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Journal of Surgical Oncology 2015;111:615621

Rehabilitation of the Sarcoma Patient-Enhancing the Recovery and Functioning


of Patients Undergoing Management for Extremity Soft Tissue Sarcomas
KERRY TOBIAS, DO1* AND THERESA GILLIS, MD2,3
1

Supportive Care & Survivorship, University of Arizona Cancer CenterPhoenix, St. Josephs Hospital and Medical Center, Phoenix, Arizona
Oncology Pain & Symptom Management, Helen F. Graham Cancer Center and Research Institute, Christiana Care Health System, Newark,
Delaware
3
Clinical Associate Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Philadelphia, Pennsylvania

Although relatively rare, soft tissue sarcomas cause signicant morbidity and mortality due to their advanced stage at initial diagnosis.
Rehabilitation and surgical outcomes have traditionally focused on physical parameters to assess function and recovery, emphasizing return to
ambulation, activities of daily living (ADLs) and community re-integration. Assessments of functional impairment and other quality-of-life
parameters are necessary to better understand the experience of the patient with extremity soft tissue sarcoma and thereby improve outcomes.

J. Surg. Oncol. 2015;111:615621. 2014 Wiley Periodicals, Inc.

KEY WORDS: soft tissue sarcoma; prehabilitation; limb salvage; amputation; quality-of-life; rehabilitation

INTRODUCTION
Soft tissue sarcomas account for slightly over 20% of pediatric solid
malignancies and <1% of all adult solid malignancies [1] and are more
prevalent than malignant bone tumorsaccounting for almost 87% of
all sarcomas versus 13% being malignant bone tumors [1,2]. More than
50% occur in the extremities [3,4]. In 2014, the estimated new number
of cases of sarcomas in the United States is over 12,000 and
approximately 4700 people will die this year from these [46].
Estimated ve-year survival rate at time of diagnosis for those with
localized sarcomas is 83% and 54% if regional lymph node spread is
present. For those patients with distant metastases, the ve-year
survival rate is 16% [4,6,7]. Mean age at diagnosis of soft tissue
sarcomas was 58 and mean age at death was 65; the incidence has a
dramatic increase in people over the age of 50 [1].

DIAGNOSIS AND TREATMENT


RECOMMENDATIONS
Staging of soft-tissue sarcomas depends on tumor size, extent of
spread on surrounding tissues, and distant metastases and this, in turn,
guides treatment recommendations. Surgery remains the mainstay of
treatment, either alone or after chemotherapy, radiation therapy or both.
Distant metastases or recurrent disease within the surgical site then
guides future treatment recommendations. Recurrent disease within the
previous surgical bed may be resectable, or an amputation may be
required. Concerns for adequate wound closure and healing, and neural
injury with sensory and/or distal motor function impairment would be
signicant.
Treatment depends on patients underlying comorbidities and
therefore estimated tolerance of specic therapies (i.e., chemotherapy,
surgery, radiation). Limb-salvage or limb-preservation surgery is now the
surgically preferred treatment for extremity sarcomas with survival rates
of 6070% [8]. However, choice of this also depends on a patients preexisting physical function and medical comorbiditiesspecically, if
any pre-existing medical conditions such as cardiovascular or pulmonary
disease would limit the physical endurance of an individual required for
rehabilitation.
Rehabilitation burden may be more extensive for a patient
undergoing limb-salvage surgery rather than an amputation. Multiple

2014 Wiley Periodicals, Inc.

surgical procedures, including reconstructions and revisions, wound


healing, and complications not only take time away from typical life
events but delay the process of physical and emotional recovery. Patient
preference may also play into the decision for limb-salvage versus
amputation, bearing in mind these differences in burden and also an
individuals personal experiences (e.g., a childs wedding, birth of a
grandchild, professional career goals).
The treatment selection process should also include consideration of
a patients environmental surroundings for eventual return home,
family/caregiver assistance and support, pre-existing independence,
nancial concerns for vocational status and possible return-to-work.
Living situations such as a multilevel home, or a third oor apartment
without elevator access may impact the patients independence and
safety. A wheelchair-inaccessible bathroom may complicate hygiene,
safety and independence as well. Awareness of these situations early in
the treatment plan can give the rehabilitation team, patient, and
caregivers time to adapt the functional goals or revise the environment.
Knowledge of the sarcoma treatment plan recommendations would
then guide rehabilitation specialists in tailoring a program for a patient.
If post-surgical chemotherapy or radiation therapy is planned, this can
impact the feasibility of participation in a rehabilitation program.
Chemotherapy and side effects from this can limit a patients ability to
participate in therapy, follow an independent exercise expectation or
even fulll typical daily functions. Planned radiation therapy can also
cause limitations in a patients participation in a rehabilitation program,
either due to side effects or the logistics of attending two different
locations of care. Daily transportation between radiation and
rehabilitation facilities may not be feasible if they are not co-located.
Goals of rehabilitation would be determined by the cancer itself and
extent of disease and whether rehabilitation would be considered

