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Functional rehabilitation in cancer care
Functional
Rehabilitation
in Cancer Care
Joanne Futile
ITH THE DEVELOPMENT of new treatment techniques, patients with cancer are living longer with functional, psychological, vocational, and economic disabilities. This article reviews the functional aspectsof cancer rehabilitation based on this author’s experience in an oncology rehabilitation unit. The other aspectsof rehabilitation are addressedelsewherein this issue. When effectively applied, cancer rehabilitation has the power to reduce the impact of cancer and its treatment on individuals and their families. Early and ongoing assessmentof a patient’s rehabilitation needs is essential for prompt and effective treatment. Many of the disabilities or functional limitations can be predicted based on the patient’s diagnosis, treatment, and physical condition. One can identify and addressthese physical needsby using a systemsapproach and/or the diseasemodellm4;however, a functional approachis a more useful rehabilitation model.5 For example, two patients may experience alteration in mobility but will have different needs and interventions basedon their diseaseand treatment (eg, one due to an amputation for a sarcoma and the other related to fatigue as a result of radiation therapy for Hodgkin’s disease). One of the most frequent problems cancer patients face are physical problems.6 Therefore, evaluating the functional level of the individual with cancer is the cornerstone for cancer rehabilitation. It allows the rehabilitation team to identify physical and functional problems, to develop an individualized treatment plan, establish realistic goals, and facilitate discharge planning. Ideally, functional problems are identified during the initial diagnosis in order to facilitate the patient’s referral to appropriate resources(Fig 1). From the Oncology Rehabilitation Program, New England Rehabilitation Hospital, Woburn, MA. Joanne Futile, BSN, CRRN, OCN: Oncology Program Administrator, New England Rehabilitation Hospital. Address reprint requests to Joanne Futile, BSN, CRRN, OCN, Oncology Program Administrator, New England Rehabilitation Hospital, One North, 2 Rehabilitation Way, Woburn, MA 01801. Copyright 0 1992 by W.B. Saunders Company 0749-2081l92lO803-CQO5$5.00/0
186
The Functional IndependenceMeasure (FIM) is the tool that we have used at the New England Rehabilitation Hospital in assessingoncology patients.’ The FIM measuresself-care, mobility, ambulation, bowel and bladder dysfunction, communication, cognition, social interaction, and emotion. An FIM score can range from 18 (total assistance needed) to 126 (maximally independent). It doesnot measurepain, family support, or community involvement. It allows for the evaluation of a patient’s burden of care and provides a tool for measuring progress (Fig 2). Oncology patients can have a multitude of medical problems (eg, anemia, neutropenia, superior vena cava syndrome, pneumonia, hypercalcemia, neurological and bone metastases), However, theseproblems do not indicate a patient’s rehabilitation needs,therefore, a functional assessmentis a priority in determining physical rehabilitation needs. Combining the medical data, functional assessment,and social support network information enablesclinicians to set realistic goals and develop a plan of care to facilitate referrals and discharge planning. * The basic treatment plans in physical therapy, occupational therapy, speechtherapy, and rehabilitation nursing are essentially the sameas for other diagnoses. They may include activities of daily living treatment plan, bowel and bladder programs, a strengthening and endurance program, gait training, and pain management.1*239 Oncology patients who benefit most from rehabilitation are shown in Table 1. The inpatient oncology program at New England Rehabilitation Hospital is staffed by a multidisciplinary team consisting of a physiatrist, medical oncologist, rehabilitation nurses, physical therapists, occupational therapists, speechpathologists, a social worker, pastoral care, dietitian, movementtherapist, psychiatrist, family therapist, and vocational counselor. Multidisciplinary team conferencesare held on a weekly basis to facilitate mutual goal setting and discharge planning. The program uses the functional independence measureto document patient progress throughout their hospitalization. The dispositions of 116 patients discharged in 1991 were reviewed. Table 2 Seminars in Oncology Nursing,
Vol 8, No 3 (August),
1992:
pp 186-189
FUNCTIONAL
REHABILITATION
IN CANCER
187
CARE
tients had metastaticrenal cell carcinoma, one had lung cancer, and one patient had a recurrent astrocytoma. The following case study provides an example of how the FIM assiststhe development of a treatment plan.
