Professional Documents
Culture Documents
DOI 10.1007/s13670-016-0162-0
Abstract Older patients with cancer may have multiple physical impairments, such as limitation in range of motion, muscle weakness, lack of coordination, and balance and gait dysfunction. A patients physical function may be further limited
by pain, fatigue, depression, and shortness of breath that hasten the deconditioning process and affect their overall quality
of life. Understanding the common impairments in cancer
would help the therapist to assess and treat them effectively;
thus, this article aims to provide an overview of functional
limitations associated with cancer and its treatments and the
use of the International Classification of Functioning,
Disability and Health as a keystone for selection of appropriate outcome measures to assess physical function that would
help the physiotherapist to design an effective treatment for
older patients with cancer.
Introduction
Cancer, a leading cause of deaths worldwide in 2012, is highly
associated with patients aged greater than 65 years [1, 2]. It is
the umbrella term that comprises more than 100 diseases [3].
Of them, breast and prostate cancers are the most frequently
diagnosed cancers in females and males, respectively [4, 5].
Most cancer patients undergo surgery, and about half of the
patients receive radiation treatment only or with concomitant
chemotherapy, either pre-operatively or post-operatively.
Advances in medical treatment improves the survival rates
of the cancer patients; however, adjuvant therapies, such as
radiation treatment, chemotherapy, hormonal therapy, or a
combination of these therapies cause significant changes in
the patients quality of life, fatigue, physical functioning,
and body composition [58]. Research reveals that only
22 % of the cancer survivors are physically active. Exercise
interventions play a vital role in improving physical, psychosocial well-being, and overall quality of life and in reducing
the disease recurrence by 24 % [914]. During hospitalization,
the elderly patients are often admitted with reduced mobility
and activity levels because of multiple co-morbidities that lead
to well-documented physiological deprivation in multiple systems. It is further triggered by the inability to maintain physical function in the hospital which increases the length of
hospital stay [17]. Evidence shows that this is due to inadequate physiotherapy services and poorly performed bedside
strengthening exercises [18]. However, regular exercise improves the adverse effects of bed rest [1518]. It is vital for
the physiotherapist to do a comprehensive assessment by integrating geriatrics principles into assessment of older populations with cancer to design an effective treatment to improve
their physical function and reduce the length of hospital stay.
The International Classification of Functioning, Disability,
and Health (ICF) is an internationally recognized framework
Health condition
(disorder or disease)
Activity
Participation
Personal Factors
Environmental Factors
Contextual Factors
Activity(Limitation)
Bed mobility - EMS
Transfer- EMS, FIM
Sitting to standing - FSTST
Walking- 10 MWT, 6MWT
Environmental Factors
House- Stairs, Lighting, Walking surface- House Assessment, Availability of
resources and ambulatory aids
Outdoor- Sidewalks, Curbs, Accessible to transport- Accessible to health care
Participation (Restriction)
Activities of Daily Living (ADL)
- BI, FIM
Fatigue- ESAS
Dizziness- DHI
Quality o f life - EORTC QLC-C30
Personal Factors
Fear of falling/fall risk behaviour: HFRM, SFRAT
Coping
Behaviour: Motivation , Depression, Anxious, aggression, etc.,
Habits: Physical activity, Smoking, Alcohol, etc.,
Socio-economic status
tissues. The therapist can determine which structure is involved by comparing the pain in AROM and PROM and the
location of pain. In addition, performing resisted isometrics at
the mid-range of motion will help to rule out contractile tissue
pathology [47].