*Correspondence to: Dr. Kerry Tobias, DO, Supportive Care & Survivorship University of Arizona Cancer Center Phoenix 500 W, Thomas Road,
Suite 720, Phoenix 85013, AZ. Fax: 602-406-6242.
E mail: Kerry.tobias@att.net
Received 3 June 2014; Accepted 3 October 2014
DOI 10.1002/jso.23830
Published online 21 November 2014 in Wiley Online Library
(wileyonlinelibrary.com).

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Tobias and Gillis

restorative or palliative [8,9]. Restorative rehabilitation is the intent if


surgical treatment is expected to be curative, and the goal is a return of
the patient to their prior level of function. Supportive rehabilitation is
appropriate if surgery is anticipated to be palliative; the goal is to
increase independence as much as possible and improve the patients
quality of life [8].

REHABILITATION PROGRAMS
The rehabilitation course after acute surgical inpatient care and postsurgical rehab may continue with either a transfer to a comprehensive
acute rehabilitation facility, subacute rehabilitation facility,
continuation with rehabilitation at home, or initiation of outpatient
rehabilitation. Utilization of more than one of these programs may be
necessary depending on any acute medical issues that arise and
trajectory of recovery medically. Decisions regarding the location of
care are impacted by availability within a center or a community, the
cost and source of payment, and patient/family social factors.
Comprehensive rehabilitation programs seek to maximize quality of
life in sarcoma patients through recovery of physical function and
adaptation of the patient and their physical environs in order to attain
greater independence. A comprehensive team consists of a physical
therapist, prosthetist, occupational therapist, recreational therapist,
nurse, wound/ostomy care specialist, social worker, chaplain,
nutritionist, rehabilitation physician (physiatrist), and psychologist.
These teams provide care during the inpatient phase of rehabilitation in
a structured, efcient and cohesive strategy. This team can also tailor an
outpatient program to be continued by the patient when discharged from
inpatient care [10].
Rehabilitation programs in hospitals afliated with cancer centers
may provide continuity of care once a patient is discharged. Outpatient
rehabilitation programs within a cancer center provide better access to
patients for ongoing rehabilitation needs as continued surveillance and
followup appointments with their oncologists and surgeons typically
take place there. Patients often experience burnout and fatigue from the
frequency of medical appointments they must attend, especially during
the course of radiation treatments. A patient, therefore, may be more
amenable to attending outpatient rehab therapies if this care is within the
cancer center itself. Compliance with therapy will promote better
outcomes with function and recovery.

Inpatient Acute Rehabilitation Versus Subacute


Rehabilitation
The differentiation between acute and subacute rehabilitation is
based upon the number of hours of therapy provided during a patient
day, and these levels of care are a product of the health insurance system
in the U.S. Acute rehabilitation typically provides a comprehensive
team of professionals and a more intense therapy regime, whilst
subacute may be fewer hours of therapy daily provided by a smaller
team of fewer disciplines. The decision regarding the level of care is
determined by patient factors and payor factors. Patients with extensive
co-morbidities, or signicant restrictions in weight-bearing, range of
motion or positioning, or difcult wound healing may be cared for in a
subacute setting where the course of recovery may be expected to be
slower paced. Acute rehabilitation may be provided in a free-standing
rehabilitation hospital or in a specially designated unit within another
hospital. Subacute rehabilitation may be provided in a skilled nursing
facility.

Home Rehabilitation and Outpatient Rehabilitation


Patients who have either recovered enough function and safety with
mobility and medical stability may leave the acute surgical setting and
return home. Others return following acute or subacute rehabilitation.
Journal of Surgical Oncology

The focus continues on improving overall function and further


assessment of what patients will encounter in their home
environment. Attending outpatient rehabilitation requires an active
caregiver(s) to provide transportation to and from appointments ideally
three times a week for several weeks. Negotiating transfers in and out of
vehicles, environmental challenges such as steps, curbs, gravel, and
managing fatigue and reduced endurance are typical gross mobility
goals in this setting. Outpatient programs can address specic
vocational and avocational/recreational skills with therapists to
facilitate patient adaptations and problem solving.

