1. 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

3. 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 Sep;59(9):410-9.

4. 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.

5. Research methodology

6. 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

7. 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

8. Results

9. Cancer statistics in Pakistan
Two cancer registries
new cancer cases each year
% 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

10. 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 ;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 May;90(5 Suppl 1):S63-8.

11. 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 ;38(3):

12. 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 ;77(1):54-7.

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

14. 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

15. 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

16. Multidisciplinary team approach

17. 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

18. 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

19. Cancer Rehabilitation in Pakistan: The current scenario

20. 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

21. How to develop cancer rehabilitation Service?

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

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

24. Disability assessment

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

34. Questions ! Comments ! Additions !

35.
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