- Email: [email protected]
Rehabilitation needs of an inpatient medical oncology unit1
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Rehabilitation Needs of an Inpatient Medical Oncology Unit Sheryl B. Movsas, DO, Victor T. Chang, MD, Richard S. Tunkel, MD, Vipul V. Shah, MD, Lynn S. Ryan, MS, OTR/L, Scott R. Millis, PhD ABSTRACT. Movsas SB, Chang VT, Tunkel RS, Shah VV, Ryan LS, Millis SR. Rehabilitation needs of an inpatient medical oncology unit. Arch Phys Med Rehabil 2003;84:16426. Objective: To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. Design: Prospective cohort study. Setting: Inpatient medical oncology unit at a Veterans Affairs hospital. Participants: Fifty-five patients admitted over a 6-month period. Interventions: Not applicable. Main Outcome Measures: FIM™ instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. Results: On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. Conclusions: Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.
From the Departments of Physical Medicine and Rehabilitation (Movsas, Shah, Millis) and of Medicine (Chang), University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ; Spinal Cord Injury Service and Pain Medicine Service (Movsas), Section of Hematology/Oncology (Chang), and Physical Medicine and Rehabilitation Service (Shah, Ryan), Veterans Affairs New Jersey Health Care System, East Orange, NJ; Department of Rehabilitation Medicine, Mount Sinai School of Medicine–Queens Health Network, Queens and Elmhurst Hospital Centers, Queens, NY (Tunkel); and Research Department, Kessler Medical Rehabilitation Research and Education Corporation, West Orange, NJ (Millis). Presented in part at the American Academy of Physical Medicine and Rehabilitation’s 61st Annual Assembly, November 3, 2000, San Francisco, CA. Supported by the Resident Research Fund, Department of Physical Medicine and Rehabilitation, UMDNJ–New Jersey Medical School, and Kessler Medical Rehabilitation Research and Education Corporation. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Sheryl B. Movsas, DO, VA New Jersey Health Care System, Spinal Cord Injury Service, Box 128, 385 Tremont Ave, East Orange, NJ 07018, e-mail: [email protected]. 0003-9993/03/8411-7792$30.00/0 doi:10.1053/S0003-9993(03)00345-9
Arch Phys Med Rehabil Vol 84, November 2003
Key Words: Neoplasms; Outcome assessment (health care); Rehabilitation. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ANCER HAS BECOME an all too common condition and continues to be a significant source of disability. More C than 1 million people are diagnosed with cancer each year, with a prevalence of more than 8 million people in the United States. Individuals with cancer are also living longer now than before, with a relative 5-year survival rate of 58%.1 As survival improves and cancer becomes a chronic condition in many patients, measures to maximize the level of function and, thereby, the quality of life, of cancer patients become increasingly relevant. The importance of rehabilitation needs in patients with cancer has recently received increasing recognition.2-4 However, since the first major description of rehabilitation needs in patients with cancer, published more than 20 years ago,5 few studies have addressed these patients from a rehabilitation perspective.6 The settings of most of the previous studies have been in cancer referral centers, acute inpatient oncology and surgical services, rehabilitation units at acute care hospitals, hospice settings, and inpatient rehabilitation facilities. A need exists for more data to clarify the extent of rehabilitation needs and to allow for improved planning of rehabilitation services. The objective of this exploratory study was to identify prospectively functional impairments and rehabilitation needs in patients admitted to an acute care medical oncology unit at a Veterans Health Administration hospital and thereby to examine these issues in a unique manner in the acute medical oncology ward. METHODS Participants Eligibility criteria for this study included a documented diagnosis of cancer, as well as a willingness to answer questionnaires and participate in a physical examination. Exclusion criteria were an inability to answer questions, an anticipated length of stay (LOS) in the hospital of less than 1 week, a refusal to participate, and previous participation. Therefore, patients who were readmitted subsequently were not reenrolled in the study. Procedure The study was designed as a prospective, cohort, singlecenter study performed at an inpatient oncology unit. The study was approved by the Veterans Affairs (VA) New Jersey Health Care System Institutional Review Board, and patients gave consent before participating. The Hematology/Oncology Service at the VA New Jersey Health Care System is unique in that it provides a wide range of care, including management of newly diagnosed, acutely ill cancer patients, as well as those with exacerbation or worsening of previously diagnosed cancer.
REHABILITATION NEEDS IN MEDICAL ONCOLOGY, Movsas
All patients consecutively admitted to the medical oncology service floor at the beginning and middle of the week (when the full complement of assessments were available) were asked to enroll in this study and were assessed within 1 to 2 days of admission at mid week. Subject accrual continued for a 6-month period. Patients could enroll only once. Subjects were assessed on admission and discharge for functional ability by using the FIM™ instrument,7 a functionally based physical examination, a Rehabilitation Needs Assessment, and a Recreational Needs Assessment. The FIM score was measured by a trained, certified rater (LSR); the other 3 assessments were performed by a physical medicine and rehabilitation senior resident (SBM). Assessments The primary assessment measures used were the FIM, a functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. The FIM is a disability scale widely used in the rehabilitation literature; it has proven reliability and validity as a measure in assessment of functional independence. It is an 18-item scale, with each item scored on a scale from 1 (totally dependent) to 7 (fully independent). It has traditionally been divided into 2 component subscales: FIM motor (13 items) and FIM cognitive (5 items), with a total range in scores from a minimum of 18 points (total assistance) to a maximum of 126 points (complete independence). The FIM motor subscale includes the areas of self-care (eating, grooming, bathing, upper-body dressing, lower-body dressing, toileting), sphincter control, mobility, and locomotion; scores range from 13 to 91. The FIM cognitive subscale includes the areas of communication (comprehension, expression) and social cognition (social interaction, problem solving, memory); scores range from 5 to 35. The FIM score was measured on patient admission and at discharge by a trained rater. Patients’ scores were determined by using standard protocols established by Uniform Data Systems for Medical Rehabilitation.8 We developed a functionally based physical examination, which was performed on each participant at admission and discharge. Patients were assessed for a number of abilities: coordination, proprioception strength, range of motion (ROM), balance, transfers, and gait (table 1). We analyzed data to see whether physical findings in these patients, as identified through the functional physical examination, correlated with FIM scores. We also considered that there might be a change in specific physical findings in these patients from admission to discharge. Rehabilitation needs were assessed on admission and discharge in the areas of deconditioning, mobility impairment, ROM, activities of daily living (ADLs), recreational therapy, patient education, hot or cold modalities, edema control, and wound care (table 2). Our primary hypothesis was that unrecognized rehabilitation needs exist in cancer patients. To assess the patients’ recreational needs, we asked patients an openended question, “What would you like to do for fun while in the hospital?” Statistical Analysis The patients’ FIM scores were analyzed with the paired signed-rank test. Physical examination findings and their relationships to the FIM scores were analyzed with the pairwise Pearson correlation coefficient. Summary measures were made of the demographic variables of age, type of cancer, number of referrals for rehabilitation consultation, and number of indications for rehabilitation interventions. Data were analyzed with the STATA programa for statistical and data analysis.