REHABILITATION PHASES
Prehabilitation
Typically, patients have not been seen or assessed by a physiatrist or
therapists much less by an entire rehabilitation team prior to surgery.
However, consideration by the surgical team for referral to a physiatrist
skilled in cancer rehabilitation can begin the process of adequate
rehabilitation prior to planned surgery. This referral and early
intervention is now referred to as prehabilitation [11]. This is
initiated prior to cancer therapy to assess: baseline level of function,
prior physical decits or weakness, evaluation of current medical status
and any comorbidities that may affect a patients tolerance to surgery
and postop course, review plan of postsurgical treatment (radiation and/
or chemotherapy), cardiovascular health and baseline endurance (e.g.,
need to take into account increased energy expenditure for level of
amputation) [11]. Pre-existing medical conditions should be assessed,
as well, in the prehabilitation phase. These can include evaluation for
pre-existing osteoporosis, underlying cardiovascular or pulmonary
disease or decits, history of deep vein thrombosis (DVT)/pulmonary
embolus (PE) and current anticoagulation status (including presence of
inferior vena cava [IVC] lter or not), anemia, and thrombocytopenia.
Consideration of a patients current stage of disease is necessary to
guide rehabilitation goals and whether a patient has metastases at
presentation or if there is a high likelihood of recurrence predicted.
Although not traditionally included when one considers
prehabilitation, attention should be paid to a patients home
environment prior to surgery and assessing feasibility of returning to
that environment with or without modications. Assessment of the
patients vocation and possibility of return to work and specic physical
tasks their job entails is benecial. Recreational activities and social
responsibilities, including child- or elder-care are important
components of their psychosocial milieu. For example, ones ability
to return to driving may signicantly promote independence and
autonomy, whereas another individual may value this less highly. The
impact of the patients possible disability upon family responsibilities
may be overwhelming. Anticipation of these issues will help
psychosocial function and promote quality of life throughout the
course of sarcoma care.
Assessment by a physical therapist, occupational therapist, and
lymphedema therapist may be enlisted as well prior to surgery if preexisting decits are noted. Then, accordingly, proper anticipation and
tailoring of the patients specic rehabilitation program may be put in
place. For instance, a lymphedema therapist may be enlisted in the
prehabilitation phase to evaluate any pre-existing lymphedema present.
Pre-surgical or pre-radiation manual lymph drainage and compression
bandaging to optimize lymph control and minimize post-operative
infection risk may be helpful. Planning for compression garment use
intraoperatively or peri-operatively may also diminish the risk of
postoperative lymphedema exacerbation.
Another example of prehabilitation can be demonstrated in a patient
with cardiovascular disease. Understanding the pre-treatment level of
function and existing tolerance for sustained exercise and activities of
daily living (ADLs) is needed. The patient may be a candidate for pre-

Rehabilitation of the Sarcoma Patient


treatment interventions to improve cardiopulmonary tness and
endurance, or involvement in a structured exercise program during
radiation therapy may benet his/her post treatment level of
independence. A patient with a very poor cardiac ejection fraction or
low cardiac functional capacity according to the New York Heart
Association (NYHA) may not tolerate the increased energy expenditure
required for prosthetic ambulation with transfemoral amputation [12].

