Feature

Telerehabilitation program improves function, reduces pain among patients with late-stage cancer

Andrea L. Cheville, MD
Andrea L. Cheville

A telerehabilitation program improved physical function, pain and quality of life among patients with advanced-stage cancer, according to study results.

“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,” Andrea L. Cheville, MD, physician in the department of physical medicine and rehabilitation at Mayo Clinic in Rochester, Minnesota, said in a press release. “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.”

Researchers of the COPE study set out to determine whether collaborative telerehabilitation and pharmacological pain management improve function and reduce pain and requirements for inpatient care among 516 patients (mean age, 65.6 years; women, n = 257) considered to be low-level community or household ambulators with late-stage solid or hematologic cancers.

Researchers randomly assigned patients to telerehabilitation, telerehabilitation plus pharmacological pain management, or a control group.

According to study results, telerehabilitation alone appeared associated with improved function (difference, 1.3; 95% CI, 0.08-2.35; P =.03) and quality of life (difference, 0.04; 95% CI, 0.004-0.071; P=.01) compared with controls. Both telerehabilitation groups demonstrated decreased pain interference and average intensity compared with controls.

In addition, telerehabilitation was associated with significantly increased odds for home discharge in the telerehabilitation group (OR = 4.3; 95% CI, 1.3-14.3) and the telerehabilitation-plus-pharmacological pain management group (OR = 3.8; 95% CI, 1.1-12.4).

Telerehabilitation alone also was associated with fewer days in the hospital (difference, –3.9 days; 95% CI, –2.4 to –4.6; P = .01).

HemOnc Today spoke with Cheville about the study, the clinical implications of the findings, and the next steps for research.

Question: What prompted this research ?

Answer : From what I have observed during the past 20 years, most patients with advanced cancer become progressively disabled and their caregivers are burdened and often become depressed. Some patients lose sufficient function that they require nursing home stays and even institutionalization. These patients are seldom referred for effective rehabilitation services as outpatients before they become dependent — our care delivery models are not proactively addressing their functional decline. Knowing that patients want to remain independent and preserve their functioning, we developed a light exercise program that could be easily adapted to patients’ unique needs. With 10 to 15 minutes of light exercise per day, in addition to a walking program, most patients can maintain their strength and stamina. It is much easier for patients to preserve their ability to function than to regain it once lost. We wanted to find a user-friendly way of delivering care to these patients without adding more office visits — hence the telecare approach.

Q: How did you conduct the study?

A: We identified patients with late-stage cancers treated at one of the three Mayo Clinic sites. Patients’ electronic health records were reviewed and those meeting diagnostic criteria were screened by telephone interview. We targeted low-level community ambulators — individuals who were able to get around in their communities but with increasing difficulty. We randomly assigned these patients to a control arm of automated monitoring, a telerehabilitation arm, and a third arm identical to the telerehabilitation arm with the addition of nurse-led pharmacological pain management. We included the third arm because we were concerned that uncontrolled pain could attenuate patients’ benefit from the intervention.

All patients underwent automated function and pain monitoring with data reporting to their care teams. Participants in the two rehabilitation arms received 6 months of centralized telerehabilitation provided by a physical therapist-physician team. Participants worked over the phone with a physical therapist specialized in cancer rehabilitation who helped them partner with local generalist therapists as needed.

Q: Can you elaborate on your findings?

A: We found that both intervention groups improved. However, with respect to function, the telerehabilitation-alone arm improved to a greater degree. Although the benefit was modest, it was sufficient to impact patients’ health care utilization. Pain relief was the same in the two telerehabilitation arms and significantly greater than in the control arm. Both intervention arms spent less time in nursing homes and hospitals, although the effects were more pronounced in the telerehabilitation-alone arm.

Q: Did any of your findings surprise you?

A: We were quite surprised that the third arm, which we assumed would be the superior intervention, did not do as well as the telerehabilitation-alone arm. Pain was less problematic for patients in the trial than we thought it would be based on our pilot work, which may partly explain the result. However, an important difference that we recognized only through post-hoc analyses was that the physical therapy delivered to participants in the third arm was less likely to include treatments targeting pain, whereas such treatments were much more common among participants in the second arm. This is a potentially important finding because we have not used physical therapy approaches to address cancer-related pain, even though many of these patients have pain from muskoskeletal problems.

Q: What is next for research ?

A: I am interested in exploring how to best target pain and functional decline simultaneously. We received a grant from the NCI to examine whether embedding patient-reported outcome-based assessments of symptoms and function can improve patients’ care experiences and outcomes. We are conducting a pragmatic clinical trial to pursue this aim. Specifically, we are screening patients for sleep disturbance, pain, anxiety, depression, fatigue and functional decline. If patients endorse problematic levels of these issues, we will provide them with self-management education, alert their care teams, and refer patients to therapists and other specialists, if indicated.

Q: Would you like to mention anything else?

A: Patients want to be able to move, function and remain in their own homes. Given our rapidly aging cancer population, finding ways to keep these patients active is very important. – by Jennifer Southall

Reference:

Cheville AL, et al. JAMA Oncol. 2019;doi:10.1001/jamaoncol.2019.0011.

For more information:

Andrea L. Cheville , MD, can be reached at Mayo Clinic, 200 First St. SW, Rochester, MN 55905; email: cheville.andrea@mayo.edu.

Disclosure : Cheville reports no relevant financial disclosures.