Outcome measures
Body structure
and function
Range of motion
X
X
Lab values
Sitting Balance
Standing Balance
X
X
Activity and
participation
X
X
X
X
X
X
X
X
X
X
X
X
X
Body structure/
tumor location
Cardiovascular
systema
Respiratory
systema
Neuromuscular
system
Fibrosis
Genito-urinary
system
a
Physical impairments
Chest pain
Shortness of breath
Fatigue
Decreased endurance
Decreased mobility
Decreased ADL ability
Decreased transfer ability
Chest pain
Shortness of breath
Decreased endurance
Decreased mobility
Decreased ADL ability
Decreased transfer ability
Decreased ROM of
chest wall and upper
extremities
Gait abnormalities
Balance deficits/falls
Postural impairments
Decreased mobility
Decreased ADL ability
Decreased transfer ability
Assessment of vital signs such as heart rate, blood pressure, respiratory rate, cyanosis, light headedness and oxygen saturation are important to protect
the patient from adverse events
Hgb
(120160 g/L)*
Hct
(0.40.5 L/L)*
Platelet count
(130400 109/L)*
WBC
(4.010.0 109/L)*
Glucose
(3.87.00 mmol/L)*
INR
Exercise guidelines
<80
80100
<0.25
>0.25
<20
2050
No exercisea
Light exercise
>100
>0.300.32
>50
>5 as tolerable
Resistive exercise
Hgb hemoglobin, Hct hematocrit, WBC white blood cell, INR International Normalized Ratio
*
flat on the floor and the arms across the shoulder for 30 s. The
nudges can be applied in forward, backward, and sideways
directions if the patient can sit without swaying for 30 s.
Dynamic sitting balance is assessed by having the patient
reach each the arm forward and across the midline to the
opposite side, then down to each ipsilateral foot. The postural
sway were recorded to reach without losing balance. The
standing balance can be assessed in 3 different positions
(feet with shoulder width apart, semi-tandem, and tandem
position) as per the Short Physical Performance Battery
(SPPB) guidelines [61, 62].
Berg Balance Scale (BBS) The BBS is a reliable, valid, and
commonly administered test for mobility, fall risk assessment,
and the effectiveness of intervention in acute care settings. The
scale is comprised of 14 tasks of varied difficulties, and performances are scored on a 5-point scale in accordance with
descriptions. Scores range from 0 to 56. BBS scores of 0 to 20,
21 to 40, and 41 to 56 are interpreted as wheelchair-bound,
using assistance for mobility, and independent, respectively.
Evidence reveals that BBS mean scores of 49.6, 48.3, 45.3,
and 33.1 indicate that the patient requires no gait aid, canes for
outdoors, canes for indoors, and walker for safe mobility, respectively [6366].
Assessment of Fall Risk Evidence reveals that the Hendrich
II Fall Risk Model is potentially useful in identifying the fall
risk in acute care, compared to Morse Fall Scale, St Thomas
Risk Assessment Tool in Falling Elderly Inpatients. On the
other hand, the Schmid fall risk assessment screening tool
correctly predicts 93 % of the fallers and is commonly used
by the Alberta Health Services [64].
Modified Total Neuropathy Scale Chemotherapy-induced
peripheral neuropathy is a complication following taxane,
oxaliplatin, vincristine, vinblastine, vinorelbine, bortezomib,
thalidomide, brentuximab vedotin, ixabepilone, and eribulin
chemotherapy intervention and also causes muscle weakness,
movement related disorders in later stage. The modified total
neuropathy scale is a clinically feasible and valid tool to
fatigue and pathologic (cancer) fatigue is that the cancer fatigue appears during normal activities, persists for long periods, and does not improve after rest, which leads to declines
in physical, social, and emotional function; this can be subjectively assessed by the Edmonton Symptom Assessment Scale
(ESAS) and objectively assessed by administering a 6-min
walk test, as cardiorespiratory fitness is a powerful independent predictor of fatigue and mortality in older people
[7782].
Assessment of Activity and Participation
Activity It assesses the execution of a task or action by the
patient. Impairments in body structure and function limit the
activities. For example, muscle weakness and balance impairments that limit a patients ability to walk. The activities can
be influenced by physical and functional performance of an
individual.
Participation It measures the patients ability to conduct activities of daily living (ADL) and his or her involvement in
social situations. An example would be the ability to walk to
the hospital or a restaurant.
Assessment of physical or functional performance is one of
the essential components for the management of elderly people to improve or to prevent declines in physical function to
reduce morbidity and hasten the discharge process [83, 84]. It
is important to select appropriate reliable and valid tools to
determine the effectiveness of assessment and treatment; in
choosing the test, it is crucial to consider the time to complete
the test and the patients tolerance because fatigue limits cancer patient test tolerances. The most commonly used reliable
and valid physical function measures are discussed later in this
article.