Postsurgical Management
Location of the sarcoma itself and involvement of surrounding
structures (muscles, fascial planes, vasculature, lymphatics, and nerves)
guide the surgery proposed and eld of excision. Discussion of the
proposed procedure(s) with the surgeon prior to surgery would be ideal
to anticipate immediate post-op decits that can be addressed by the
inpatient rehabilitation team. For instance, proximity of excision(s) to
nerve plexi lends special consideration to motor and sensory decits
likely to result and which can be addressed early on. Proximity of the
tumor to lymph nodes and whether lymphadenectomy will be a
component of proposed surgery, or radiation therapy, will drive
consideration of post-op edema control, but also the possibility of
developing long-standing, chronic lymphedema which will need to be
addressed.
Early rehabilitation post-surgery depends on immediate surgical postop condition and recovery. Type of surgery and restrictions regarding
weight-bearing and limitations in range-of-motion will be dictated by the
surgeon and affect immediate therapies that can be started. For instance, a
patient undergoing internal hemipelvectomy may have restricted weightbearing of several months; a patient with an external hemipelvectomy
will typically be ambulating within days with an assistive device.
Complex reconstructions, skin grafts, and myocutaneous ap closures
may also limit limb mobility. Brachytherapy catheters may preclude early
mobilization.
Immediate post-op issues are mainly symptom-based and couched in
controlling these adequately for comfort. A challenging early issue will
be post-surgical pain which can physically impede ability to participate
in physical therapy and perform even simple tasks such as range-ofmotion (ROM) activities and bed mobility. Chronic pain issues can
develop as well as phantom pain. In addition to deterring a patients
physical performance of therapy goals immediately post-op, pain can
also lead to depression and despondency regarding potential recovery
and, again, affect a patients participation in therapies. Fear of
overwhelming and unmanaged pain can impede a patients willingness
to move.
Other physical symptoms can be present in the immediate post-op
period, necessitating coordination between therapists, rehabilitation
specialists, nursing and the surgical team, such as: nausea, postoperative ileus, opioid-associated constipation, insomnia, and fatigue.
Fatigue may be multifactorial and due to the cancer itself, poor
nutritional status, lack of adequate sleep, and depression or difculty
coping due to body image changes and grief over loss of limb or body
part.
Weight-bearing restrictions and length of time these need to
be maintained should be claried with the surgical team. These
also need to include weight-bearing for upper extremity, as
limitations for this can signicantly affect bed mobility, transfers,
and ADLs.
Vigilant wound care and adherence to limitations must be
maintained during initial healing. After the initial dressing is
unwrapped, frequent wound inspection should occur as well as
patient education on signs of infection and inspection and care of
insensate areas. Pressure relief to reduce risk of breakdown on typical
sites (coccyx, ischii, bular heads, and heels) as well as at-risk sites
caused by special positioning, casting or bandaging is reviewed with
nursing staff, patient and caregivers.
Journal of Surgical Oncology

617

Much of the rehabilitation during this phase will need to be tailored


according to each individuals medical course and issues. Tolerance of
therapies in the hospital will depend on a patients post-operative
recovery and healing.

Amputation Rehabilitative Care


Upper extremity considerations. Considerations include handedness,
vocation, recreational activities, and ADLs, in the context of family
members (e.g., does patient have infants or small children at home requiring
care that would be compromised by the use of just one functional upper
extremity) (Table I).
Distal vs proximal procedure predicts the feasibility of being t with
a prosthesis in the future or not if the residual limb is resected
proximally. Proximal resection also determines motor level of function
within that limb depending on involvement of brachial plexus and
planned resection, for instance, at levels of nerve root or branches.
Lower extremity considerations. Considerations include any preexisting motor or sensory decits in non-amputated limb that may
impact weight-bearing, ambulation, and proprioception (Table I). Preexisting co-morbidities such as diabetes and vascular disease may not
only impair healing but any neuropathy from these two conditions may
severely impact ambulatory status in rehabilitation by affecting the
good limb and necessary coordination required for balancing.
Level of amputation and whether proximal (above-the-knee [AKA])
vs. distal (below-the-knee [BKA]) will also affect energy expenditure
and so consideration of pre-existing cardiopulmonary issues need to be
taken into account in the rehabilitation phase. For instance, presence of
pulmonary metastases or possible development of these and effect on
cardiorespiratory expenditure can decrease endurance for ambulation in
the future and thus feasibility of being t for a prosthesis or not.
For example, normal ambulation in an individual without
amputation requires 3 METs (metabolic equivalent tasks). For a
unilateral BKA with prosthesis, energy expenditure can increase
anywhere from 928% and for a unilateral AKA with a prosthesis, it can
increase from 4065%. Without use of a prosthesis and crutches alone,
ambulatory energy expenditure can range from 5075% from unilateral
AKA to BKA [12] (Table II).
Preprosthetic management. Continued wrapping of residual limb
and assessment of a patients ability to do this themselves should be
assessed by therapists and nursing in this phase. Continued use of stump
shrinkers and evaluation of stabilization of residual limb circumference
and volume will determine when a patient is at the stage where a
prosthesis may now be prescribed. Stump shrinkers should be worn
24 hr a day and removed for cleaning, basic hygiene and skin inspection.
These may still be worn at night, as well, if a patient has continued
edema at night [13].
Focus of rehabilitation in this stage should be on continued reduction
of residual limb edema with use of stump shrinkers, increasing muscle
strengthening for transfers and ambulation, muscle stretching to prevent
contractures in residual limb, skin inspection for integrity, beginning
scar massage and desensitization therapies to prevent development of
chronic pain [13].
Striving for more patient independence should be a goal during this
phase with emphasis on transfers and performance of ADLs. Ideally,
ambulation with crutches or walker should be encouraged as opposed to
use of a wheelchair, unless patient anticipates needing to walk for a long
distance where fatigue may become an overwhelming factor. Use of
crutches can enhance ROM and help deter development of hip
contractures (in the case of AKAs) or knee contractures (in the case of
BKAs) which can occur from sitting in a wheelchair for extended periods
of time. Encouraging a patient to lie prone for a specied period of time
each day may also help prevent development of contractures [13].
Prosthetic training. During this stage, introduction and usage of
the prosthesis itself takes place. As opposed to prosthetic training for

