriers in Pakistan Patient and care givers education Motivating the patient Insight into disease Understanding the value of MDT rehabilitation approach Peer support groups Patient education material Care for the care givers

Overcoming the barriers in Pakistan Engage all team members Sharing responsibility Close coordination Frequent and open communication Respect for each other Common and defined goals

Take Home message Cancer Rehabilitation is important but neglected It is a multi-disciplinary team work Increase awareness about cancer rehabilitation and early referral Conduct Research on effectiveness of cancer rehab interventions Better and Close coordination among all stake holders

Acknowledgments Prof Andrew J Haig , Dept of Rehabilitation Medicine, Michigan State University, Ann Arbor, USA Sean Smith MD, Dept of Physical Medicine & Rehabilitation, University of Michigan, USA Prof Steven Kirshblum, Director Spinal Injuries services, Kessler Institute of Rehabilitation Medicine, NJ, USA Colleen O'Connell, MD, FRCPC, Research Chief, Physical Medicine & Rehabilitation, Stan Cassidy Centre for Rehabilitation, Canada Dr Khaula Ashraf FCPS, Consultant, Dept of Rehabilitation Medicine, SIH, Islamabad Dr Fahim Anwar  MRCS, FRCP Consultant in Rehabilitation Medicine Addenbrooke’s Hospital, Cambridge, UK Dr Zaheer Gill, Consultant in Rehabilitation Medicine , CMH Malir Cantt Dr Taslim Uddin, Professor, Dept of Rehabilitation Medicine, BSMMU, Dhaka, Bangladesh

Questions ! Comments ! Additions !

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