Sunday, April 3, 2011
The lead research article in the current issue of the American Journal of Physical Medicine and Rehabilitation is Inpatient Rehabilitation Improved Functional Status in Asthenic Patients with Solid and Hematologic Malignancies. It was written by a team from the Department of Palliative Care and Rehabilitation Medicine and the Department of Biostatistics at the University of Texas, MD Anderson Cancer Center. This study sought to compare functional outcomes in asthenic patients with hematologic malignancies with those of asthenic patients with solid tumors after inpatient rehabilitation.
Their hypothesis was that asthenic patients with hematologic malignancies were less likely than patients with solid tumors to make functional improvement after rehabilitation. This was a retrospective chart review of 60 asthenic cancer patients (30 consecutive patients with solid tumors and 30 consecutive patients with hematologic malignancies) who completed inpatient rehabilitation at a comprehensive cancer center between October 2005 and October 2007. Patients in whom the admitting physiatrist determined asthenia to be the main cause for admission to the rehabilitation unit were included in this study. Patients who developed new focal functional deficits because of brain or spinal cord lesions (same hospital admission) and patients who were unexpectedly transferred back to acute service were excluded. All patients admitted to the inpatient rehabilitation unit received 3 hours or more of therapy per weekday.
The main outcomes included total, motor, and cognitive Functional Independence Measure (FIM) scores (I'll offer some information on FIM scores below), hospital and rehabilitation length of stay (LOS), and FIM efficiency (calculated by dividing the total improvement in FIM score by the rehabilitation LOS).
The solid tumor patients were significantly older than the hematologic malignancy patients (mean ± SD (range), 71 ± 11 (48-93) vs. 64 ± 12 (33-88); P = 0.02). Most patients had advanced disease. A significantly higher percentage of patients in the solid tumor group underwent recent surgery (70% vs. 17%; P = 0.0001), whereas a significantly higher percentage of patients in the hematologic malignancy group received recent chemotherapy (67% vs. 17%; P = 0.0001). Similarly, a significantly higher percentage of patients in the solid tumor group underwent previous surgery (43% vs. 17%; P = 0.02), whereas a significantly higher percentage of patients in the hematologic malignancy group received previous chemotherapy (70% vs. 30%; P = 0.001).
The FIM™ instrument is a validated, rehabilitation assessment tool in wide use at skilled nursing facilities, subacute facilities, long-term care hospitals, Veterans Administration programs, international rehabilitation hospitals, and other related venues of care. It was developed at SUNY-University at Buffalo (UB), and is administered within the FIM System® on a subscription-basis by the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. The FIM instrument enables clinicians and programs to document the severity of patient disability, the results of medical rehabilitation and establishes a common measure for the comparison of rehabilitation outcomes. It is widely recognized by, and familiar to, most rehabilitative staff across disciplines. It operates as the gold standard for measuring and documenting the functional status, from admission to rehabilitative care through discharge and follow-up. In short, the FIM instrument functions at the core of rehab IDT communication and decision-making.
It is a 18-item instrument, which assesses the following areas:
Self Care (1. Eating, 2. Grooming, 3. Bathing, 4. Dressing - Upper Body, 5. Dressing - Lower Body, 6. Toileting)
Sphincter Control (7. Bowel Management, 8. Bladder Management)
Transfers (9. Bed/Chair/Wheelchair, 10. Toilet, 11. Tub/Shower)
Locomotion (12. Walk/Wheelchair, 13. Stairs)
Communication (14. Comprehension [auditory/visual], 15. Expression [vocal /non-vocal])
Social Cognition (16. Social Interaction, 17. Problem Solving, 18. Memory)
These items are scored on a 7-point, natural-number scale, i.e., 7 through 1, assessing the level of functioning from complete independence to complete dependence, as follows:
7. Complete Independence - All of the tasks described as making up the activity are typically performed safely without modification, assistive devices, or aids and within reasonable time.
6. Modified Independence - Activity requires any one or more of the following: An assistive device, more than reasonable time, or there are safety (risk) considerations.
5. Supervision or Setup - Subject requires no more help than standby, cueing or coaxing, without physical contact. Or, helper sets up needed items or applies orthoses.
4. Minimal Contact Assistance - With physical contact the subject requires no more help than touching, and subject expends 75% or more of the effort.
3. Moderate Assistance - Subject requires more help than touching, or expends half (50%) or more (up to 75%) of the effort.
2. Maximal Assistance - Subject expends less than 50% of the effort, but at least 25%.
1. Total Assistance - Subject expends less than 25% of the effort.
If an item cannot be assessed due to risk it is scored a 1.
Total FIM scores range from 18 - 126. Average FIM scores can be calculated by dividing the total FIM score by 18 yielding a global assessment of functional independence on the 7-point scale.
