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Curr Geri Rep

DOI 10.1007/s13670-016-0162-0

HEMATOLOGY AND ONCOLOGY (TM WILDES, SECTION EDITOR)

Assessment of physical function in geriatric oncology


based on International Classification of Functioning, Disability
and Health (ICF) framework
Venkadesan Rajendran 1 & Deepa Jeevanantham 2

# Springer Science+Business Media New York 2016

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.

Keywords Assessment . Cancer . Geriatrics . Physiotherapy .


Physical function

This article is part of the Topical Collection on Hematology and Oncology


* Venkadesan Rajendran
venkadphysio@gmail.com
Deepa Jeevanantham
djeevana@uwo.ca

Medicine, Oncology and Palliative care, Health Sciences North,


Sudbury, Ontario, Canada

Health and Rehabilitation Science, Western University,


London, Ontario, Canada

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

Curr Geri Rep

which allows its user to describe the consequences of a health


condition on an individual in the context of their environment.
With growing recognition that rehabilitation for cancer patients can have broad ranging physical and psychosocial factors, the aim of this paper is to use the ICF framework to
describe outcome measures that the physiotherapist will find
useful in assessing older patients with cancer. This proposal
may be a landmark as a first article that suggests the usefulness
of the ICF for cancer in the old people in acute care settings.
International Classification of Functioning, Disability and
Health (ICF) The ICF is an international framework for describing the functioning and disability aspects of health and
health-related status of an individual developed by the World
Health Organization. The ICF consists of two domains (i.e.,
functioning and disability and contextual factors) which are
further divided into two components (Fig. 1). The functioning
and disability domain is divided into body structure and function, activity, and participation components. The contextual
factors are divided into environmental and personal factors.
The components of the ICF consists of various domains. The
domains are explained in terms of constructs and recorded
using qualifiers for the purpose of classification. The body
function refers to the Bchanges in body function (physiological)^ and the body structure refers to the BChanges in body
structure (anatomical)^. The activity refers to the BCapacity
execution of a task in a standard environment^ and participation
refers to the BPerformanceexecution of a task in the persons
typical environment.^ The environmental factors refers to the
Bimpact of the features of physical, social and attitudinal world^
and the personal factors refers to the Bimpact of attributes of the
person^ as explained by the ICF [19].
Application of ICF in Geriatric Oncology
The ICF provides a universal language for physiotherapists in
clinical practice because it encompasses core components of
physiotherapy practice [19]. Figure 2 depicts potential physiotherapy outcomes of interest and the assessment tools for

assessing older patients with cancer within the ICF


framework.
Outcome Measures Selecting an outcome measure depends
on the therapeutic goals as well as psychometric properties of
the tool. Table 1 delineates the potential outcome measures
that fit into ICF domains [1941]. The potential impairments
experienced by cancer patients and commonly used outcome
measures are discussed in the following section.
Assessment of Body Structure and Function It evaluates
anatomical and physiological functions through a comprehensive subjective and objective examination. Impairments in anatomical structure will affect physiological functions, for example, lung cancer causes shortness of breath and limits a
patients ability to walk. It provides specific information about
cancer related impairments, prognostic considerations, and
safety factors [42]. Table 2 delineates selected impairments,
due to cancer and or their treatment side effects, which may
limit the physical function [43, 4446]. There are numerous
assessment tools available to measure physical function in
geriatric patients with cancer; however, the commonly used
outcome measures are discussed as an example to measure the
ICF domains.
Assessment of Neuro-Musculoskeletal and Neurological
Functions
Assessment of Range of Motion The active range of motion
(AROM) and passive (PROM) range of motion is assessed
with a universal goniometer at all major joints, as described
by Norkin and White. It can be documented as within functional limits (WFL) and within normal limits (WNL). ROM
also gives an idea regarding the structure involved; pain that
occurs during AROM is due to pathology over the contractile
tissues, such as muscle, tendons, and their attachment to the
bone. If the patient can complete AROM easily and painlessly,
further testing is not necessary. Pain that occurs during PROM
is often due to stretching or pinching of non-contractile

Health condition
(disorder or disease)

Body Functions & Structure

Activity

Participation

Personal Factors

Environmental Factors
Contextual Factors

Fig. 1 The International Classification of Functioning, Disability, and


Health (ICF) Model. Reproduced from BTowards a Common Language
for Functioning, Disability and Health.^ International Classification of