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Table 1: Functional Physical Examination Coordination Finger-to-nose testing Rapid alternating movements Rhythmic toe tap Thumb to alternating fingertips Proprioception Great toe Strength Finger flexors Elbow extensors Thumb-index finger pinch strength ROM Active arm flexion and abduction of at least 135° each Balance Dynamic sitting balance Single foot balance Transfers Standing from seated position Gait Reciprocal Tandem Heel walk
RESULTS Sixty-two patients were screened, and 55 subjects participated in the study. The median age ⫾ standard deviation (SD) of the participants was 65⫾11.7y (range, 27– 86y). Of 62 admissions, 7 could not be evaluated (1 was preterminal, 5 were admitted more than once, 1 was unavailable to participate). The sample consisted of patients with a wide range of malignancies. Primary diagnoses were hematologic in 22 (40%); lung in 10 (18%); genitourinary in 9 (16%); gastrointestinal in 6 (11%); head and neck in 5 (9%); and miscellaneous, including carcinoid, skin, and double malignancies, in 3 (5%) patients. The extent of the disease was metastatic in 38 (69%) and local in 17 (31%) patients. On admission, the mean FIM total ⫾ SD was 105⫾15.7. The mean FIM motor score was 72⫾14, and the mean FIM cognitive score was 34⫾1.9 (table 3). A sizable proportion of patients in this sample had functional limitations, as seen by the interquartile range for the FIM (measuring 25% to 75% of the total FIM score), which was 102 to 116. For a smaller group of approximately 26 patients, we were able to obtain discharge FIM scores and to compare them with admission scores. The FIM total score of 105⫾15.7 points on admission was very similar to the FIM total score of 98⫾19.3 points on discharge and did not differ statistically. Patients who received a rehabilitation program had a mean FIM total on admission of 109⫾13.0, a FIM motor score of 75⫾12.5, and a FIM cognitive score of 34⫾1.6; their mean FIM total on discharge was 87⫾22.0; their FIM motor score was 55⫾20.9, and their FIM cognitive score was 32⫾2.9. The FIM scores of this group on admission were very similar to the FIM scores on discharge, but the number of patients was too small for a meaningful comparison. This subpopulation also had significantly greater illness and rapid medical deterioration. The functionally based physical examination did not generally correlate with scores obtained on the FIM at admission or discharge. The functionally based physical examination was also statistically unchanged in the rehabilitation group at admission as compared with discharge. Arch Phys Med Rehabil Vol 84, November 2003
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REHABILITATION NEEDS IN MEDICAL ONCOLOGY, Movsas Table 2: Rehabilitation Needs Assessment and Potential Interventions
Deconditioning General conditioning exercises, aerobic activities, walking, strengthening exercises Mobility impairment Ambulation training, assistive device trial, balance training, wheelchair training, bed mobility, and transfer training ROM Passive ROM exercises, active assisted ROM exercises, active ROM exercises, stretching, Codman exercises, wall-climbing exercises to enhance upper-limb ROM, static and dynamic orthotics for joint contractures ADLs Evaluation and training with necessary adaptive equipment Recreation therapy Leisure activities and social programs Patient education Braces/splints/orthotics use, joint protection, proper lifting techniques, energy-conservation techniques, walking program, home exercise program, family training Hot or cold modalities, edema control, wound care
The Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients, mobility impairment in 32 (58%) patients, need for increased ROM in 23 (42%) patients, deficits in ADLs in 12 (22%) patients, need for recreational therapy in 7 (13%) patients, potential for benefit from patient education in 30 (55%) patients, and need for hot or cold modalities, edema control, or wound care in fewer than 5% of patients. The summary of subjects’ rehabilitation needs showed that 48 (87%) patients had rehabilitation needs on admission and that 46 (84%) patients had rehabilitation needs on discharge. Rehabilitation consultation was requested in 10 (18%) patients, and 9 (16%) received therapy. One possible reason for the paucity of rehabilitation medicine consultations is that the medical oncology floor staff was not cognizant of the rehabilitation needs of patients on admission. In 38 (69%) patients, the medical oncology floor staff did not recognize the need for rehabilitation of their patients on admission. These patients showed the need for rehabilitation as assessed on the study’s Rehabilitation Needs Assessment but were not referred by the medical oncology floor staff for rehabilitation medicine consultation. Other factors included short LOS; 21 (38%) patients were discharged by 1 week. Ten (18%) patients were deemed too ill or unstable to be considered for rehabilitative intervention. The responses of patients regarding what they would like to do for fun while in the hospital were reading (19%), watching