Table 1. Primary Diagnosis of Oncology Patients Who Could Most Benefit From Physical Rehabilitation Esophageal cancer Laryngeal cancer Brain neoplasms-primary/metastatic Spinal cord compression-primary/metastatic Breast cancer-bone/neurological metastatses Prostate cancer-bone/neurological metastatses Colon cancer Lymphoma Multiple myeloma Lung cancer
Case Study Jenny, a 45year-old woman was admitted to the acute care hospital on November 29, 1991, with complaints of back pain and leg weakness. Six months earlier she had a resection of a left frontal brain metastasisfrom a primary lung cancer. She also completed a course of chemotherapy and radiation therapy for the brain lesion. A magnetic resonanceimage of her spine revealeda metastatic lesion at T4, and on December3, 1991, she had a decompressivelaminectomy with debulking of the tumor and spine stabilization with rods/wires. She was transferred to the oncology program at New England Rehabilitation Hospital for a comprehensive inpatient rehabilitation program. Her Initial Functional Status showed an FIM measurementof 68. She needed moderate assistance with bed mobility, transfersfrom wheelchair to commode and bed, and bathing and dressing. Her balancewas moderately impaired and she was
shows the diagnostic categories of these patients and Table 3 lists the discharge dispositions. There was no correlation between patient diagnosis and ability to predict rehabilitation outcome becauseof the additional factors of social support and progression of disease. The majority of cancer patients were discharged home with functional improvement. In fact, the oncology patients were dischargedhome after an averagelength of stay of 24 days after admission comparedwith 42 days for our stroke patient population. Of the 8% dischargedto the acute hospital, 5% returned to complete their rehabilitation program. Of the 7% who died, four patients had spinal cord compression secondary to metastatic prostate cancer, two pa-
CANCER
ONCOLOGY
FUNCTIONAL
PROBLEM
PHYSICAL THERAPY, THERAPY,
NURSING,
ASSESSMENT
INDEPENDENCE
IDENTIFICATION
MEASURE
AND REFERRAL
PHYSIATRY,
SPEECH THERAPY,
OCCUPATIONAL
PSYCHIATRY,
SOCIAL SERVICE,
OTHER SERVICES
I
I Fig 1. Functional assessment of oncology patients.
PATIENT
----T-
INPATIENT
HOME
HOSPITAL
REHABILITATION
SERVICES
OUTPATIENT
HOSPITAL
DEPARTMENT
NONE
JOANNE
19.
Olhrr Olsgnarrr: wee dlschvpr)
A. 8. C. D. E. F.
I
6,ung Gmomlng B,lhlng Dr4a&lQ,.UPpw Dro~8lng.Lorer Tollatlng
co Cede for IlOW Imprlmwits, co.morbidit!
FOLLOWUP
Body Body
I. Sed,Chalr. Whrrlchalr J. TolInt K. Tub. Showa
e. Therapy
Fig 2. Uniform data system for mediil rehabilitation. Rehabiliition followup coding sheet. Reprinted with permission.’
unable to maintain sitting balance without upper extremity support, and pain in her left shoulder/ scapula interfered with mobility. Jenny experienced a moderate decreasein her ability to use energy conservation techniques in performing Table 2. Diagnostic Categories of 116 Cancer Patients Involved in the New England Rehabilitation Program in 1991
Diagnostic Categories Spinal cord compression secondary to: Metastatic prostate cancer Metastatic breast cancer Primary brain tumor Metastatic brain tumor secondary to: Lung cancer Breast cancer Multiple myeloma Lymphoma Pathological fractures secondary to metastatic prostate/breast cancer Miscellaneous diagnoses
FUCILE
No. Patients
39 28 11 8 9 2 3 6 10
functional tasks; stressrelated to decreasedfunctional status and change in body image; and anxiety due to prolonged bedrest and recurrent hospitalization. She also had impaired bowel function secondaryto constipation. The multidisciplinary team established goals and inmvenfions based on the results of Jenny’s functional status. She received 3 hours of active therapy per day; activity of daily living training using adaptive equipment; balance and mat activities for instruction in paraplegia techniques; and strengthening exercises to help with bed and wheelchair mobility that also included therapeutic Table 3. Discharge
Dispositions
of 116 Cancer Patients
Dispositions
%
Home Acute care Died Nursing home
83 8 7 2
FUNCTIONAL REHABILITATION IN CANCER CARE
189
pool exercises. Relaxation and pain management were addressedalong with institution of a bowel program to prevent constipation and instruction on appropriate skin care to prevent decubiti. Family teaching took place to facilitate discharge to her home. The acrual outcomes at the time of Jenny’s discharge showed an FIM of 96, a considerable improvement over her initial FIM of 68. She was independentin bed mobility and transfersfrom bed to commode to wheelchair using a sliding board. Shewas independentwith wheelchair mobility at a
functional distance. Shehad improved body image and coping mechanismsto deal with stress. She was discharged home with her husband and two sons after 28 days. Arrangements were made for continued therapy and family teaching in the home. Indeed, oncology patients can benefit from a multidisciplinary oncology rehabilitation program. However, achieving successis often tedious, slow, and frustrating. But for individuals living with cancer, rehabilitation can add the vital dimension of quality to survival.