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TABLE I. Functional and Prosthetic Considerations in Amputation versus Limb-Salvage Surgery


Segment/Region
Shoulder

Procedure
Forequarter amputation
Limb salvage

Humerus

Proximal transhumeral
amputation

Distal transhumeral
Limb salvage

Forearm

Transradial amputation

Pelvic Girdle

Limb salvage Radial nerve/


extensor compartment
Median/ulnar or flexor
compartment
External hemipelvectomy

Limb salvageinternal
hemipelvectomy

Prosthesis considerations

Transfemoral amputation
(AKA)

Limb Salvage

Tibia/Fibula

Transtibial amputation (BKA)

Limb salvage

Typical functional outcome

Noneinadequate suspension for


functional prosthesis
Endoprosthesis, APC, or
osteoarticular allograft

Monohanded

Depends upon nerve injury;


sling vs wristhand orthosis
(WHO)

Requires good scapular mobility and


kinesthetic awareness for elbow
and hand control, low patient
acceptance due to prosthetic
weight
Good elbow and wrist control via
pulley or myoelectric sensors
ProximalEndoprosthesis or
allograft reconstruction and
fixation if preservation of shoulder
and elbow joints possible
DistalEndoprosthesis and total
elbow arthroplasty.
Excellent control of hand/wrist unit
via pulley or myoelectric sensors
Wrist disarticulation or radial
endoprosthesisa
Wrist disarticulation or ulnar head
endoprosthesis
Suspension with shoulder strap;
singleaxis versus polycentric hip
jointmicroprocessor knee
required if polycentric joint usedb
No reconstructionflail

Extrarticular resectionNo active shoulder


motion, /hand, elbow functional
strength, variable functional use
Intra-articular sectionPossible 45 abduction
and forward flexion. Greater ROM possible
if APC or osteoarticular allograft used
Prosthetic limb becomes nondominant arm,
provides stability for contralateral
manipulation

Allograft

Hip abduction brace while


healing; Anklefoot arthosis
(AFO) for sciatic n. injury;
Knee extension support for
femoral n. injury may be
needed chronically.
Hip abduction brace while
healing; Anklefoot orthosis
(AFO) for sciatic n. injury;
Knee extension support for
femoral n. injury may be
needed chronically

Custom or saddle prosthesis

Femur

Orthosis options

Requires adequate edema control and


hip flexion contracture prevention;
choice of knee mechanism
depends on level of expected
activity
Endoprosthesis or APC

Requires adequate edema control and


knee flexion contracture
prevention; choice of foot/ankle
mechanism depends on level of
expected activity
Endoprosthesis or APC

See above

Depends upon nerve injury;


sling vs WHO

May require assisted elbow flexion to place


hand in functional position if endoprosthesis
used; functional outcome good but use of
arm limited to light lifting and activities.

WHO

May achieve fine motor function in prosthetic


terminal device
Supported wrist extension enables grip, pincer

Poorly functional hand without endoprosthesis

Ambulation achievable with some reduction in


gait speed; limitations mainly with stair
climbing, standing, and sitting.

Non/limited weight-bearing; swingto hip


motion
Lengthy nonweight bearing, longterm hip
ROM restriction, variable active hip motion

Hip abduction brace for approx.