television (17%), being with family (12%), playing cards (10%), exercise (8%), and religious activities (8%). Other activities are described in table 4. DISCUSSION Cancer rehabilitation is the process by which people are enabled to live as fully and effectively as possible within the limitations of impairments resulting from their disease and its treatment. The need for cancer rehabilitation was documented in 1978 by Lehmann et al,5 who studied 805 patients at cancer referral centers. They found that 35% of patients had generalized weakness, 30% had impairment of ADLs, and 25% had difficulties with ambulation. The potential benefits of rehabilitation interventions in cancer patients are many. Simple interventions such as gait training and training in bed-to-chair transfers may be of major value to the patient, family, and caregivers. Even in debilitated patients, rehabilitation interventions may transform a patient from someone who is confined to bed to a person who is enabled to maintain some independence and functional capacity. This is especially important because many patients with cancer and metastatic disease may live and function well for many years even though cure is not possible.9 As a result, this area has
Table 4: Results of Recreational Needs Assessment Recreational Activity
Table 3: FIM Scores on Admission and Discharge Variable
Mean ⫾ SD
Baseline admission FIM total 105⫾15.7 FIM motor 72⫾14 FIM cognitive 34⫾1.9 Rehabilitation program admission FIM total 109⫾13 FIM motor 75⫾12.5 FIM cognitive 34⫾1.6 Rehabilitation program discharge FIM total 87⫾22 FIM motor 55⫾20.9 FIM cognitive 32⫾2.9
Range
60–125 26–90 27–35 60–125 26–90 28–35 50–111 19–77 26–35
NOTE. Score ranges for the FIM scores are as follows: FIM total, 18 –126; FIM motor, 13–91; FIM cognitive, 5–35.
Arch Phys Med Rehabil Vol 84, November 2003
Read Watch TV Family Play cards Exercise Religion Crossword puzzles Movies Helping others Visit friends Rest Group activities Singing Eat Work
%
19 17 12 10 8 8 6 6 4 4 4 2 2 2 2
NOTE. Total exceeds 100% because some patients expressed several preferences.
REHABILITATION NEEDS IN MEDICAL ONCOLOGY, Movsas
continued to receive attention by the rehabilitation community.10-12 Recent studies suggest that rehabilitation performed in rehabilitation units does benefit patients with cancer. Marciniak et al13 showed that patients with various cancers undergoing inpatient rehabilitation at a freestanding, university-affiliated rehabilitation hospital achieved significant functional gains across various diagnostic categories. McKinley et al14 investigated individuals with spinal cord tumors admitted to a spinal cord injury rehabilitation unit at a tertiary university medical center and found that these patients also achieved significant functional gains and maintained these gains up to 3 months after discharge. In a study of hospice patients, Wallston et al15 reported that 22% of the patients with terminal cancer wished to be physically able to do as they chose even in the last 3 days of life. Answers to questionnaires showed that more than half of patients with terminal cancer complained about problems in performing ADLs and that about 88% of patients had a strong desire for mobility. Yoshioka16 instituted a rehabilitation program in a hospice facility for patients with terminal cancer and then questioned caregivers about the usefulness of the program. Seventy-eight percent of the respondents were satisfied with rehabilitation in the terminal stage, and 63% found the rehabilitation program to be effective.16 A recent study by Scialla et al17 retrospectively examined the medical records of 110 weak, elderly inpatients with cancer asthenia at an acute care rehabilitation hospital who were transitioning from curative treatment toward palliative care. Their data suggested that physical and cognitive functioning may improve after comprehensive inpatient rehabilitation. In our study, we examined the rehabilitation needs of patients in a different manner in an acute medical setting. We found that many oncology patients have easily remediable but unrecognized rehabilitation problems, such as deconditioning, which points to the importance of interdisciplinary efforts to preserve patient function. An important finding was that rehabilitation of cancer patients was underused in the population studied. Reasons for underuse may include failure to identify functional impairments by acute care staff, lack of appropriate rehabilitation referral, lack of awareness of rehabilitation services, and lack of knowledge among family members.5 These barriers can be overcome by educational efforts and by enlisting the cooperation of the clinical staff in oncology, whose background in rehabilitation and functional issues may be limited or underemphasized. It is also very important for all practitioners to keep in mind that once the patients are stabilized and discharged from the hospital, physical medicine and rehabilitation services must be considered on an outpatient basis or in the form of home-based programs to maintain gains and prevent further deconditioning, because currently the vast majority of patients are never referred for rehabilitation follow-up after discharge. Special issues may exist in assessing the rehabilitation needs of oncology inpatients by physical examination. In our study, we assessed balance, gait, coordination, and muscle strength— specifically in the arms, hands, and hip and knee extensors—as a possible guide to maximizing functional independence. We did not find a statistically significant relationship between physical examination findings and FIM scores. We hypothesized that a more specific physical examination in oncology patients might yield a significant correlation with FIM scores. One possibility for not finding this association is that the FIM scoring is highly weighted toward functional activities, such as eating, grooming, dressing, and bathing, rather than toward the individual components of the functions themselves that we