Functioning, Disability and Health, World Health Organization,


Geneva, 2002, with permission from the World Health Organization

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Geriatric Cancer

Structure & Function (Impairments)


Blood Cells- Anemia, Neutropenia*
Cognition- MOCA
Depression- ESAS
Balance- Sitting & Standing Balance- SCT, TUG, EMS,
SPPB, FRT
Range of Motion- Universal goniometer
Muscle strength- MMT
Posture
Swelling
Pain - NPRS
Endurance - 6 MWT
Coordination
Gait Pattern

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

Fig. 2 An International Classification of Functioning, Disability, and


Health (ICF) model framework for consideration of measures for outcome for cancer in geriatric population. MOCA Montreal Cognitive
Assessment, NPRS Numerical Pain Rating Scale, ESAS Edmonton
Symptom Assessment Scale, MMT Manual Muscle Testing, SCT StairClimbing Test, TUG Timed Up and Go Test, FTSTS Five Times Sit to
Stand Test, EMS Elderly Mobility Scale, SPPB Short Physical

Performance Battery, FRT Functional Reach Test, 6 MWT 6 Minute


Walk Test, 10 MWT 10 Meter Walk Test, BI Barthel Index, FIM
Functional Independence Measures, EORTC QLC-C30 European
Organization for Research and Treatment of Cancer Quality of Life
Questionnaire, BBS Berg Balance Scale, HFRM Hendrich II Fall Risk
Model, SFRAT Schmid fall risk assessment screening tool; *See Table 2

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].

Assessment of Lymphedema Lymphedema is most common


in breast and prostate cancers or associated peripheral vascular
disease and may arise immediately or many years after cancer
treatment due to lymphatic system damage. Limb volume is
commonly measured by circumference measurement or water
displacement, which is highly reliable method. For circumferential measurements, measurements are taken at the following
four points on both arms and differences >2 cm between arms
are considered positive: the metacarpo-phalangeal joints
(MCP), the wrist, 10 cm distal to the lateral epicondyle, and
15 cm proximal to the lateral epicondyle. The cut-off points
for definitive lymph oedema is a water displacement difference of >200 ml between the affected and non-affected limbs
[5052].

Assessment of Muscle Strength A one repetition maximum


(1 RM) for the shoulder or chest press and leg press or squat is
the gold standard for the assessment of global muscle strength
[48]. Also, the Manual Muscle Testing (MMT) is a commonly performed test by physiotherapists to assess the muscle
strength and has been used in cancer population [42].
Alternatively, Five Times Sit to Stand Test (FTSTS) is a reliable
test that assesses functional lower extremity strength, transitional movements, such as sit to stand, and fall risk. A
standard-height chair with back rest is used. To perform the
test, the patient is instructed to fold the arms across the chest
and stand up and sit down as quickly as possible five times.
The time is recorded in seconds. The reference values are 11.4,
12.6, and 14.8 s for 6069, 7079, and 8089 years old, respectively [49]. The recurrent fall risk of falling is double if
the patient scored greater than 15 s. Transition movement
would be difficult for that patient who has difficulty standing
up without using the arms, and the occupational therapist can
be referred for bed and toilet modifications.

Assessment of Cognitive Function The Montreal cognitive


assessment (MOCA) is a widely used reliable screening tool
to assess cognitive impairment, consisting of 16 items and has
a total score of 30. It is available in many languages, freely
available, and can be administered by anyone. The scores can
be interpreted as follows: <10/30, 1017/30, and 1826/30 are
categorized as severe, moderate, and mild cognitive impairment, respectively [53]. The Mini-Mental State Examination
(MMSE) is another simple test commonly administered by a

Curr Geri Rep


Table 1

The outcome measures and ICF domains

Outcome measures

Body structure
and function

Range of motion

Manual Muscle Testing

Montreal Cognitive Assessment


Mini-Mental State Examination

X
X

Lab values

Numerical Pain Rating Scale


Dizziness Handicap Inventory

Sitting Balance
Standing Balance

X
X

Berg Balance Scale


Edmonton Symptom Assessment Scale
Brief Fatigue Inventory

Activity and
participation

Physiotherapists working with cancer patients are more likely


to stretch the exercise guidelines boundaries when weighing
the benefits of mobilizing patient versus risk of continuous
bed rest complications [57]. It is also recommended to discuss
with the physician the risks versus the benefits of physiotherapy intervention if the lab values are not within normal levels.
The therapist can use their professional judgment to prescribe
exercise to promote the patients essential activities of daily
living if the lab values are remarkable. Lab values and exercise
guidelines are outlined in Table 3.
Assessment of Sensory Functions