3 months

Limited weight-bearing initially, longterm hip


ROM restriction, variable hip motion

Ambulation without assistive devices


achievable with some increase in energy
expenditure

Hip ROM restrictions 68 weeks or longer;


may progress to independent non-assisted
(or noassistive device) ambulation; limb
length discrepancy possiblec
Excellent, especially for younger patients

AFO

Peroneal palsy commonc

APC, allograft prosthesis composite; ROM, Range of motion; AKA, above-the-knee amputation; BKA, below-the knee amputation.
a
Gokaraju K, Sri-Ram K, Donaldson J, Parratt MTR, Blunn GW, Cannon WR, Briggs TWR.Use of a distal radius endoprosthesis following resection of a bone tumour:
A Case Report. Sarcoma, Volume 2009 (2009), Article ID 938295, 5 pages.
b
Houdek, MT, Kralovec, ME, ANdress, KL. Hemipelvectomy: High-level amputation surgery and prosthetic rehabilitation. Am. J. Phys. Med Rehabil. Vol. 93, No. 3,
March 2014, pp. 18.
c
Oren R, Zagury A, Katzir O, Kollender Y, Meller I. Principles of rehabilitation after limb-sparing surgery for cancer. In Malawer M, Sugarbaker PH (eds):
Musculoskeletal Cancer Surgery. Dordrecht/Boston/London: Kluwer Academic Publishers, 2001: 584591.

Journal of Surgical Oncology

Rehabilitation of the Sarcoma Patient


TABLE II. Energy Cost of Amputee Ambulation

No prosthesis, with crutches


Unilateral BK with prosthesis
Unilateral AK with prosthesis
Bilateral BK with prosthesis
BK plus AK with prosthesis
Bilateral AK with prosthesis
Unilateral hip disarticulation with prosthesis
Hemipelvectomy with prosthesis
No prosthesis, with crutches

Increase (%)

MET

50
928
4065
41100
75
280
82
125
75

45
3.33.8
4.25.8
4.26.0
5.3
11.4
5.5
6.75
5.3

AK, above knee; BK, below knee; MET metabolic equivalent tasks.
a
Based on percentage increase above cost of normal (3 METs).

noncancer patients, this phase of rehabilitation may be signicantly


delayed due to post-operative radiation if that is planned. Radiation
itself may prolong already-present edema or cause development of
edema which will delay the tting of a prosthesis. This cannot be done
until residual limb edema is stabilized.
Prescription for the prosthesis itself depends on several factors and
these include a patients age, prior level of function and feasibility of
returning to this level of function. Other factors include: residual limb
factors (length), a patients weight, daily activities, scar/skin integrity
and vascular health, and cost [14].
Education regarding donning and dofng and care of the prosthesis
need to be taught by the therapists to the patient and evaluation of
patients comprehension and ability to perform this must be monitored.
Training during this phase focuses on transfers with prosthesis,
increasing ambulation and endurance with the prosthesis (if lower
extremity) and increasing dexterity with ADLs (if upper extremity)
and evaluating safety especially with advanced ambulation such
as negotiating uneven surfaces and ascending/descending stairs.
Optimizing pain management and patient education on examining
skin integrity for areas of breakdown need to be done as modications to
prosthesis can be done during this period.

619

For example, a patient may have complete loss of ankle dorsiexion


following resection of a posterior thigh sarcoma. The patient would
require an ankle-foot-orthosis (AFO) for safe ambulation. However, if
the sciatic nerve was devascularized or stretched during sarcoma
resection, but not transected, dorsiexion strength may recover and
eventually be sufcient for ambulation without the AFO. This patient
might still require an AFO for long-distance ambulation due to easy
fatigability of the re-innervated muscle.

CANCER RECURRENCE
Spread is via vascular system rather than lymphatic system so numeric
staging has different connotations for prognosis and severity than it does
for carcinomas. Majority of metastases occur in lungs. Recurrence rates
can range from 16% to 45%, depending on whether a patient has received
a referral to a specialized sarcoma treatment center [4].
Recurrence can occur locally at the previously resected site or may
appear in other bony structures close by or may manifest as pulmonary
metastases or both. Pain may be the rst sign of recurrence and can occur
during rehabilitation depending on the aggressive nature of the sarcoma.
It is crucial that any new pain or increased pain at previous surgical site be
assessed to discover whether this is due to recurrence versus increased
pain due to biomechanical factors on surrounding structures (i.e.,
increased stress on unused muscles required for altered gait or upper
extremity ROM), or due to development of phantom limb pain.