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tested in this examination. Another factor may have been that these patients were seen after admission for nonemergent reasons and may not have been ill enough to show many of the findings for which they were tested. We believe that the concept of a functionally based physical examination is promising, but it may need further development. As an unplanned subset analysis, we examined the effect of rehabilitation on the patients who were seen by the rehabilitation service. The FIM scores were unchanged from admission to discharge in these patients. This is likely explained by the fact that the only patients referred for rehabilitation services were so ill that they were able to participate in a rehabilitation program for only 1 to 2 sessions before having to stop because of medical deterioration. Sabers et al18 found significant functional gains on the Barthel Index and the Karnofsky Performance Status scales in patients on oncology and surgical services who received (1) interdisciplinary rehabilitation services on a consultation basis and (2) more than 6 therapy sessions. Further work needs to be performed in this area. In generalizing these results, it is important to note that the VA hospital has a distinctive high-risk population. VA patients have higher age-adjusted rate of mortality,19 tend to come from lower socioeconomic strata,20 have a median 12th grade education, and are predominantly older men. Further studies with other populations are indicated to test the usefulness of a functionally oriented physical examination. Little is known about the recreational needs of medical oncology inpatients, and it may have been assumed that cancer patients do not have any because they are so ill. The large variety of answers suggests that these patients do in fact have recreational needs. The information from this pilot assessment may be useful in designing recreational interventions in future studies. CONCLUSION The results of our study showed that patients admitted to a medical oncology service have many unmet rehabilitation needs and that only a small fraction were referred to physical medicine and rehabilitation. This study also documented that cancer patients have potentially remediable rehabilitation issues, which may not be recognized by nonrehabilitation physicians and other clinical staff. That such needs are already present on admission may make identifying them more urgent to prevent even further deterioration. These findings have implications for oncologists, primary care physicians, and other health care personnel providing care for these patients, because it is important that they are made aware of the great need for active rehabilitation involvement in this population. This study reinforces prior findings that the rehabilitation needs of cancer patients are unmet. Awareness of these needs should be increased, and the outcomes of rehabilitation interventions require further study. References 1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. CA Cancer J Clin 1998;48:6-31. 2. Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer 2001;92(Suppl 4):1049-52. 3. Cheville A. Rehabilitation of patients with advanced cancer. Cancer 2001;92(Suppl 4):1039-48. 4. Ganz PA. The status of cancer rehabilitation in the late 1990s [editorial]. Mayo Clin Proc 1999;74:939-40. 5. Lehmann JF, DeLisa JA, Warren CG, deLateur BJ, Bryant PL, Nicholson CH. Cancer rehabilitation: assessment of need, development and evaluation of a model of care. Arch Phys Med Rehabil 1978;59:410-9. 6. DeLisa JA. A history of cancer rehabilitation. Cancer 2001;92 (Suppl 4):970-4. Arch Phys Med Rehabil Vol 84, November 2003
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7. Keith RA, Granger CV, Hamilton BB, Sherman FS. The Functional Independence Measure; a new tool for rehabilitation. In: Eisenberg MG, Grzesiak RC, editors. Advances in clinical rehabilitation. Vol 2. New York: Springer; 1987. p 6-18. 8. Guide for the Uniform Data System for Medical Rehabilitation (adult FIM), version 4.0. Buffalo: State Univ New York; 1995. 9. Mellete S. Cancer rehabilitation. J Natl Cancer Inst 1993;85: 781-4. 10. Gamble GL, Brown PS, Kinney CL, Maloney FP. Cardiovascular, pulmonary, and cancer rehabilitation. 4. Cancer rehabilitation: principles and psychosocial aspect. Arch Phys Med Rehabil 1990; 71(4 Suppl):S244-7. 11. Brennan MJ, DePompolo RW, Garden FH. Cardiovascular, pulmonary, and cancer rehabilitation. 3. Cancer rehabilitation. Arch Phys Med Rehabil 1996;77(3 Suppl):S52-8. 12. Gillis TA, Cheville AL, Worsowicz GM. Cardiopulmonary rehabilitation and cancer rehabilitation. 4. Oncologic rehabilitation. Arch Phys Med Rehabil 2001;82(Suppl 1):S63-8. 13. Marciniak CM, Sliwa JA, Spill G, Heinemann AW, Semick PE. Functional outcome following rehabilitation of the cancer patient. Arch Phys Med Rehabil 1996;77:54-7.
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14. McKinley WO, Conti-Wyneken AR, Vokac CW, Cifu DX. Rehabilitative functional outcome of patients with neoplastic spinal cord compression. Arch Phys Med Rehabil 1996;77:892-5. 15. Wallston KA, Burger C, Smith RA, Baugher RJ. Comparing the quality of death for hospice and non-hospice cancer patients. Med Care 1988;26:177-82. 16. Yoshioka H. Rehabilitation of the terminal patient. Am J Phys Med Rehabil 1994;73:199-206. 17. Scialla S, Cole R, Scialla T, Bednarz L, Scheerer J. Rehabilitation for elderly patients with cancer asthenia: making a transition to palliative care. Palliat Med 2000;14:121-7. 18. Sabers SR, Kokal JE, Girardi JC, et al. Evaluation of consultationbased rehabilitation for hospitalized cancer patients with functional impairments. Mayo Clin Proc 1999;74:855-61. 19. Fisher ES, Welch HG. The future of the Department of Veterans Affairs Health Care System. JAMA 1995;273:651-5. 20. Harris RE, Hebert JR, Wynder EL. Cancer risk in male veterans utilizing the Veterans Administration system. Cancer 1989;64: 1160-9. Supplier a. Stata Corp, 4905 Lakeway Dr, College Station, TX 77845.
