Feasibility and benefit of long-dose stroke neurorehabilitation which produced and maintained balance and mobility gains throughout cancer surgery and radiation treatment

Purpose: This case study provides quantitative evidence of the feasibility and benefit of a long-dose, 10-month neurorehabilitation program for a chronic stroke survivor who, in the midst of the neurorehabilitation program, underwent surgery and radiation treatment for breast cancer. Methods: The patient was age 60 years, and 6 years post-stroke (left middle cerebral artery stroke), exhibiting impairments in balance, strength, and gait coordination, as well as deficits in functional mobility, and compromised quality of life. Her comprehensive mobility/fitness neurorehabilitation program included aerobics, strength and coordination training, and balance and gait coordination training. Treatment was 1.5 2 hours per day, 5 days/week for 6 months, followed by an additional 4 months of treatment 3 days/week. Outcome measures were acquired at entry into the neurorehabilitation program, and at months 2, 4, 6, 8 and 10. Measures included the following: modified Ashworth (mASH, spasticity); Fugl-Meyer (FM; isolated limb joint coordination); 6-minute walk test (6MWT; walking endurance); gait speed; Berg Balance Scale (BBS; static and dynamic balance); Timed Up and Go (TUG; mobility); 10 Meter Walk Test (10MWT; short distance, self-selected and fast walking speed); Functional Gait Assessment (FGA; dynamic balance and postural stability during gait); Functional Independence Measure (FIM; assessment of functional status and disability); Craig Handicap Assessment and Reporting Technique (CHART; quality of life assessment of how patients with disabilities function in the community and at home); 36-Item Short Form Survey (SF36; quality of life measure); and the Stroke Impact Scale (SIS; stroke-specific quality of life measure). Fatigue level was queried during and following radiation therapy. Results: From baseline through month 4, the patient demonstrated improvements in most outcome measures. For example, she improved from 3 minutes of cycling endurance to 45 minutes, and balance improvement reached the threshold for functional independence. At month 5, she was diagnosed with breast cancer and underwent a partial mastectomy. She underwent radiation treatment, which concluded in month 7. Prior, during, and after the cancer treatment, she continued participation in the neurorehabilitation program. Following the partial mastectomy, she exhibited continued improvement in BBS, 10MWT-normal speed, FGA, CHART, SF-36, and SIS. Notably, the TUG continued to improve significantly by 4.73sec. She showed some decline in values for the 6MWT, gait speed, and 10MWTfast walking speed. Four weeks following the end of the course of radiation therapy, most measures showed a small decline. But in contrast, by 12 weeks after the end of radiation (which coincided with 10 months of participation in the neurorehabilitation program), the following measures showed a revival in improvement: Fugl-Myer (limb coordination); 6MWT (walking endurance); gait speed; BBS (balance); FIM (functional tasks); subdomains of the CHART quality of life measure (physical independence, cognitive independence); SF-36 subdomain of energy/fatigue; and the SIS (subdomains of strength, memory and thinking, and mobility. Conclusions: Years after stroke, intensive, long-dose neurorehabilitation can improve lower limb coordination, balance, strength, mobility, activities of daily living/ instrumental activities of daily living (ADL/IADL),, overall function, and quality of life. It was feasible for a severely impaired stroke survivor to participate in an intensive neurorehabilitation program. It was feasible for a stroke survivor to participate in a neurorehabilitation program throughout surgical and radiation treatment for cancer. For a chronic stroke survivor, many aspects of impairment, function, and quality of life were maintained by neurorehabilitation throughout treatment for cancer. *Correspondence to: Janis J Daly, Department of Neurology, College of Medicine, University of Florida, Gainesville Florida, Tel: (352) 273-5550; Fax: (352) 273-5575; E-mail: janis.daly@neurology.ufl. edu Received: April 25, 2018; Accepted: May 07, 2018; Published: May 09, 2018 Introduction To our knowledge, there have been no studies published on the response to neurorehabilitation for the co-morbidities of chronic stroke and breast