MEASURES OF RECOVERY AND FUNCTION


Typically, measures of recovery and function of soft tissue sarcoma
patients after surgery have used studies assessing physical function in
general after recovery as the main indicator of quality of life. These
studies have looked at patients mobility and ADLs, [10,1519]
examined outcomes comparing limb-salvage vs amputation, internal vs
external hemipelvectomy [2022], and outcomes comparing pre- to
post-surgical radiation [23]. However, it is only recently that evaluation
of quality-of-life (QOL) has expanded beyond traditional physical
functioning and begun examining psychosocial and vocational factors
in these patients [24].

Limb Salvage Rehabilitation Care


When soft tissue sarcoma can be adequately resected without
amputation of the involved limb, limb salvage with multimodality
treatment may be offered. The combination of muscle or muscle
compartment resection, with or without adjacent bone resection, with or
without neural resection or neuropraxial injury, may cause profound
functional impairment. In some cases, with minimal tissue resection and
no neural involvement, recovery may be rapid with very limited
functional impact. In other cases, impairment is long-lasting or
permanent, and disability and handicap may result. The functional
outcome is therefore highly individualized and dependent on
intraoperative ndings, the extent of reconstruction needed, and the
inclusion of multimodal therapy, particularly radiation therapy.
Multimodal treatment with external beam radiation therapy and
brachytherapy increase risks of limb edema, soft tissue brosis and
contracture formation. Patients must perform stretching at least daily to
reduce the degree of soft tissue contracture and brosis in the irradiated
tissue. Radiation involving a joint space or muscles which cross a
typically exed joint (e.g., iliopsoas, pectoralis major, biceps brachii,
etc.) is likely to lead to muscular edema, musculotendinous shortening
and reduced range of motion. Daily stretching aligns and organizes
forming scar tissues to permit greater mobility.
Orthoses can support weakened distal limbs to permit function when
neural injury or muscle resection has occurred. If neuropraxia
completely resolves, the orthosis may no longer be required. With
partial recovery, an orthosis may be used temporarily or intermittently.
Journal of Surgical Oncology

Performance and Assessment Tools and Scales


The World Health Organization (WHO) developed the International Classication of Function (ICF) to measure health and
disability but with a focus on ones function and not solely on their
disability and view it in the context of their environment. This is a
biopsychosocial model of disease examining three levels of function
(body structure and function; activity; and participation) and how
they interact with ones environment (external factors) and personal
factors (internal elements, e.g., gender, occupation, family, age, and
family/social roles, etc.) [25]. The development of this construct of
disability and function has then led to greater emphasis in the health
professions on assessing quality of life.
Standard performance scales for oncology patients such as the
Eastern Cooperative Oncology Group (ECOG) and Karnofsky scales
include assessment of physical function but not with inclusion of other
factors affecting and interplaying with physical function. This is
examined in more depth and summarized by Yasko et al. [10] in their
discussion of these indices in article emphasizing quality of life in limb
salvage patients. Their review detailed the emphasis of most indices of
postsurgical patients on physical functioning. But, the tide has been
turning through the ensuing years to include other parameters to assess
overall quality of life.
Traditionally, functional outcomes following limb-salvage surgery
have been measured using the Musculoskeletal Tumor Society
International Symposium on the Limb Salvage (MSTSISOLS) and

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Toronto Extremity Salvage Score (TESS). The MSTS scoring system is


a validated, standardized scoring system which looks at pain, function,
emotional acceptance, gait and ambulation for lower extremities and
upper extremity dexterity and strength [15,16]. The TESS scoring
system evaluates physical function in lower extremity sarcoma patients
looking at activity limitations in mobility and ADLs [1618]. Again,
focus is on physical function and not other domains.
Rehabilitation-specic scales such as Barthel Index or Functional
Independence Measure (FIM) are used routinely by physical and
occupational therapists throughout the course of a patients
rehabilitation to chart progress. But, again, these are only examining
ADLs as measurements of quality of life.
Another factor to consider in the measure of recovery of
patients is that no standard rehabilitation protocol exists for sarcoma
patients [8,26]. Additionally, successful recovery may be dependent on
the availability of adequately trained rehabilitationists, the access to
continued outpatient rehabilitation, the motivation of the patient and the
caregivers, and where a patient reside. Quality physiatrists, prosthetists,
and therapists skilled specically in treating amputees are not
widespread, not to mention that even those that are well-trained may
not be attuned to the specic needs of these cancer patients. Much of the
rehabilitation course also entails a psycho-emotional component as fear
of recurrence remains prevalent in all cancer patients. Rehabilitation
specialists must be aware of treatment-related conditions such as
electrolyte disturbances and anemia as causes of fatigue which may also
limit their participation in therapies.
Despite consensus on goals of rehabilitation for limb salvage
patients, no specic standardized rehabilitation protocol and detailed
steps have been established to provide individualized therapy
guidelines for anatomic location of resection. In order to address
this, Shehadeh et al. [9] established a protocol for this based on ve
anatomic sites of surgery: pelvic resection, proximal/total femur
replacement, distal femur replacement, proximal tibia replacement, and
proximal humerus and shoulder girdle resection. After undergoing these
specic rehabilitation programs, patients functional outcomes were
measured with the MSTS-ISOLS scoring system, resulting in scores
ranging from 60100% which represents an improvement over previous
functional scores from past studies [8].