REFERENCES 1. Gunn AE: Cancer Rehabilitation. New York, NY, Raven, 1984 2. Dietz JH: Rehabilitation Oncology. New York, NY, Wiley & Sons, 1981 3. Broadwell DC: Rehabilitation needs of the patient with cancer. Cancer 60:563-568, 1987 4. Ganz PA: Current issues in cancer rehabilitation. Cancer 651742-751,
1990
5. Watson P: Cancer rehabilitation: The evolution of a concept. Cancer Nurs 13:2-12, 1990
6. Lehman JF: Cancer rehabilitation: Assessment ot need, development and evaluation of a model of care. Arch Phys Med Rehab 59:410-419, 1978 7. Uniform Data System for Medical Rehabilitation: Rehabilitation Follow-up Coding Sheet. UDS Data Management Service, Buffalo, NY, SUNY South Campus, 1990 8. O’Toole D, Golden A: Evaluating cancer patients for rehabilitation potential. J Western Med 155:384-387, 1991 9. McGarvey C: Physical Therapy for the Cancer Patient. New York, NY, Churchill Livingstone, 1990
Rehabilitation
in Cancer Care
Joanne Futile
ITH THE DEVELOPMENT of new treatment techniques, patients with cancer are living longer with functional, psychological, vocational, and economic disabilities. This article reviews the functional aspectsof cancer rehabilitation based on this author’s experience in an oncology rehabilitation unit. The other aspectsof rehabilitation are addressedelsewherein this issue. When effectively applied, cancer rehabilitation has the power to reduce the impact of cancer and its treatment on individuals and their families. Early and ongoing assessmentof a patient’s rehabilitation needs is essential for prompt and effective treatment. Many of the disabilities or functional limitations can be predicted based on the patient’s diagnosis, treatment, and physical condition. One can identify and addressthese physical needsby using a systemsapproach and/or the diseasemodellm4;however, a functional approachis a more useful rehabilitation model.5 For example, two patients may experience alteration in mobility but will have different needs and interventions basedon their diseaseand treatment (eg, one due to an amputation for a sarcoma and the other related to fatigue as a result of radiation therapy for Hodgkin’s disease). One of the most frequent problems cancer patients face are physical problems.6 Therefore, evaluating the functional level of the individual with cancer is the cornerstone for cancer rehabilitation. It allows the rehabilitation team to identify physical and functional problems, to develop an individualized treatment plan, establish realistic goals, and facilitate discharge planning. Ideally, functional problems are identified during the initial diagnosis in order to facilitate the patient’s referral to appropriate resources(Fig 1). From the Oncology Rehabilitation Program, New England Rehabilitation Hospital, Woburn, MA. Joanne Futile, BSN, CRRN, OCN: Oncology Program Administrator, New England Rehabilitation Hospital. Address reprint requests to Joanne Futile, BSN, CRRN, OCN, Oncology Program Administrator, New England Rehabilitation Hospital, One North, 2 Rehabilitation Way, Woburn, MA 01801. Copyright 0 1992 by W.B. Saunders Company 0749-2081l92lO803-CQO5$5.00/0
186
The Functional IndependenceMeasure (FIM) is the tool that we have used at the New England Rehabilitation Hospital in assessingoncology patients.’ The FIM measuresself-care, mobility, ambulation, bowel and bladder dysfunction, communication, cognition, social interaction, and emotion. An FIM score can range from 18 (total assistance needed) to 126 (maximally independent). It doesnot measurepain, family support, or community involvement. It allows for the evaluation of a patient’s burden of care and provides a tool for measuring progress (Fig 2). Oncology patients can have a multitude of medical problems (eg, anemia, neutropenia, superior vena cava syndrome, pneumonia, hypercalcemia, neurological and bone metastases), However, theseproblems do not indicate a patient’s rehabilitation needs,therefore, a