X
X
X

10 Meter Walk Test


Timed Up and Go test

X
X

Stair Climb Test


Elderly Mobility Scale
Short Physical Performance Battery

X
X
X

6 Minute Walk Test


Functional Ambulation
Barthel Index
Functional Independent Measures
European Organization for Research
and Treatment of Cancer Quality
of Life Questionnaire

X
X
X
X
X

physiotherapist to assess cognitive function in brain tumor


patients [54].
Assessment of Cancer Symptoms The common symptoms
experienced by cancer patients can be measured by using the
Edmonton Symptom Assessment Scale (ESAS). The ESAS is
a simple, freely available, and reliable tool that assesses nine
common symptoms in cancer patients: pain, tiredness, nausea,
depression, anxiety, drowsiness, appetite, well-being, and
shortness of breath. Each symptom is rated from 0 (absent)
to 10 (worst symptoms) on a numerical scale. This can be
completed by the patient, family, or both [55]. The effectiveness of physiotherapy treatment on various symptoms can be
measured using the ESAS.
Review of Laboratory Values Patients with cancer most likely have an abnormal cell count; red blood cell (RBC), white
blood cell (WBC), and platelet (PLT) cell counts go down for
a time following chemotherapy, as it kills the normal blood
cells along with cells that are actively multiplying, though
they may be replaced after a few days. It is the professional
responsibility of the physiotherapist to consider the lab values
to design a safe and effective exercise program [56].

The common sensory impairments (such as pain, dizziness,


balance dysfunction, and sensory neuropathy) and the outcome measures used in cancer patients and/or receiving adjuvant therapies are described in the following section.
Pain Assessment Cancer patients often report the presence of
pain in several different anatomical sites that may be caused
by the cancer, cancer treatment, general debility, or concurrent
disorders. The patients diagnosed with cancer who report pain
should undergo a comprehensive pain assessment. Cancer patients, and their care givers, should use a pain diary to track
pain levels and the effectiveness of treatment. The Numerical
Rating Scale (010) is valid tool to assess the intensity of pain
in cancer patients within the hospital. The assessment of pain
should include the following information regarding the pain:
location, characteristics/description, severity/intensity, duration, aggravating factors, relieving factors, effects on function
and activities of daily living, and the impact on quality of life
[5862].
Assessment of Dizziness Dizziness in elderly population is
primarily due to cardiovascular disease (57 %), adverse effects
of drugs (23 %), peripheral vascular disease (14 %), and 10 %
due to psychiatric illness [58]. A chemotherapeutic drug (e.g.,
cisplatin) used to treat variety of tumors that causes vestibular
and ototoxicity. It is important to assess vestibular function
and balance during and after treatment [59]. Postural hypotension (SBP drops >20 mmHg or DBP drops >10 mmHg) is
another major symptom that causes dizziness. Dizziness
Handicap Inventory is a 25-item self-report questionnaire
quantifies the impact of dizziness on functional activities
and has been used in cancer population [60].
Assessment of Balance Balance impairments are the leading
cause of falls in the elderly population and affect the activities
of daily living. Balance is the modifiable risk factor for falls,
so it is important to assess and treat balance issues to avoid
falls. The static and dynamic balance is tested typically in
sitting and standing positions. To assess the sitting balance,
the patient sits at the edge of the bed without support, with feet

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Table 2

Selected effects of tumors and its adjuvant treatment effects [1941]

Body structure/
tumor location

Chemotherapy drugs and its


complications

Cardiovascular
systema

Anthracyclines and trastuzumab Cardiac and coronary scarring leads


damages cardiac myocytes and
to restrictive cardiac disease and
cause congestive heart failure
coronary heart disease that
superimposes already existing
cardiac diseases in elderly
population.
Bleomycin, methotrexate, and
Damages the lining of alveoli results
docetaxeldamages
in fibrosis. Also, it affects the
pnemocytes and pulmonary
musculoskeletal system of chest
parenchyma that leads to
wall which further limits chest
obliteration of alveoli
wall expansion

Respiratory
systema

Neuromuscular
system

Vinca alkaloids, taxanes, and


platinum agents reduces
strength by damaging
muscle or peripheral nerves

Gastrointestinalc Most common: nausea/vomiting


Others: loss of appetite
Constipation
Diarrhea

Radiotherapy and its complications

Fibrosis

Genito-urinary
system
a

Major system related


symptoms which limits
physical functionsb

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

Range of motion limitation:


For example: 1. Surgery
and radiation to head
or neck tumorcervical
ROM, shoulder flexion
and abduction.
2. Mastectomyshoulder
flexion and abduction
3. Axillary web syndrome
shoulder abduction.
Poor posture
For example: Mastectomyprotracted shoulder or
kyphosis
Decreased muscle strength:
Use of corticosteroid
potentially damages
proximal muscle that
limits overhead reaching
and sit o stand.
Spinal/brain tumor
For example: Quadriplegia,
paraplegia/hemiplegia
Cognitive impairment
Amputation: loss of limb
Decreased endurance
Nausea or vomiting
Decreased mobility
Pain
Decreased transfer ability
Acid reflux
Cachexia
Shortness of breath
Malnutrition
Diarrhea
Constipation
Abdominal cramps
Post-surgical: Decreased
air entry Decreased
chest wall expansion
Lung secretion
Urinary incontinence

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

Common impairments such as fatigue

Nutrition affects physical functionphysiotherapist can liaise with clinical dietician

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Table 3

Laboratory values and exercise prescription [56]

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

<5 with fever


>5

<3.8 > 22.2

>3 with Warfarin

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
*

Reference values are expressed in SI units (Canada)

Essential activities of daily living or bed activities can be considered

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

measure the severity of peripheral neuropathy in cancer


population [68, 69].
Assessment of Cardiorespiratory Functions
The cardiorespiratory system can be affected by cancer in that
areas or side effects of adjuvant therapies [67, 70]. Measuring
vital signs such as heart rate, blood pressure, respiratory rate,
and oxygen saturation will help to identify the hemodynamic
stability as well as to terminate exercise to prevent adverse
events (Table 4). The most commonly administered outcome
measures are discussed below.
Six Minute Walk Test (6 MWT) The six minute walk test
(6 MWT) is a simple, reliable, and commonly used practical
test that assesses aerobic exercise capacity or functional capacity of the patient. 6 MWT requires a 30-m hallway, stop watch,
and pedometer to measure the distance but does not require
Table 4 Criteria to terminate the exercise or exercise testing or to
mobilize the patient if any of the following signs and symptoms
develop [43, 44]
Cardiovascular system
Heart rate (HR):
<40 beats/min >130 beats/min; >20 decrease in resting HR
Blood pressure (BP):
Systolic blood pressure (SBP) >180 mmHg; drop in SBP >10 mmHg
from the baseline despite an increase in workload; diastolic blood
pressure (DBP) > 110 mmHg; >20 % decrease in SBP/DBP
Mean arterial blood pressure (MAP) = (2/3 DBP+ 1/3 SBP): No less than
60 mmHg
Other signs and symptoms:
Hypotension associated with dizziness, fainting, and diaphoresis, chest
pain, signs of poor perfusion such as cyanosis/pallor; patient refusal/
request to stop, extreme fatigue
Respiratory system
Respiratory rate (RR):
Increase in RR of greater than 20 breaths/min from baseline
Saturation of peripheral oxygen (SP02):
< 8892 % while on supplemental oxygen
Intolerable shortness of breath at rest and or with activities; paradoxical
breathing

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training. The therapist should check blood pressure and pulse


rate and rule out all the contraindications specified in Table 4
prior to performing the test. The American Thoracic Society
(ATS) recommends that the patient should not be engaged in
any strenuous activity for 2 h prior to the test, and the patients
can use ambulatory aids and supplementary oxygen, if dependent. Before the test and at the end, the patient is advised to rate
the intensity of shortness of breath using the Borg scale and
fatigue level. In order to perform the test, the patient is
instructed to walk at a self-paced speed, as far as possible, for
6 min and record the distance walked in feet or meters. The
patient is permitted to slow down, stop walking, or leans
against the wall for rest and can resume walking if they are
ready to continue walking; however, the timing should not be
paused for any reason. The test should be terminated if the
patient presents with any of the contraindications listed in
Table 4. The ATS also recommends using anti-angina medication prior to performing the test for stable exertional angina
patients and is not an absolute contraindication to 6 MWT.
The normative values of the 6 MWT for men and women, aged
60 to 69 years, is 572 and 538 m, respectively, for men and
women aged 70 to 79 years, it is 527 and 471 m, respectively,
and for men and women aged between 80 and 89 years, is 417
and 392 m, respectively. A distance less than 200 m is predictive of hospitalization and mortality. Small, meaningful, detectable change in 6 MWT for older adults is 19 to 22 m, and
substantial change is 47 to 49 m [62, 7174].
Mean peak oxygen update can be predicted with the following equation (SEE 1.1 ml/kg/min) and is not suitable if the
6 MWD is over 600 m [75].
Mean peak V02 (ml/km/min) = 4.948+ 0.023 mean 6
MWD (meters).
Metabolic equivalents (METs) can be computed with the
following steps [76].
1. 1 m = 3.28 ft; 1 mph = 5280 ft
2. Calculate distance walked in miles per hour (mph) = Feet
walked in 6 min 10
3. Calculate METs = (Distance walked in miles per
hour) (26.83 m/min) (0.1 mL*kg 1 *min 1 ) +
(3.5 mL*kg1*min1) / (3.5 mL*kg1*min1)