Rehabilitation Needs of an Inpatient Medical Oncology Unit Sheryl B. Movsas, DO, Victor T. Chang, MD, Richard S. Tunkel, MD, Vipul V. Shah, MD, Lynn S. Ryan, MS, OTR/L, Scott R. Millis, PhD ABSTRACT. Movsas SB, Chang VT, Tunkel RS, Shah VV, Ryan LS, Millis SR. Rehabilitation needs of an inpatient medical oncology unit. Arch Phys Med Rehabil 2003;84:16426. Objective: To identify prospectively functional impairments and rehabilitation needs in an acute care medical oncology unit. Design: Prospective cohort study. Setting: Inpatient medical oncology unit at a Veterans Affairs hospital. Participants: Fifty-five patients admitted over a 6-month period. Interventions: Not applicable. Main Outcome Measures: FIM™ instrument, functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. Results: On admission, the mean FIM total score was 105 out of 126, the FIM motor score was 72 out of 91, and the FIM cognitive score was 34 out of 35. The functionally based physical examination did not generally correlate with scores obtained on the FIM. Forty-eight (87%) patients had rehabilitation needs on admission. Forty-six (84%) patients had rehabilitation needs on discharge. Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients; mobility impairment in 32 (58%) patients; a significant decrease in range of motion in 23 (42%) patients; deficits in activities of daily living in 12 (22%) patients; a need for recreational therapy in 7 (13%) patients; potential for benefit from patient education in 30 (55%) patients; and a need for modalities, edema control, or wound care in fever than 5% of patients. The most commonly requested recreational activity was reading. Conclusions: Patients admitted to inpatient medical oncology units have many unmet, remediable rehabilitation needs that may not be recognized by nonrehabilitation physicians and other clinical staff. These findings suggest that assessment of medical oncology patients may be enhanced by consultation with rehabilitation medicine specialists.
From the Departments of Physical Medicine and Rehabilitation (Movsas, Shah, Millis) and of Medicine (Chang), University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ; Spinal Cord Injury Service and Pain Medicine Service (Movsas), Section of Hematology/Oncology (Chang), and Physical Medicine and Rehabilitation Service (Shah, Ryan), Veterans Affairs New Jersey Health Care System, East Orange, NJ; Department of Rehabilitation Medicine, Mount Sinai School of Medicine–Queens Health Network, Queens and Elmhurst Hospital Centers, Queens, NY (Tunkel); and Research Department, Kessler Medical Rehabilitation Research and Education Corporation, West Orange, NJ (Millis). Presented in part at the American Academy of Physical Medicine and Rehabilitation’s 61st Annual Assembly, November 3, 2000, San Francisco, CA. Supported by the Resident Research Fund, Department of Physical Medicine and Rehabilitation, UMDNJ–New Jersey Medical School, and Kessler Medical Rehabilitation Research and Education Corporation. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Sheryl B. Movsas, DO, VA New Jersey Health Care System, Spinal Cord Injury Service, Box 128, 385 Tremont Ave, East Orange, NJ 07018, e-mail: [email protected]. 0003-9993/03/8411-7792$30.00/0 doi:10.1053/S0003-9993(03)00345-9
Arch Phys Med Rehabil Vol 84, November 2003
Key Words: Neoplasms; Outcome assessment (health care); Rehabilitation. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ANCER HAS BECOME an all too common condition and continues to be a significant source of disability. More C than 1 million people are diagnosed with cancer each year, with a prevalence of more than 8 million people in the United States. Individuals with cancer are also living longer now than before, with a relative 5-year survival rate of 58%.1 As survival improves and cancer becomes a chronic condition in many patients, measures to maximize the level of function and, thereby, the quality of life, of cancer patients become increasingly relevant. The importance of rehabilitation needs in patients with cancer has recently received increasing recognition.2-4 However, since the first major description of rehabilitation needs in patients with cancer, published more than 20 years ago,5 few studies have addressed these patients from a rehabilitation perspective.6 The settings of most of the previous studies have been in cancer referral centers, acute inpatient oncology and surgical services, rehabilitation units at acute care hospitals, hospice settings, and inpatient rehabilitation facilities. A need exists for more data to clarify the extent of rehabilitation needs and to allow for improved planning of rehabilitation services. The objective of this exploratory study was to identify prospectively functional impairments and rehabilitation needs in patients admitted to an acute care medical oncology unit at a Veterans Health Administration hospital and thereby to examine these issues in a unique manner in the acute medical oncology ward. METHODS Participants Eligibility criteria for this study included a documented diagnosis of cancer, as well as a willingness to answer questionnaires and participate in a physical examination. Exclusion criteria were an inability to answer questions, an anticipated length of stay (LOS) in the hospital of less than 1 week, a refusal to participate, and previous participation. Therefore, patients who were readmitted subsequently were not reenrolled in the study. Procedure The study was designed as a prospective, cohort, singlecenter study performed at an inpatient oncology unit. The study was approved by the Veterans Affairs (VA) New Jersey Health Care System Institutional Review Board, and patients gave consent before participating. The Hematology/Oncology Service at the VA New Jersey Health Care System is unique in that it provides a wide range of care, including management of newly diagnosed, acutely ill cancer patients, as well as those with exacerbation or worsening of previously diagnosed cancer.
