Acute care is usually associated with disease progression, treatments for cancer, and medical comorbidities. Patients with cancer may develop sudden functional deficits that require rehabilitation. Some of these patients benefit from acute rehabilitation, others benefit from subacute rehabilitation. After acute rehabilitation, continuous care for these patients has not been well described. Three studies are presented to demonstrate that cancer rehabilitation is a continuous process. Rehabilitation professionals should know how to detect fall risk, monitor symptoms, and render symptom management. Patients with cancer often require rehabilitation services during their entire disease trajectory.
Key points
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Symptom management is a crucial part of cancer rehabilitation.
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Cancer patients’ functional status can change depending on their disease progression, treatment side-effect, and comorbidities.
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Postacute care cancer rehabilitation is a continuous process, requiring frequent monitoring, early detection of functional loss, management of symptoms, and adjustment of goals.
Introduction
The American Cancer Society estimated 1.6 million new diagnoses of cancer in 2015. With advances in cancer diagnosis and treatment, the 5-year survival rate for all cancers has increased from 49% (1975–1977) to 67% (2006–2012). With such improvements in survival, cancer has become more a chronic disease. Cancer survivors can be defined as persons “living with a cancer diagnosis following primary cancer treatment through the end of life.” Older adults are much more likely to be diagnosed with cancer and this group already has a higher incidence of other medical comorbidities such as diabetes, stroke, arthritis, and obesity.
In the cancer treatment trajectory, many patients are cured of disease and are able to function normally in society again, although most patients, especially older patients, may experience fluctuations of function, with a trend of decline with cancer diagnosis and treatments. This decline is due to cancer and its treatment, and it may result from pain, misalignment, contracture of joints, muscle atrophy, fatigue, peripheral neuropathy malnutrition, and other symptoms. These pathologic states lead to impairment of gait and poor balance. The most common factors contributing to functional decline include asthenia, anorexia, pain, fatigue, depression, and anxiety. Asthenia is characterized by significant fatigue, both mental and physical, resulting in limited endurance, tiring easily, difficulty in initiating activity and maintaining concentration, and impaired memory. Patients admitted to acute care hospitals due to medical or surgical reasons are likely to suffer from functional deficits and further decline. Rehabilitation can help survivors and patients with cancer with physical, psychosocial, and vocational functional limitations posed by the disease and treatments. Some patients may require inpatient rehabilitation, whereas others require subacute rehabilitation, home health, or outpatient rehabilitation.
Studies have shown that inpatient rehabilitation can improve functional status. However, the following questions remain unanswered:
- 1.
Can functional gains achieved during inpatient rehabilitation be sustained in patients with cancer?
- 2.
When encountering a patient with cancer, how should clinicians evaluate his or her risk for falling?
- 3.
When patients with cancer are followed up in an outpatient rehabilitation clinic after acute care, what characteristics do these patients have, and what interventions can physiatrists offer?
This article presents the authors’ research in functional status following acute inpatient rehabilitation, detection of fall risk in elderly patients with cancer, and functional needs and symptoms in the outpatient cancer survivor setting.
Introduction
The American Cancer Society estimated 1.6 million new diagnoses of cancer in 2015. With advances in cancer diagnosis and treatment, the 5-year survival rate for all cancers has increased from 49% (1975–1977) to 67% (2006–2012). With such improvements in survival, cancer has become more a chronic disease. Cancer survivors can be defined as persons “living with a cancer diagnosis following primary cancer treatment through the end of life.” Older adults are much more likely to be diagnosed with cancer and this group already has a higher incidence of other medical comorbidities such as diabetes, stroke, arthritis, and obesity.
In the cancer treatment trajectory, many patients are cured of disease and are able to function normally in society again, although most patients, especially older patients, may experience fluctuations of function, with a trend of decline with cancer diagnosis and treatments. This decline is due to cancer and its treatment, and it may result from pain, misalignment, contracture of joints, muscle atrophy, fatigue, peripheral neuropathy malnutrition, and other symptoms. These pathologic states lead to impairment of gait and poor balance. The most common factors contributing to functional decline include asthenia, anorexia, pain, fatigue, depression, and anxiety. Asthenia is characterized by significant fatigue, both mental and physical, resulting in limited endurance, tiring easily, difficulty in initiating activity and maintaining concentration, and impaired memory. Patients admitted to acute care hospitals due to medical or surgical reasons are likely to suffer from functional deficits and further decline. Rehabilitation can help survivors and patients with cancer with physical, psychosocial, and vocational functional limitations posed by the disease and treatments. Some patients may require inpatient rehabilitation, whereas others require subacute rehabilitation, home health, or outpatient rehabilitation.