Assessment of Fatigue Fatigue is one of the most common


symptoms in cancer patients that prevent them from carrying
out activities of daily living and or going back to work following treatment, affecting up to 70 % of patients during
chemotherapy and radiotherapy; about 30 % of cancer survivors report that it persists for years after the end of therapy.
Chemotherapy-related fatigue is primarily due to anemia the
cancer treatment, such as radiotherapy, chemotherapy, stem
cell transplant, and immunotherapy, which kills normal and
cancerous cells. The difference between normal physiologic

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,

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0.8 to 1.2, and >1.2 m/s are categorized as household walker,


limited community ambulation, community ambulation, and
cross-street ambulation, respectively. An improvement in walking speed of 0.05 to 0.1 m/s following intervention is a useful
predictor of well-being, while a decline of the same amount is
linked to longer hospital stays and poorer health [87].
Stair Climb Test The stair climb test assesses the patients
ability to climb stairs, functional lower extremity strength balance, and cardiorespiratory fitness and is important to assess
because most falls associated with descending stairs. In order
to perform the test, the patient is asked to climb the stairs up
and down, using the hand rail or assistive devices. Timing
starts (in seconds) when the patient raises their leading foot
off the ground and climbs the first step, and stops when both
feet are placed on top of the stairs. The patient is asked to
climb down the stairs after a brief rest period; the timing starts
when the leading foot is off the ground for the first stair and
stops when both feet are placed on the bottom of the stairs.
Because descending stairs is more difficult than ascending
stairs, both times are recorded separately. The therapist should
stand close by to guard the patient and consistently record the
use of handrails, assistive devices, orthotics, transfer belt,
number of steps, and time required to complete ascending
and descending stairs. The therapist should be cautious not
to urge the patient to climb down fast, as this may increase
the risk of a fall. Stair assessment is one of the important
determinants in discharge planning for patients who live in
homes with stairs. Two-step, 3-step, 11-step, and 12-step stair
climb tests are most commonly used for research purposes;
however, stair assessment can be modified, based on individual environmental situations. The normal stair-climbing
speeds range from 1.1 to 1.7 steps per second for older adults.
The best predictors of the stair-climbing test are gait speed and
the one leg standing test [8790, 91, 92].
Timed Up and Go Test The Timed Up and Go test (TUG) is a
simple and reliable tool that assesses a patients lower extremity function, mobility, and fall risk. In order to perform the test,
the patient is instructed to get up from the chair and walk for
3 m, with or without assistive devices, then turn and walk back
to the chair. The time is recorded in seconds (s), and the averages of two trails are summed. TUG scores of <10, >15, <20,
and >30 are interpreted as independent in safe mobility, frequent fallers, independent mobility but requires gait aid, and
dependent on transfers, i.e., needed help to enter/ exit shower
or tub and did not go out alone, respectively, excluding TUG
scores of <10 s for patients with multiple impairments, who
are at greater risk of falls. The TUG scores will decrease over
the course of balance exercises and ambulation in an acute
care setting. Assessment of mobility aids, such as walkers, is
recommended if the patients TUG scores are >15 s, to prevent
falls [9395].

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.