REHABILITATION NEEDS IN MEDICAL ONCOLOGY, Movsas
All patients consecutively admitted to the medical oncology service floor at the beginning and middle of the week (when the full complement of assessments were available) were asked to enroll in this study and were assessed within 1 to 2 days of admission at mid week. Subject accrual continued for a 6-month period. Patients could enroll only once. Subjects were assessed on admission and discharge for functional ability by using the FIM™ instrument,7 a functionally based physical examination, a Rehabilitation Needs Assessment, and a Recreational Needs Assessment. The FIM score was measured by a trained, certified rater (LSR); the other 3 assessments were performed by a physical medicine and rehabilitation senior resident (SBM). Assessments The primary assessment measures used were the FIM, a functionally based physical examination, Rehabilitation Needs Assessment, and Recreational Needs Assessment. The FIM is a disability scale widely used in the rehabilitation literature; it has proven reliability and validity as a measure in assessment of functional independence. It is an 18-item scale, with each item scored on a scale from 1 (totally dependent) to 7 (fully independent). It has traditionally been divided into 2 component subscales: FIM motor (13 items) and FIM cognitive (5 items), with a total range in scores from a minimum of 18 points (total assistance) to a maximum of 126 points (complete independence). The FIM motor subscale includes the areas of self-care (eating, grooming, bathing, upper-body dressing, lower-body dressing, toileting), sphincter control, mobility, and locomotion; scores range from 13 to 91. The FIM cognitive subscale includes the areas of communication (comprehension, expression) and social cognition (social interaction, problem solving, memory); scores range from 5 to 35. The FIM score was measured on patient admission and at discharge by a trained rater. Patients’ scores were determined by using standard protocols established by Uniform Data Systems for Medical Rehabilitation.8 We developed a functionally based physical examination, which was performed on each participant at admission and discharge. Patients were assessed for a number of abilities: coordination, proprioception strength, range of motion (ROM), balance, transfers, and gait (table 1). We analyzed data to see whether physical findings in these patients, as identified through the functional physical examination, correlated with FIM scores. We also considered that there might be a change in specific physical findings in these patients from admission to discharge. Rehabilitation needs were assessed on admission and discharge in the areas of deconditioning, mobility impairment, ROM, activities of daily living (ADLs), recreational therapy, patient education, hot or cold modalities, edema control, and wound care (table 2). Our primary hypothesis was that unrecognized rehabilitation needs exist in cancer patients. To assess the patients’ recreational needs, we asked patients an openended question, “What would you like to do for fun while in the hospital?” Statistical Analysis The patients’ FIM scores were analyzed with the paired signed-rank test. Physical examination findings and their relationships to the FIM scores were analyzed with the pairwise Pearson correlation coefficient. Summary measures were made of the demographic variables of age, type of cancer, number of referrals for rehabilitation consultation, and number of indications for rehabilitation interventions. Data were analyzed with the STATA programa for statistical and data analysis.
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Table 1: Functional Physical Examination Coordination Finger-to-nose testing Rapid alternating movements Rhythmic toe tap Thumb to alternating fingertips Proprioception Great toe Strength Finger flexors Elbow extensors Thumb-index finger pinch strength ROM Active arm flexion and abduction of at least 135° each Balance Dynamic sitting balance Single foot balance Transfers Standing from seated position Gait Reciprocal Tandem Heel walk
RESULTS Sixty-two patients were screened, and 55 subjects participated in the study. The median age ⫾ standard deviation (SD) of the participants was 65⫾11.7y (range, 27– 86y). Of 62 admissions, 7 could not be evaluated (1 was preterminal, 5 were admitted more than once, 1 was unavailable to participate). The sample consisted of patients with a wide range of malignancies. Primary diagnoses were hematologic in 22 (40%); lung in 10 (18%); genitourinary in 9 (16%); gastrointestinal in 6 (11%); head and neck in 5 (9%); and miscellaneous, including carcinoid, skin, and double malignancies, in 3 (5%) patients. The extent of the disease was metastatic in 38 (69%) and local in 17 (31%) patients. On admission, the mean FIM total ⫾ SD was 105⫾15.7. The mean FIM motor score was 72⫾14, and the mean FIM cognitive score was 34⫾1.9 (table 3). A sizable proportion of patients in this sample had functional limitations, as seen by the interquartile range for the FIM (measuring 25% to 75% of the total FIM score), which was 102 to 116. For a smaller group of approximately 26 patients, we were able to obtain discharge FIM scores and to compare them with admission scores. The FIM total score of 105⫾15.7 points on admission was very similar to the FIM total score of 98⫾19.3 points on discharge and did not differ statistically. Patients who received a rehabilitation program had a mean FIM total on admission of 109⫾13.0, a FIM motor score of 75⫾12.5, and a FIM cognitive score of 34⫾1.6; their mean FIM total on discharge was 87⫾22.0; their FIM motor score was 55⫾20.9, and their FIM cognitive score was 32⫾2.9. The FIM scores of this group on admission were very similar to the FIM scores on discharge, but the number of patients was too small for a meaningful comparison. This subpopulation also had significantly greater illness and rapid medical deterioration. The functionally based physical examination did not generally correlate with scores obtained on the FIM at admission or discharge. The functionally based physical examination was also statistically unchanged in the rehabilitation group at admission as compared with discharge. Arch Phys Med Rehabil Vol 84, November 2003
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REHABILITATION NEEDS IN MEDICAL ONCOLOGY, Movsas Table 2: Rehabilitation Needs Assessment and Potential Interventions
Deconditioning General conditioning exercises, aerobic activities, walking, strengthening exercises Mobility impairment Ambulation training, assistive device trial, balance training, wheelchair training, bed mobility, and transfer training ROM Passive ROM exercises, active assisted ROM exercises, active ROM exercises, stretching, Codman exercises, wall-climbing exercises to enhance upper-limb ROM, static and dynamic orthotics for joint contractures ADLs Evaluation and training with necessary adaptive equipment Recreation therapy Leisure activities and social programs Patient education Braces/splints/orthotics use, joint protection, proper lifting techniques, energy-conservation techniques, walking program, home exercise program, family training Hot or cold modalities, edema control, wound care