functional assessmentis a priority in determining physical rehabilitation needs. Combining the medical data, functional assessment,and social support network information enablesclinicians to set realistic goals and develop a plan of care to facilitate referrals and discharge planning. * The basic treatment plans in physical therapy, occupational therapy, speechtherapy, and rehabilitation nursing are essentially the sameas for other diagnoses. They may include activities of daily living treatment plan, bowel and bladder programs, a strengthening and endurance program, gait training, and pain management.1*239 Oncology patients who benefit most from rehabilitation are shown in Table 1. The inpatient oncology program at New England Rehabilitation Hospital is staffed by a multidisciplinary team consisting of a physiatrist, medical oncologist, rehabilitation nurses, physical therapists, occupational therapists, speechpathologists, a social worker, pastoral care, dietitian, movementtherapist, psychiatrist, family therapist, and vocational counselor. Multidisciplinary team conferencesare held on a weekly basis to facilitate mutual goal setting and discharge planning. The program uses the functional independence measureto document patient progress throughout their hospitalization. The dispositions of 116 patients discharged in 1991 were reviewed. Table 2 Seminars in Oncology Nursing,
Vol 8, No 3 (August),
1992:
pp 186-189
FUNCTIONAL
REHABILITATION
IN CANCER
187
CARE
tients had metastaticrenal cell carcinoma, one had lung cancer, and one patient had a recurrent astrocytoma. The following case study provides an example of how the FIM assiststhe development of a treatment plan.
Table 1. Primary Diagnosis of Oncology Patients Who Could Most Benefit From Physical Rehabilitation Esophageal cancer Laryngeal cancer Brain neoplasms-primary/metastatic Spinal cord compression-primary/metastatic Breast cancer-bone/neurological metastatses Prostate cancer-bone/neurological metastatses Colon cancer Lymphoma Multiple myeloma Lung cancer
Case Study Jenny, a 45year-old woman was admitted to the acute care hospital on November 29, 1991, with complaints of back pain and leg weakness. Six months earlier she had a resection of a left frontal brain metastasisfrom a primary lung cancer. She also completed a course of chemotherapy and radiation therapy for the brain lesion. A magnetic resonanceimage of her spine revealeda metastatic lesion at T4, and on December3, 1991, she had a decompressivelaminectomy with debulking of the tumor and spine stabilization with rods/wires. She was transferred to the oncology program at New England Rehabilitation Hospital for a comprehensive inpatient rehabilitation program. Her Initial Functional Status showed an FIM measurementof 68. She needed moderate assistance with bed mobility, transfersfrom wheelchair to commode and bed, and bathing and dressing. Her balancewas moderately impaired and she was
shows the diagnostic categories of these patients and Table 3 lists the discharge dispositions. There was no correlation between patient diagnosis and ability to predict rehabilitation outcome becauseof the additional factors of social support and progression of disease. The majority of cancer patients were discharged home with functional improvement. In fact, the oncology patients were dischargedhome after an averagelength of stay of 24 days after admission comparedwith 42 days for our stroke patient population. Of the 8% dischargedto the acute hospital, 5% returned to complete their rehabilitation program. Of the 7% who died, four patients had spinal cord compression secondary to metastatic prostate cancer, two pa-
CANCER
ONCOLOGY
FUNCTIONAL
PROBLEM
PHYSICAL THERAPY, THERAPY,
NURSING,
ASSESSMENT
INDEPENDENCE
IDENTIFICATION
MEASURE
AND REFERRAL
PHYSIATRY,
SPEECH THERAPY,
OCCUPATIONAL
PSYCHIATRY,
SOCIAL SERVICE,
OTHER SERVICES
I
I Fig 1. Functional assessment of oncology patients.