Ten-meter Walk Test that measures the gait speed is one of
the standard clinical evaluations of older persons because it is
a quick, inexpensive, and reliable test [85]. Gait speed can
predict functional decline, future health status, hospitalization,
and discharge destination. To assess the gait speed, a hallway
length of 14 m is needed, and lines are drawn with tape at 0, 2,
12, and 14 m. The patient is asked to walk 10 m at their normal
comfortable pace, with or without assistive devices (but is inappropriate if patients require physical assistance to walk), and
the time is recorded in seconds. Start the stopwatch when the
patients leading foot crosses the 2-m line, and stop the stopwatch when the patients leading foot crosses the 12-m line, but
have the patient continue walking until they reach the 14-m
line. The averages of two trails are summed for the scores
[43]. The gait velocity can be measured by the time the patient
took to walk the distance in meters, divided by 60 (seconds).
The patient is at high risk of negative health-related outcomes if
they require interventions to reduce falling risk and their gait
speed is less than 1 m/s [86]. Gait speeds of 0 to 0.4, 0.4 to 0.8,
Elderly Mobility Scale The Elderly Mobility Scale is a reliable and valid tool to assess bed mobility and functional mobility in frail, elderly hospital patients over 55 years old. It
tests the following 7 items: lying to sitting, sitting to lying,
sitting to standing, standing, gait, timed walk (6 m), and functional reach, with a total score range from zero (totally dependent) to 20 (independent mobility). It takes no more than
5 min to complete the test. The minimally clinical important
difference for the Elderly Mobility Scale (EMS) is 2 points or
10 % of the scale width; EMS scores are useful to allocate
patients to appropriate care settings, following discharge from
the hospital. The patients cognitive function should be considered before deciding discharge destination. This scale is an
integral part of assessment to determine the possible discharge
destination and the effectiveness of interventions, such as bed
mobility exercises, balance exercises, and locomotion training. The scores, corresponding functional level, and possible
destination are depicted in Table 5 [9699, 100, 101].
Short Physical Performance Battery The Short Physical
Performance Battery (SPPB) is a reliable and valid functional
test that assesses three sub-components, such as self-paced
walking speed over 4 m, standing balance in 3 different positions (feet with shoulder width apart, semi-tandem, and tandem position), and lower extremity strength (5 times sit to
stand test) in older patients over 50 years old and cancer patients; it also predicts mortality and nursing home admissions.
Each test is scored on a scale of 0 to 4, with a total performance score of 0 to 12. The patients with SPPB scores of 46,
79, and 1012 are classified as increased risk of developing
future disability, relative risk of developing disability, and no
future disability, respectively. An SPPB score of less than 6 is
a strongest predictor of nursing home admission but, in contrast, an SPPB score >7 with better lower extremities performance at the time of discharge is associated with a lower risk
of re-hospitalization and death [102, 103, 104, 105].
Assessment of Functional Ambulation Cancer patients may
have sudden declines in mobility. It is important to assess their
functional ambulation, broadly categorized as dependent or
independent, to determine the amount of physical assistance
required for ambulation. Determining the need of assistive
devices is also crucial to prevent falls; the patient may use
assistive devices, such as walkers, canes, or crutches, to complete the task.
Independent: The patient can ambulate safely without the
help of another person.
Supervision: The patient can ambulate independently without the manual contact of another person; however, they may
need constant verbal cueing due to poor judgment.
Hands-on Supervision: The patient may require the
continuous or intermittent manual contact of one person
to assist balance.
Score
Functional level
Possible destination
<10
Nursing home
1014
Independent in ADL and indoor locomotion and may need help at times
>14
4.
5.
6.
7.
8.
9.
10.
Conclusion
Integrating the ICF model for physiotherapy assessment in an
older patiently with cancer could be an effective first step to
design an effective treatment and address the need for communication with other health professionals. Understanding the
common clinical features of cancer, physiotherapist may integrate the principles of geriatrics in to the assessment of older
patients with cancer. The study has the following limitations:
(1) it provides a generic framework for the assessment of
geriatric patients with cancer; (2) it does not provide a cancer
specific assessment model.
11.
12.
13.
14.
15.
16.
17.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
18.
19.
20.
References
21.
22.
23.
24.
25.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
106.
107.
108.
109.
110.
111.
112.