Quality of Life Measures


Measuring recovery and function cannot take place without an
adequate discussion of quality of life. And The World Health
Organization (WHO) denes Quality of Life as an individuals
perception of their position in life in the context of the culture and value
systems in which they live and in relation to their goals, expectations,
standards, and concerns. It is a broad ranging concept affected in a
complex way by the persons physical health, psychological state,
personal beliefs, social relationships, and their relationship to salient
features of their environment [27]. Its domains consist of: physical
well-being, psychologic well-being, level of independence, social
relationships, environment, and spiritual well-being [27].
What is important to note here is that ones quality of life is never
static but always dynamic as ones position and self-context in life will
change as domains change and shift in ones lifetime. In terms of
surgical sarcoma patients, assessing these patients over the ensuing time
period after rehabilitation is a true parameter of quality of life as these
measures can change over time [10]. Although a patient may be in a
disease-free period of survival after surgery and treatment, this does not
mean that their quality of life has been enhanced by adequate
rehabilitation, and, in fact, patients with soft tissue sarcomas have been
shown to have a decreased quality of life when compared with their
counterparts who have undergone organ-specic tumor resection [28].
More specically, control of disease does not impact a patients
quality of life as much as their interpretation of their life in the context of
Journal of Surgical Oncology

length of surgery, time lost in recovery and rehabilitation that couldve


been spent with family/friends, nancial strains, and time lost from
work (in some cases loss of job due to extended period of time required
for treatment), and adjustment to body image [28].
Schreiber et al. [29] looked at the function and its impact on quality
of life in their survey of limb-salvage sarcoma patients pre- and one year
post-surgery. They found that although impairments and activity
limitations seemed initially to affect quality of life, when adjustments
were made based on demographics and clinical factors, they found that
it was really overall participation restrictions that affected these
patients quality of life. To be more specic, they referred to
restrictions in participation of life roles [29] as resuming care
within their families, return to work, and resumption of recreational
activities and that it was lack of performing these that affected their
quality of life moreso than performing ADLs and basic mobility.

CONCLUSION
Rehabilitation of soft tissue sarcoma patients ideally begins before
any surgery takes place so an adequate assessment of pre-morbid
function, medical issues, and social and environmental habitats is
included in tailoring an adequate rehabilitation program. This then
continues in the immediate post-op period and through the continuum
of recovery whether with transfer to further inpatient rehab or
outpatient rehabilitation. Adequate cognizance of possible sequelae
and complications from surgery need to be managed as well as these
can affect an adequate rehabilitation course. These can include
continued or chronic pain or phantom limb pain, fatigue, depression,
skin breakdown, anemia, electrolyte abnormalities, bowel/bladder
dysfunction, or poorly controlled edema or lymphedema. These
complications can all severely impact rehabilitation and patients
participation in rehabilitation and may lead to long-term disability
from their surgery and cancer.
Although optimizing physical function of patients after surgical
resection for extremity soft tissue sarcomas is necessary to achieve as
much independence and premorbid activity level as possible, quality
rehabilitation programs need to look beyond the physical parameters of
measurement as represented by the Barthel Index, FIM score, MSTS,
TESS systems, etc. Physical functioning is just one aspect of recovery
and psychosocial functioning needs to be emphasized as well.
Through a model of multidisciplinary rehabilitative care, emphasis
can be placed on how patients need to function within their own specic
environments. Psychological, emotional, spiritual, vocational, and
nancial issues can be addressed by skilled members of the
rehabilitation team to help a patient achieve optimal quality of life
and function.

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