If this sounds to you like performance status, then you'd be right. There are various performance scales that have arisen the oncology and palliative medicine communities for clinical decision-making and prognositcation, e.g., the ECOG Performance Scale, the [New] Edmonton Functional Assessment Tool (EFAT), the Katz Index of Independence of Activities of Daily Living, the Karnofsky Perfromance Status Scale, and the Palliative Performance Scale. Please see the Pallimed Prognosis Links for more information on these. Perhaps the most corresponding is the Palliative Performance Scale version 2 (PPSv2) developed at the Victoria Palliative Research Network.
We now return to our regularly scheduled programming
The mean admission FIM score was 80 ± 14, the mean discharge FIM score was 96 ± 14, and the mean total increase in FIM score was 16 ± 10, and these did not differ significantly (P = 0.64, 0.21, and 0.25, respectively). The groups' mean rehabilitation LOS of 10 days, and hospital LOS were similar (P = 0.82, and 0.41, respectively). The mean FIM efficiency was 1.7, but the FIM efficiency was significantly higher in the patients with hematologic malignancies than in the patients with solid tumors (1.9 ± 0.9 vs. 1.4 ± 1.0; P = 0.049). Also, the congitive FIM at discharge compared with admission was significantly higher in patients with hematologic malignancies, but not in the patients with solid tumors (31.0 ± 3.7 at admission, 31.8 ± 3.7 at discharge; P = 0.004 vs. 31.5 ± 3.8 at admission, 31.5 ± 3.6 at discharge; P = 0.82).
This study adds information about functional gains from inpatient rehabilitation of advanced-cancer patients with asthenia. Most previous inpatient cancer rehabilitation studies looked at functional gains in patients with neoplastic brain injuries and spinal cord compressions, which were similar to those without cancer. Other previous studies looked at inpatient cancer rehabilitation for patients with a broad range of problems, where asthenia was only a small subset.
I like this study for several reasons. First, the scientist in me likes this because this is the first time in a long time that I have seen a study in a peer-reviewed journal with a clearly stated alternative hypothesis, with the data supporting acceptance of the null hypothesis. So, props on the team, and props on the editors. Second, the physiatrist in me likes the rehabilitation of patients with life-threatening/life-limiting diagnoses that still translates into significant functional gains, which may enable some patients to receive further treatment. Thirdly, the palliatrician [this is so tempting, but alas it's mixing Latin apples with Greek oranges, we're still trying to replace quadriplegia with tetraplegia for just such a lingusitc faux pas; another post beckons] in me likes the rehabilitation of patients with life-threatening/life-limiting diagnoses that translates into significant functional gains, which suggest higher QOL.
So, I'm going to don my lighted, speculative-spelunking hard-hat (with rearview mirror) and retrospectively mine a little data. For solid tumor patients and hematologic malignancy patients respectively (mean ± SD), admission FIM score was 79 ± 16 vs. 80 ± 13; their discharge FIM score was 93 ± 14 vs. 98 ± 14; and their mean total increase in FIM score was 14.6 ± 11 vs. 17.5 ± 8 . I'm going to now posit the wildly irresponsible and completely unvalidated McMichael Method that says [(average FIM score)+1] x 10 [and stated as %] = PPSv2 Level (for levels ≥20% and ≤80%, only). I think the PPSv2 is more nuanced and wide-ranging than the FIM because patients above 80% and below 20% performance levels will not likely be admitted to or remain in inpatient rehabilitation. This correspondence between functional independence and performance levels is also useful, mainly because there have been correlational studies for PPS assessments on admission and duration of subsequent survival. So, performance status (and by inference functional status) suggests prognosis. So, for solid tumor patients and hematologic malignancy patients respectively, average admission FIM was 4.39 vs. 4.49 (in the minimal assist range); estimated admission PPSv2 is 53.9% vs. 54.4%; average discharge FIM was 5.17 vs. 5.44 (in the supervision range); and estimated discharge PPSv2 is 61.7% vs. 64.4%.
I think too that this raises the question of whether such changes in functional-independence/performance level translates into changes of prognostic-trajectory. Although only 1 of 3 studies that correlated PPS level with survival would suggest a clear survival advantage based on a difference in performance-level between ~50% to ~60% (and these observations were single prospective assessments, not changes in levels over time due to interventions). That being said, I still like generating hypotheses about contributing factors for the, yet-to-be replicated, Palliative Care Paradox seen in the Temel et al. study last August. And, if functional-independence/performance level changes due to inpatient rehab interventions translate into prognostic-trajectory changes (and even if not), do these changes in functional-independence/performance levels seen after inpatient rehab translate into improved QOL for these patients, and their families?
Guo, Y., Shin, K., Hainley, S., Bruera, E., & Palmer, J. (2011). Inpatient Rehabilitation Improved Functional Status in Asthenic Patients with Solid and Hematologic Malignancies American Journal of Physical Medicine & Rehabilitation, 90 (4), 265-271 DOI: 10.1097/PHM.0b013e3182063ba6