PATIENT
----T-
INPATIENT
HOME
HOSPITAL
REHABILITATION
SERVICES
OUTPATIENT
HOSPITAL
DEPARTMENT
NONE
JOANNE
19.
Olhrr Olsgnarrr: wee dlschvpr)
A. 8. C. D. E. F.
I
6,ung Gmomlng B,lhlng Dr4a&lQ,.UPpw Dro~8lng.Lorer Tollatlng
co Cede for IlOW Imprlmwits, co.morbidit!
FOLLOWUP
Body Body
I. Sed,Chalr. Whrrlchalr J. TolInt K. Tub. Showa
e. Therapy
Fig 2. Uniform data system for mediil rehabilitation. Rehabiliition followup coding sheet. Reprinted with permission.’
unable to maintain sitting balance without upper extremity support, and pain in her left shoulder/ scapula interfered with mobility. Jenny experienced a moderate decreasein her ability to use energy conservation techniques in performing Table 2. Diagnostic Categories of 116 Cancer Patients Involved in the New England Rehabilitation Program in 1991
Diagnostic Categories Spinal cord compression secondary to: Metastatic prostate cancer Metastatic breast cancer Primary brain tumor Metastatic brain tumor secondary to: Lung cancer Breast cancer Multiple myeloma Lymphoma Pathological fractures secondary to metastatic prostate/breast cancer Miscellaneous diagnoses
FUCILE
No. Patients
39 28 11 8 9 2 3 6 10
functional tasks; stressrelated to decreasedfunctional status and change in body image; and anxiety due to prolonged bedrest and recurrent hospitalization. She also had impaired bowel function secondaryto constipation. The multidisciplinary team established goals and inmvenfions based on the results of Jenny’s functional status. She received 3 hours of active therapy per day; activity of daily living training using adaptive equipment; balance and mat activities for instruction in paraplegia techniques; and strengthening exercises to help with bed and wheelchair mobility that also included therapeutic Table 3. Discharge
Dispositions
of 116 Cancer Patients
Dispositions
%
Home Acute care Died Nursing home
83 8 7 2
FUNCTIONAL REHABILITATION IN CANCER CARE
189
pool exercises. Relaxation and pain management were addressedalong with institution of a bowel program to prevent constipation and instruction on appropriate skin care to prevent decubiti. Family teaching took place to facilitate discharge to her home. The acrual outcomes at the time of Jenny’s discharge showed an FIM of 96, a considerable improvement over her initial FIM of 68. She was independentin bed mobility and transfersfrom bed to commode to wheelchair using a sliding board. Shewas independentwith wheelchair mobility at a
functional distance. Shehad improved body image and coping mechanismsto deal with stress. She was discharged home with her husband and two sons after 28 days. Arrangements were made for continued therapy and family teaching in the home. Indeed, oncology patients can benefit from a multidisciplinary oncology rehabilitation program. However, achieving successis often tedious, slow, and frustrating. But for individuals living with cancer, rehabilitation can add the vital dimension of quality to survival.
REFERENCES 1. Gunn AE: Cancer Rehabilitation. New York, NY, Raven, 1984 2. Dietz JH: Rehabilitation Oncology. New York, NY, Wiley & Sons, 1981 3. Broadwell DC: Rehabilitation needs of the patient with cancer. Cancer 60:563-568, 1987 4. Ganz PA: Current issues in cancer rehabilitation. Cancer 651742-751,
1990
5. Watson P: Cancer rehabilitation: The evolution of a concept. Cancer Nurs 13:2-12, 1990
6. Lehman JF: Cancer rehabilitation: Assessment ot need, development and evaluation of a model of care. Arch Phys Med Rehab 59:410-419, 1978 7. Uniform Data System for Medical Rehabilitation: Rehabilitation Follow-up Coding Sheet. UDS Data Management Service, Buffalo, NY, SUNY South Campus, 1990 8. O’Toole D, Golden A: Evaluating cancer patients for rehabilitation potential. J Western Med 155:384-387, 1991 9. McGarvey C: Physical Therapy for the Cancer Patient. New York, NY, Churchill Livingstone, 1990