Studies have shown that inpatient rehabilitation can improve functional status. However, the following questions remain unanswered:
- 1.
Can functional gains achieved during inpatient rehabilitation be sustained in patients with cancer?
- 2.
When encountering a patient with cancer, how should clinicians evaluate his or her risk for falling?
- 3.
When patients with cancer are followed up in an outpatient rehabilitation clinic after acute care, what characteristics do these patients have, and what interventions can physiatrists offer?
This article presents the authors’ research in functional status following acute inpatient rehabilitation, detection of fall risk in elderly patients with cancer, and functional needs and symptoms in the outpatient cancer survivor setting.
Sustaining functional gain achieved during inpatient rehabilitation
General weakness and asthenia due to cancer and its treatments are common. Of patients who underwent inpatient rehabilitation, 40% to 50% did so because of deconditioning, asthenia, or general weakness.
Inpatient rehabilitation has been shown to improve functional status in deconditioned patients with cancer, yet no study has assessed whether these patients are able to maintain their functional level after discharge from inpatient rehabilitation. The objective of the authors’ study was to assess whether patients with general weakness can maintain their functional status measured by the Timed Get-Up-and-Go (TGUG) test and timed 50-foot walk 4 weeks after discharge from acute rehabilitation or from a consult-based rehabilitation mobile team in a comprehensive cancer center.
Methods
This study was conducted at a National Cancer Institute (NCI) Comprehensive Cancer Center with Institutional Review Board approval. Subjects with cancer who underwent rehabilitation with an acute inpatient rehabilitation or a consult-based rehabilitation inpatient mobile team and were able to ambulate with or without an assistive device or assistance from another person were recruited and assessed within 3 days of discharge. These subjects were also reassessed at a 4-week follow-up visit.
The consult-based rehabilitation team (known as the mobile team) consists of a physiatrist, physical therapist, and occupational therapist, as well as a speech therapist when indicated. This mobile team serves a similar role as inpatient rehabilitation, providing 2 hours of therapy, with a goal to directly discharge patients from acute care to home. A similar model has been described at the Mayo Clinic.
Patients who had other serious orthopedic conditions or active central nervous system (CNS) disease were excluded in this study.
Functional tests were performed with or without assistive devices, including
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TGUG, as previously described
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50-foot walk at fastest speed.
Symptoms were assessed by the Edmonton Symptom Assessment System (ESAS). Each subject received standard-of-care rehabilitation on discharge, which consisted of either home health, out-patient therapy, or a maintenance exercise program.
Statistical Analysis
Descriptive statistics were used to calculate demographic data. A Wilcoxon Two-Sample t-test (continuous or ordinal data) was used to compare the variable at baseline and 4 weeks later. Statistical analyses were performed using SAS version 9.2 (SAS Institute Inc, Cary, NC, USA). A P value less than .05 was considered statistically significant.
Results
Table 1 presents the characteristics of all participants at baseline. Twenty-four eligible subjects were enrolled in the study; 12 subjects returned for follow-up at 4 weeks after discharge. The remaining 12 subjects dropped out of the study. Reasons for failure to follow-up included: hospitalization (6), death (1), procedure (2), withdrawal (1), and no-show (2, they lived 204 and 430 miles from the cancer center, respectively).