cancer. A 2018 statement from the American Heart Association [1] highlights the shared risk factors between breast cancer and cardiovascular disease, as well as the cardiotoxic effects of radiation and chemotherapy (including hypertension, arrhythmias, and thromboembolic disease) and the associated increased mortality risk due to cardiovascular disease in post-menopausal breast cancer survivors. However, the impact of cancer treatment on a chronic stroke survivor’s neurorehabilitation response has not been explored. Therefore, this case study provides the treatment response to a longdose, 10-month neurorehabilitation program for a chronic stroke Boissoneault C (2018) Feasibility and benefit of long-dose stroke neurorehabilitation which produced and maintained balance and mobility gains throughout cancer surgery and radiation treatment Vascul Dis Ther, 2018 doi: 10.15761/VDT.1000148 Volume 3(2): 2-4 Her lower limb coordination improved 6 points (Fugl-Meyer MDC = 3.57 [7]. Function. The Functional Gait Assessment improved 6 points (minimum detectable change (MCD) = 4.2, Lin et al 2010). The mobility test, the TUG, improved 9.82sec (MDC = 3.16sec; [7]). Aerobic capacity/fitness endurance progressed from initial capability of only 3 min continuous cycling to ability to cycling for 45 min at a moderate intensity level, 2x/week. After cancer surgery Following the partial mastectomy, she continued the neurorehabilitation program. She exhibited continued improvement in values for the BBS, 10MWTnormal speed, FGA, CHART, SF-36, and SIS (Table 1, column D, just after the surgery for cancer). Notably, the TUG continued to improve significantly by 4.73sec. She showed some decline in values for gait speed including the 6MWT, gait speed, and 10MWTfast walking speed. (Table 1, column D, after the surgery for cancer). After cancer radiation Four weeks after the end of course of radiation therapy (Table 1, column E), most measures showed a small decline. In contrast to that, there was an improvement by 12 weeks after radiation (Table 1, column F), which coincided with 10 months of participation in the neurorehabilitation program. Table 1, column F shows that the following measures improved from month 8 to month 10: Fugl-Myer (limb coordination), 6MWT (walking endurance), gait speed, BBS (balance), FIM (functional tasks), subdomains of the CHART quality of life measure (physical independence, cognitive independence), SF36 subdomain of energy/fatigue, and the SIS (subdomains of strength, memory and thinking, and mobility. Notably, while participating in the neurorehabilitation program, Ms. White was able to either maintain or increase in many capabilities during and after the radiation treatment for cancer. Those measures (Table 1, columns E and F) include the following: the FIM (functional tasks), the CHART quality of life subdomains (mobility and cognitive independence), the SF36 subdomain (life role limitations due to physical problems, energy/fatigue, emotional wellbeing), and SIS subdomains (strength, memory and thinking, emotion, activities of daily living (ADL) and instrumental activities of daily living (IADL), mobility, and participation in life roles). Regarding fatigue level, prior to radiation, she reported zero fatigue at the time of query and slight fatigue at some point during the prior day of the query. After radiation, she reported fatigue slightly elevated above her own baseline, during weeks 1, 2, and 4 within the four-week radiation treatment, but no elevation of fatigue during the subsequent 8 weeks after the end of radiation treatment. In other words, any fatigue due to the four-week course of radiation treatment had resolved by the week after radiation and continued to be resolved throughout the subsequent 8 weeks. Some weeks prior to Month 10 data collection (Table 1, column F), Ms. Jones had the flu and it was sufficiently debilitating as to require her to miss a week of the neurorehabilitation program. At the month 10 data acquisition the following measures showed a decline: 10MWT chosen speed, 10MTW fast speed, TUG (a measure of mobility speed), and selected SF36 subdomains (physical functioning, pain, and general healthy). This could have been due to having just had the flu. After radiation treatment, abnormal muscle tone increased (mASH, column E); by month 10, abnormal muscle tone had decreased substantially, but not to baseline. survivor with breast cancer receiving surgery and radiation during neurorehabilitation.