Andrea L. Cheville, MD
Andrea L. Cheville

A telerehabilitation program improved physical function, pain and quality of life among patients with advanced-stage cancer, according to study results.

“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,” Andrea L. Cheville, MD, physician in the department of physical medicine and rehabilitation at Mayo Clinic in Rochester, Minnesota, said in a press release. “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.”

Researchers of the COPE study set out to determine whether collaborative telerehabilitation and pharmacological pain management improve function and reduce pain and requirements for inpatient care among 516 patients (mean age, 65.6 years; women, n = 257) considered to be low-level community or household ambulators with late-stage solid or hematologic cancers.

Researchers randomly assigned patients to telerehabilitation, telerehabilitation plus pharmacological pain management, or a control group.

According to study results, telerehabilitation alone appeared associated with improved function (difference, 1.3; 95% CI, 0.08-2.35; P =.03) and quality of life (difference, 0.04; 95% CI, 0.004-0.071; P=.01) compared with controls. Both telerehabilitation groups demonstrated decreased pain interference and average intensity compared with controls.

In addition, telerehabilitation was associated with significantly increased odds for home discharge in the telerehabilitation group (OR = 4.3; 95% CI, 1.3-14.3) and the telerehabilitation-plus-pharmacological pain management group (OR = 3.8; 95% CI, 1.1-12.4).

Telerehabilitation alone also was associated with fewer days in the hospital (difference, –3.9 days; 95% CI, –2.4 to –4.6; P = .01).

HemOnc Today spoke with Cheville about the study, the clinical implications of the findings, and the next steps for research.

Question: What prompted this research ?

Answer : From what I have observed during the past 20 years, most patients with advanced cancer become progressively disabled and their caregivers are burdened and often become depressed. Some patients lose sufficient function that they require nursing home stays and even institutionalization. These patients are seldom referred for effective rehabilitation services as outpatients before they become dependent — our care delivery models are not proactively addressing their functional decline. Knowing that patients want to remain independent and preserve their functioning, we developed a light exercise program that could be easily adapted to patients’ unique needs. With 10 to 15 minutes of light exercise per day, in addition to a walking program, most patients can maintain their strength and stamina. It is much easier for patients to preserve their ability to function than to regain it once lost. We wanted to find a user-friendly way of delivering care to these patients without adding more office visits — hence the telecare approach.

PAGE BREAK

Q: How did you conduct the study?

A: We identified patients with late-stage cancers treated at one of the three Mayo Clinic sites. Patients’ electronic health records were reviewed and those meeting diagnostic criteria were screened by telephone interview. We targeted low-level community ambulators — individuals who were able to get around in their communities but with increasing difficulty. We randomly assigned these patients to a control arm of automated monitoring, a telerehabilitation arm, and a third arm identical to the telerehabilitation arm with the addition of nurse-led pharmacological pain management. We included the third arm because we were concerned that uncontrolled pain could attenuate patients’ benefit from the intervention.

All patients underwent automated function and pain monitoring with data reporting to their care teams. Participants in the two rehabilitation arms received 6 months of centralized telerehabilitation provided by a physical therapist-physician team. Participants worked over the phone with a physical therapist specialized in cancer rehabilitation who helped them partner with local generalist therapists as needed.

Q: Can you elaborate on your findings?

A: We found that both intervention groups improved. However, with respect to function, the telerehabilitation-alone arm improved to a greater degree. Although the benefit was modest, it was sufficient to impact patients’ health care utilization. Pain relief was the same in the two telerehabilitation arms and significantly greater than in the control arm. Both intervention arms spent less time in nursing homes and hospitals, although the effects were more pronounced in the telerehabilitation-alone arm.

Q: Did any of your findings surprise you?

A: We were quite surprised that the third arm, which we assumed would be the superior intervention, did not do as well as the telerehabilitation-alone arm. Pain was less problematic for patients in the trial than we thought it would be based on our pilot work, which may partly explain the result. However, an important difference that we recognized only through post-hoc analyses was that the physical therapy delivered to participants in the third arm was less likely to include treatments targeting pain, whereas such treatments were much more common among participants in the second arm. This is a potentially important finding because we have not used physical therapy approaches to address cancer-related pain, even though many of these patients have pain from muskoskeletal problems.

Q: What is next for research ?

PAGE BREAK

A: I am interested in exploring how to best target pain and functional decline simultaneously. We received a grant from the NCI to examine whether embedding patient-reported outcome-based assessments of symptoms and function can improve patients’ care experiences and outcomes. We are conducting a pragmatic clinical trial to pursue this aim. Specifically, we are screening patients for sleep disturbance, pain, anxiety, depression, fatigue and functional decline. If patients endorse problematic levels of these issues, we will provide them with self-management education, alert their care teams, and refer patients to therapists and other specialists, if indicated.

Q: Would you like to mention anything else?

A: Patients want to be able to move, function and remain in their own homes. Given our rapidly aging cancer population, finding ways to keep these patients active is very important. – by Jennifer Southall

Reference:

Cheville AL, et al. JAMA Oncol. 2019;doi:10.1001/jamaoncol.2019.0011.

For more information:

Andrea L. Cheville , MD, can be reached at Mayo Clinic, 200 First St. SW, Rochester, MN 55905; email: cheville.andrea@mayo.edu.

Disclosure : Cheville reports no relevant financial disclosures.