| Male (%) | 10 (42) |
| Mean age, years (range) | 68 (41–93) |
| Mean weight ± SD (kg) | 85 ± 26 |
| Mean height ± SD (cm) | 173 ± 11 |
| Body mass index ± SD | 28 ± 8 |
| Race | |
| White: Black: Hispanic | 19:4:1 |
| Tumor diagnosis | |
| Solid: hematological | 20:4 |
| ESAS score | Mean ± SD |
| Pain | 2.8 ± 2.2 |
| Fatigue | 2.6 ± 2.6 |
| Nausea | 0.5 ± 1.5 |
| Depression | 0.8 ± 1.9 |
| Anxiety | 0.8 ± 2.1 |
| Drowsiness | 2.2 ± 2.9 |
| Shortness of breath | 1.4 ± 2.4 |
| Appetite | 3.3 ± 3.3 |
| Sleep | 3.0 ± 2.7 |
| Feeling of Well being | 3.4 ± 3.2 |
| Hemoglobin | 9.8 ± 0.9 |
| TGUG (s) | 22.7 ± 13.5 |
| Timed 50-foot fastest speed (s) | 22.8 ± 10.9 |
Despite the high drop-out rate, the authors found that the remaining 12 subjects were able to maintain their functional status and even showed a trend of improvement on TGUG from 13.1 seconds (10.5, 26.3) at time of discharge to 10.0 seconds (8.1, 15.0) 4 weeks after discharge ( P = .07) ( Table 2 ).
| Time of Discharge | 4 wk After Discharge | P (Mann-Whitney U) | |||
|---|---|---|---|---|---|
| TGUG (s) | 13.10 | (10.46, 26.3) | 10.00 | (8.07, 15.0) | .07 |
| Timed 50-foot fastest speed (s) | 16.70 | (11.95, 24.5) | 13.57 | (10.69, 18.9) | .15 |
Risk-for-fall evaluation in a patient with cancer
Falls in the elderly population are very common, affecting 30% to 60% of the population. A cancer diagnosis further increases the risk of falls and related mortality in the elderly. Falls can cause a significant amount of morbidity and mortality; 10% to 20% of falls result in injury, fracture, postfall anxiety syndrome, hospitalization, and/or death. Many risk factors for falls have been identified, including environmental causes, history of prior falls, depression, dizziness or vertigo, drop attacks, confusion, postural hypotension, visual disorders, syncope, urinary incontinence, weakness, balance deficits, gait deficits, and cognitive impairment. An awareness of risk factors for falls is not the same as having tool to assess the risk of falls. There is a need to develop a simple clinical tool to assess fall risk.
The authors conducted research in the elderly subjects with prostate cancer undergoing androgen deprivation therapy (ADT). This is a population with higher risk for fall when compared with those not receiving ADT or healthy controls. They have a high rate of osteopenia or osteoporosis that can lead to hip fracture and other devastating outcomes. Previously, there has been some effort to develop fall assessment tools, such as the TGUG test. However, this tool is time-consuming and requires trained staff. This study used 2 simple questions to determine the association with validated objective functional tests and history of fall.
Methods
After approval from the Institutional Review Board, the authors conducted a study of 34 subjects. The inclusion criteria consisted of male gender, age 65 years or older, diagnosis of prostate cancer, capability of ambulating with or without an assistive device and without assistance from another person, received ADT for at least 3 months with a response as measured by prostate-specific antigen, received chemotherapy within the last month, and English-speaking. Subjects with active CNS disease, such as clinically evident CNS metastases, leptomeningeal disease, dementia, or encephalopathy, were excluded.
While visiting their oncologist in the genitourinary oncology clinic, the participants were asked to complete a series of questionnaires:
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Two simple questions (answered yes or no)
- 1.
“Do you have difficulty climbing stairs?”
- 2.
“Do you have difficulty climbing down stairs?”
- 1.
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Fall incidence and risk factors assessment
- 1.
How many falls had they experienced in the past year?
- 2.
Did they have difficulty with their vision?
- 3.
Did they have difficulty with urinary incontinence?
- 1.
Barthel index
Using the validated Barthel index, the participants were asked 10 questions about their physical function and ability to complete activities of daily living (ADL). Subjects reported their ability for each function using a score of 0 (dependent), or 5 (needs some help but can do something alone), or 10 (independent). The Barthel index is the sum of the score ranging from 0 to 100, with 100 being the most independent level of function.
Edmonton Symptom Assessment System
The ESAS scale measures 9 symptoms of pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, appetite, and sleep on a scale from 0 to 10, with 0 being the best and 10 being the worst. In addition, overall feelings of well-being were rated from 0 to 10.
Functional tests
Timed Get-Up-and-Go test
Subjects were asked to rise from a seated position from a chair 17 inches from the floor, walk 10 feet as quickly and as safely as possible, turn around, and return to the chair and sit again. The time was recorded for 3 consecutive tests and the average of the 3 was used for analysis. A time greater than or equal to 10 seconds was associated with poorer balance, slower gait speed, and decreased functional capacity.