The Rehabilitation Needs Assessment on admission showed deconditioning in 42 (76%) patients, mobility impairment in 32 (58%) patients, need for increased ROM in 23 (42%) patients, deficits in ADLs in 12 (22%) patients, need for recreational therapy in 7 (13%) patients, potential for benefit from patient education in 30 (55%) patients, and need for hot or cold modalities, edema control, or wound care in fewer than 5% of patients. The summary of subjects’ rehabilitation needs showed that 48 (87%) patients had rehabilitation needs on admission and that 46 (84%) patients had rehabilitation needs on discharge. Rehabilitation consultation was requested in 10 (18%) patients, and 9 (16%) received therapy. One possible reason for the paucity of rehabilitation medicine consultations is that the medical oncology floor staff was not cognizant of the rehabilitation needs of patients on admission. In 38 (69%) patients, the medical oncology floor staff did not recognize the need for rehabilitation of their patients on admission. These patients showed the need for rehabilitation as assessed on the study’s Rehabilitation Needs Assessment but were not referred by the medical oncology floor staff for rehabilitation medicine consultation. Other factors included short LOS; 21 (38%) patients were discharged by 1 week. Ten (18%) patients were deemed too ill or unstable to be considered for rehabilitative intervention. The responses of patients regarding what they would like to do for fun while in the hospital were reading (19%), watching
television (17%), being with family (12%), playing cards (10%), exercise (8%), and religious activities (8%). Other activities are described in table 4. DISCUSSION Cancer rehabilitation is the process by which people are enabled to live as fully and effectively as possible within the limitations of impairments resulting from their disease and its treatment. The need for cancer rehabilitation was documented in 1978 by Lehmann et al,5 who studied 805 patients at cancer referral centers. They found that 35% of patients had generalized weakness, 30% had impairment of ADLs, and 25% had difficulties with ambulation. The potential benefits of rehabilitation interventions in cancer patients are many. Simple interventions such as gait training and training in bed-to-chair transfers may be of major value to the patient, family, and caregivers. Even in debilitated patients, rehabilitation interventions may transform a patient from someone who is confined to bed to a person who is enabled to maintain some independence and functional capacity. This is especially important because many patients with cancer and metastatic disease may live and function well for many years even though cure is not possible.9 As a result, this area has
Table 4: Results of Recreational Needs Assessment Recreational Activity
Table 3: FIM Scores on Admission and Discharge Variable
Mean ⫾ SD
Baseline admission FIM total 105⫾15.7 FIM motor 72⫾14 FIM cognitive 34⫾1.9 Rehabilitation program admission FIM total 109⫾13 FIM motor 75⫾12.5 FIM cognitive 34⫾1.6 Rehabilitation program discharge FIM total 87⫾22 FIM motor 55⫾20.9 FIM cognitive 32⫾2.9
Range
60–125 26–90 27–35 60–125 26–90 28–35 50–111 19–77 26–35
NOTE. Score ranges for the FIM scores are as follows: FIM total, 18 –126; FIM motor, 13–91; FIM cognitive, 5–35.
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Read Watch TV Family Play cards Exercise Religion Crossword puzzles Movies Helping others Visit friends Rest Group activities Singing Eat Work
%
19 17 12 10 8 8 6 6 4 4 4 2 2 2 2
NOTE. Total exceeds 100% because some patients expressed several preferences.
REHABILITATION NEEDS IN MEDICAL ONCOLOGY, Movsas
continued to receive attention by the rehabilitation community.10-12 Recent studies suggest that rehabilitation performed in rehabilitation units does benefit patients with cancer. Marciniak et al13 showed that patients with various cancers undergoing inpatient rehabilitation at a freestanding, university-affiliated rehabilitation hospital achieved significant functional gains across various diagnostic categories. McKinley et al14 investigated individuals with spinal cord tumors admitted to a spinal cord injury rehabilitation unit at a tertiary university medical center and found that these patients also achieved significant functional gains and maintained these gains up to 3 months after discharge. In a study of hospice patients, Wallston et al15 reported that 22% of the patients with terminal cancer wished to be physically able to do as they chose even in the last 3 days of life. Answers to questionnaires showed that more than half of patients with terminal cancer complained about problems in performing ADLs and that about 88% of patients had a strong desire for mobility. Yoshioka16 instituted a rehabilitation program in a hospice facility for patients with terminal cancer and then questioned caregivers about the usefulness of the program. Seventy-eight percent of the respondents were satisfied with rehabilitation in the terminal stage, and 63% found the rehabilitation program to be effective.16 A recent study by Scialla et al17 retrospectively examined the medical records of 110 weak, elderly inpatients with cancer asthenia at an acute care rehabilitation hospital who were transitioning from curative treatment toward palliative care. Their data suggested that physical and cognitive functioning may improve after comprehensive inpatient rehabilitation. In our study, we examined the rehabilitation needs of patients in a different manner in an acute medical setting. We found that many oncology patients have easily remediable but unrecognized rehabilitation problems, such as deconditioning, which points to the importance of interdisciplinary efforts to preserve patient function. An important finding was that rehabilitation of cancer patients was underused in the population studied. Reasons for underuse may include failure to identify functional impairments by acute care staff, lack of appropriate rehabilitation referral, lack of awareness of rehabilitation services, and lack of knowledge among family members.5 These barriers can be overcome by educational efforts and by enlisting the cooperation of the clinical staff in oncology, whose background in rehabilitation and functional issues may be limited or underemphasized. It is also very important for all practitioners to keep in mind that once the patients are stabilized and discharged from the hospital, physical medicine and rehabilitation services must be considered on an outpatient basis or in the form of home-based programs to maintain gains and prevent further deconditioning, because currently the vast majority of patients are never referred for rehabilitation follow-up after discharge. Special issues may exist in assessing the rehabilitation needs of oncology inpatients by physical examination. In our study, we assessed balance, gait, coordination, and muscle strength— specifically in the arms, hands, and hip and knee extensors—as a possible guide to maximizing functional independence. We did not find a statistically significant relationship between physical examination findings and FIM scores. We hypothesized that a more specific physical examination in oncology patients might yield a significant correlation with FIM scores. One possibility for not finding this association is that the FIM scoring is highly weighted toward functional activities, such as eating, grooming, dressing, and bathing, rather than toward the individual components of the functions themselves that we
