June 07, 2019
Patients with advanced-stage cancer frequently experience mobility impairments and other functional losses that degrade quality of life (QOL). These impairments can lead to prolonged hospital admissions for acute care, or transfers to nursing homes or other types of post-acute care facilities.
Research has demonstrated that providing these patients with rehabilitation services and conditioning activities can mitigate functional losses. However, several factors can limit patients' access to these services and make it more difficult for them to receive this care during the early stages of disability when treatments are more effective. These obstacles include limited access to center-based programs, low awareness among clinicians and patients about the potential associated benefits, and a shortage of rehabilitation professionals available and equipped to deliver these services.
In study findings published in JAMA Oncology, Mayo Clinic researchers studied patients with late-stage cancer who participated in a collaborative telerehabilitation program, with or without medication-based pain management. The goal of the study was to determine whether providing these patients with telerehabilitation services could improve function, preserve independence, reduce pain, and avoid extended stays at hospitals or other care facilities.
"Patients with late-stage cancers often lose their functional abilities and, with this loss, have a poorer quality of life and lowered ability to tolerate their cancer treatments," says Andrea L. Cheville, M.D., the article's lead author and a specialist in Physical Medicine and Rehabilitation at Mayo Clinic's campus in Rochester, Minnesota. "We know that rehabilitation and exercise can reverse or slow these losses, but it is often hard for patients to find, much less get, these services. The result is that too many people lose the ability to care for themselves and become needlessly dependent on others."
This three-arm randomized clinical trial involved 516 participants with late-stage cancers who were experiencing functional limitations. Study participants were randomly assigned to one of three groups:
- A control group
- The telerehabilitation treatment group (arm two)
- The telerehabilitation plus nurse-directed medication-based pain management group (arm three)
Participants in arms two and three received six months of telerehabilitation services provided by a physical therapist-physician team. All participants underwent automated function and pain monitoring.
Researchers assessed the participants' function, (using Activity Measure for Post-Acute Care computer adaptive test), pain (using the Brief Pain Inventory) and QOL (using the EQ-5D-3L), at baseline, three months and six months. They also recorded hospitalizations and discharges to post-acute care facilities for all participants.
Overall, the study suggests that expanding cancer care to include telerehabilitation services that enable people with cancer to maintain their strength and function can improve their QOL and protect them from longer hospitalizations and nursing home stays. Key findings included:
- Participants in the telerehabilitation-only group (arm two) had improved function (difference, 1.3; 95% confidence interval [CI], 0.08 to 2.35; P = 0.03), when compared with the control group.
- Participants in the telerehabilitation-only group (arm two) had improved QOL (difference, 0.04; 95% CI, 0.004 to 0.071; P = 0.01), when compared with the control group.
- Both the telerehabilitation-only group (arm two) and telerehabilitation plus medication group (arm three) had reduced pain interference (arm two, -0.4; 95% CI, -0.78 to -0.09; P = 0.01, and arm three, -0.4; 95% CI, -0.79 to -0.10; P = 0 .01), when compared with the control group.
- Both the telerehabilitation-only group (arm two) and telerehabilitation plus medication group (arm three) had reduced average pain intensity (arm two, -0.4; 95% CI, -0.78 to -0.07; P = 0.02, and arm three, -0.5; 95% CI, -0.84 to -0.11; P = 0.006), when compared with the control group.
- Telerehabilitation treatment was associated with higher odds of home discharge in arms two (odds ratio [OR], 4.3; 95% CI, 1.3 to 14.3; P = 0 .02) and three (OR, 3.8; 95% CI, 1.1 to 12.4; P = 0.03), and fewer days in the hospital in arm two (difference, -3.9 days; 95% CI, -2.4 to -4.6; P = 0.01).
According to Dr. Cheville and colleagues, these results indicated that the subjects assigned to the telerehabilitation-only group had the largest benefits: higher levels of function and independence, reduced pain, and fewer days spent in hospitals and nursing homes.
"We were not surprised that telerehabilitation was beneficial," Dr. Cheville says. "But we were very surprised that the addition of medication-based pain management did not further improve outcomes. We plan to explore this finding in future research."
For more information
Cheville AL, et al. Effect of collaborative telerehabilitation on functional impairment and pain among patients with advanced-stage cancer: A randomized clinical trial. JAMA Oncology. 2019;5:644.