Unipedal stance test
Participants stood on their dominant leg without external support for as long as possible and the time was recorded (maximum of 30 seconds). A unipedal stance test time of less than 30 seconds is associated with a history of falls.
Grip strength analysis
Grip strength was measured in kilograms in the dominant arm using the Jamar Hand Dynamometer (Lafayette Instrument Co, Lafayette, IN, USA) while the subject was in the seated position with elbow flexed. The best of 3 measures were recorded for analysis. For elderly males ages 70 to 79 years, a grip strength 38 plus or minus 9 kg is considered normal.
Statistical Analysis
Descriptive statistics were used to calculate demographic data. A Wilcoxon Two-Sample t-test (continuous or ordinal data) was used to compare the variables at baseline and 4 weeks later. Spearman rank correlation coefficients were calculated between the functional test and postural assessments. The Fisher exact test was used to test the association between TGUG greater than 30 seconds and hospital readmission within 1 month. Statistical analyses were performed using SAS version 9.2. A P value less than .05 was considered statistically significant.
Results
Thirty-four subjects met inclusion criteria and participated in the study. Table 3 shows that the mean age of participants was 72.6 years. All of the subjects had stage 4 diseases and 91% had metastases to bone.
| Mean ± SD | |
|---|---|
| Age (y) | 73 ± 4 |
| Weight (kg) | 86 ± 16 |
| Height (cm) | 173 ± 6 |
| Body mass index (kg/m 2 ) | 29 ± 5 |
| Race | n (%) |
| White | 26 (77) |
| African American | 4 (12) |
| Hispanic | 1 (3) |
| American Indian or Alaskan | 3 (9) |
| Location of metastases | |
| Bone | 31 (91) |
| Lymph nodes | 21 (62) |
| Bladder | 3 (9) |
| Rectum | 1 (3) |
| Liver | 5 (15) |
| Lung | 4 (12) |
| Peritoneum | 1 (3) |
| Abdominal wall | 1 (3) |
| Mediastinum | 1 (3) |
| Cancer treatment | |
| Receiving chemotherapy | 34 (100) |
| Receiving androgen deprivation therapy | 34 (100) |
| History of prostate surgery | 16 (47) |
| History of radiation | 20 (59) |
| Current medications | |
| Opioids | 14 (41) |
| Beta blocker | 10 (29) |
| Calcium channel blocker | 5 (15) |
| Anticholinergic | 13 (38) |
| Benzodiazepine | 3 (8.9) |
| Antipsychotic | 1 (2.9) |
| Medical comorbidities | |
| Hypertension | 23 (67.7) |
| Leg claudication | 0 (0) |
| Osteoarthritis | 17 (50) |
Table 4 shows that subjects who reported difficulty in climbing stairs had weaker grip ( P = .045) and significantly longer TGUG times, with a median of 10.2 seconds versus 6.7 seconds in those subjects who reported no difficulty ( P = .002). Subjects who reported difficulty climbing down stairs had significantly longer TGUG times with a median of 12.9 seconds versus 6.8 seconds in those subjects who reported no difficulty ( P = .008). These subjects also scored lower on the Barthel index ( P = .004).
| Difficulty Climbing Stairs? Median (Range) | Difficulty Climbing Down Stairs? Median (Range) | |||||
|---|---|---|---|---|---|---|
| Yes (n = 15) | No (n = 19) | P -Value | Yes (n = 10) | No (n = 24) | P -Value (NS = P >.05) | |
| TGUG (s) | 10.2 (6.2–1.8) | 6.7 (4.7–10.4) | .002 | 12.9 (6.2–21.8) | 6.8 (4.7–10.8) | .008 |
| Unipedal stance (s) | 2.6 (1–30) | 5.99 (1.7–30) | NS | 5.6 (1–30) | 4.86 (1.4–30) | NS |
| Grip strength (kg) | 32 (18–42) | 38 (25–50) | .045 | 31 (18–48) | 38 (25–50) | NS |
| Barthel index | 95 (70–100) | 95 (90–100) | NS | 90 (70–100) | 97.5 (90–100) | .004 |
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