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tested in this examination. Another factor may have been that these patients were seen after admission for nonemergent reasons and may not have been ill enough to show many of the findings for which they were tested. We believe that the concept of a functionally based physical examination is promising, but it may need further development. As an unplanned subset analysis, we examined the effect of rehabilitation on the patients who were seen by the rehabilitation service. The FIM scores were unchanged from admission to discharge in these patients. This is likely explained by the fact that the only patients referred for rehabilitation services were so ill that they were able to participate in a rehabilitation program for only 1 to 2 sessions before having to stop because of medical deterioration. Sabers et al18 found significant functional gains on the Barthel Index and the Karnofsky Performance Status scales in patients on oncology and surgical services who received (1) interdisciplinary rehabilitation services on a consultation basis and (2) more than 6 therapy sessions. Further work needs to be performed in this area. In generalizing these results, it is important to note that the VA hospital has a distinctive high-risk population. VA patients have higher age-adjusted rate of mortality,19 tend to come from lower socioeconomic strata,20 have a median 12th grade education, and are predominantly older men. Further studies with other populations are indicated to test the usefulness of a functionally oriented physical examination. Little is known about the recreational needs of medical oncology inpatients, and it may have been assumed that cancer patients do not have any because they are so ill. The large variety of answers suggests that these patients do in fact have recreational needs. The information from this pilot assessment may be useful in designing recreational interventions in future studies. CONCLUSION The results of our study showed that patients admitted to a medical oncology service have many unmet rehabilitation needs and that only a small fraction were referred to physical medicine and rehabilitation. This study also documented that cancer patients have potentially remediable rehabilitation issues, which may not be recognized by nonrehabilitation physicians and other clinical staff. That such needs are already present on admission may make identifying them more urgent to prevent even further deterioration. These findings have implications for oncologists, primary care physicians, and other health care personnel providing care for these patients, because it is important that they are made aware of the great need for active rehabilitation involvement in this population. This study reinforces prior findings that the rehabilitation needs of cancer patients are unmet. Awareness of these needs should be increased, and the outcomes of rehabilitation interventions require further study. References 1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. CA Cancer J Clin 1998;48:6-31. 2. Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer 2001;92(Suppl 4):1049-52. 3. Cheville A. Rehabilitation of patients with advanced cancer. Cancer 2001;92(Suppl 4):1039-48. 4. Ganz PA. The status of cancer rehabilitation in the late 1990s [editorial]. Mayo Clin Proc 1999;74:939-40. 5. Lehmann JF, DeLisa JA, Warren CG, deLateur BJ, Bryant PL, Nicholson CH. Cancer rehabilitation: assessment of need, development and evaluation of a model of care. Arch Phys Med Rehabil 1978;59:410-9. 6. DeLisa JA. A history of cancer rehabilitation. Cancer 2001;92 (Suppl 4):970-4. Arch Phys Med Rehabil Vol 84, November 2003
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7. Keith RA, Granger CV, Hamilton BB, Sherman FS. The Functional Independence Measure; a new tool for rehabilitation. In: Eisenberg MG, Grzesiak RC, editors. Advances in clinical rehabilitation. Vol 2. New York: Springer; 1987. p 6-18. 8. Guide for the Uniform Data System for Medical Rehabilitation (adult FIM), version 4.0. Buffalo: State Univ New York; 1995. 9. Mellete S. Cancer rehabilitation. J Natl Cancer Inst 1993;85: 781-4. 10. Gamble GL, Brown PS, Kinney CL, Maloney FP. Cardiovascular, pulmonary, and cancer rehabilitation. 4. Cancer rehabilitation: principles and psychosocial aspect. Arch Phys Med Rehabil 1990; 71(4 Suppl):S244-7. 11. Brennan MJ, DePompolo RW, Garden FH. Cardiovascular, pulmonary, and cancer rehabilitation. 3. Cancer rehabilitation. Arch Phys Med Rehabil 1996;77(3 Suppl):S52-8. 12. Gillis TA, Cheville AL, Worsowicz GM. Cardiopulmonary rehabilitation and cancer rehabilitation. 4. Oncologic rehabilitation. Arch Phys Med Rehabil 2001;82(Suppl 1):S63-8. 13. Marciniak CM, Sliwa JA, Spill G, Heinemann AW, Semick PE. Functional outcome following rehabilitation of the cancer patient. Arch Phys Med Rehabil 1996;77:54-7.
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14. McKinley WO, Conti-Wyneken AR, Vokac CW, Cifu DX. Rehabilitative functional outcome of patients with neoplastic spinal cord compression. Arch Phys Med Rehabil 1996;77:892-5. 15. Wallston KA, Burger C, Smith RA, Baugher RJ. Comparing the quality of death for hospice and non-hospice cancer patients. Med Care 1988;26:177-82. 16. Yoshioka H. Rehabilitation of the terminal patient. Am J Phys Med Rehabil 1994;73:199-206. 17. Scialla S, Cole R, Scialla T, Bednarz L, Scheerer J. Rehabilitation for elderly patients with cancer asthenia: making a transition to palliative care. Palliat Med 2000;14:121-7. 18. Sabers SR, Kokal JE, Girardi JC, et al. Evaluation of consultationbased rehabilitation for hospitalized cancer patients with functional impairments. Mayo Clin Proc 1999;74:855-61. 19. Fisher ES, Welch HG. The future of the Department of Veterans Affairs Health Care System. JAMA 1995;273:651-5. 20. Harris RE, Hebert JR, Wynder EL. Cancer risk in male veterans utilizing the Veterans Administration system. Cancer 1989;64: 1160-9. Supplier a. Stata Corp, 4905 Lakeway Dr, College Station, TX 77845.