Curr Geri Rep


Table 5

Elderly Mobility Score interpretation [9699, 100, 101]

Score

Functional level

Possible destination

<10

Poor mobilitydependent in mobility; require assistance with basic ADL

Nursing home

1014

Independent in ADL and indoor locomotion and may need help at times

Home with help/residential care

>14

Independent mobilitygood balance and mobility and basic ADL

Home without the need for care package

ADL activities of daily living

One-person assistance: The patient requires less than 25 %


continuous manual assistance for safe ambulation to prevent
falls.
Two-person assistance: The patient requires 26 to 50 %
continuous manual assistance for safe ambulation to prevent
falls. Wheelchairs can be followed for safety. If the patient
requires greater than 50 % manual assistance, the patient fits
in to parallel bar walking.
Barthel Index The Barthel Index (BI) assess the patients
ability to perform ADL, such as feeding, dressing, personal
hygiene, bowel control, bladder control, wheelchair transfer to
and from bed, toilet transfer, bathtub transfer, walking on level
or being propelled by wheelchair, and ascending and descending stairs. Scores ranges from 0 to 100 for dependent to independent in ADL, respectively. The Barthel Index has also
been used to determine the effectiveness of intervention in
cancer patients [106, 107].

quality of life in cancer patients; however, the European


Organization for Research and Treatment of Cancer Quality
of Life Questionnaire (EORTC QLQ-C30) is a widely used
scale to assess the quality of life of cancer patients and contains the following five subscales: functional scales, symptom
scales, global health status, and quality-of-life scale. The
EORTC QLQ-C30 includes several single-item symptom
measures and has a total score range from 0 to 100. Higher
scores indicate better levels of functioning in functional and
global quality of life, whereas higher scores in the
symptom-oriented scale indicate more severe symptoms.
The baseline global QoL and physical function provide useful
prognostic information in cancer patients [112116]. The
EORTC QlQ-C30 is not feasible to incorporate in routine
clinical practices. The Edmonton Symptom Assessment
Scale (ESAS) allows the clinician feasibly assess well-being
of cancer patients.
Assessment of Personal and Environmental Factors

Functional Independence Measures Functional Independence


Measures (FIM) are reliable and valid tools to measure the
functional outcome of cancer patients in acute care settings.
FIM consist of 18 items (self-care, 6 items; sphincter control,
2 items; mobility, 3 items; locomotion, 2 items;
communication, 2 items; social cognition, 3 items) on
7-point ordinal scale, and a score of 1 indicates total assistance
and 7 denotes independence. The total scores vary from 18 to
126. FIM also help to assess the functional recovery of cancer
patients following intervention. FIM scores less than 50 indicate that the patient is dependent in self-care activities and a
patient with FIM score >90 will be independent with most
activities of daily living, and most likely discharged to home
[108111].
Assessment of Quality of Life The quality of life components
are overlapping in most of the ICF domains. The goal of
therapy in cancer patients is prolonging their survival without
negatively impacting their quality of life (QoL), especially
those with advanced cancer. The use of HRQOL data, along
with clinical information, led to the development of new standards of care. Research consistently revealed that physical
exercise has positive effects on the quality of life of cancer
patients. There is no gold-standard scale available to assess the

Personal Factors A comprehensive subjective examination


provides information regarding personal factors that may influence the assessment and effectiveness of treatment. For
example, depression can affect a patients participation and
negatively influence treatment outcomes.
Environmental Factors These concerns the patients living
or working environment and how well she or he will function
in real-life situations. They also provide potential points to
discuss with other health professionals. For example, a physiotherapist can liaise with an occupational therapist to discuss
the option of a stair lift or ramp for those patients who demonstrate impaired stair-climbing ability but live in a house or
an apartment with multiple stairs. Modification of the environment may facilitate physical function.
The Subjective examination is a simple way to identify the
symptoms experienced by the cancer patients that helps to
identify the impairments as well as the factors (e.g., physical
or environmental or personal factors) that limits their physical
function. A comprehensive subjective examination should include demographic data such as gender, sex, marital status,
living arrangements, smoking and alcohol habits, the history
of the present illness, medical or surgical history, medication

Curr Geri Rep

use, prior level of physical function (including activities of


daily living (ADL), instrumental activities of daily living
(IADL), walking, stair climbing, and the use of mobility aids
or any other equipment used in the home, such as bed rails,
raised toilet, commode, versa frame, or stair lift) and the patient goal to help the physiotherapist design an effective
patient-specific physiotherapy treatment and the equipment
needed upon discharge. The pre-admission physical and functional status help the therapist to determine the risk of further
functional decline associated with hospitalization.
Additionally, the use of assistive devices, such as canes and
walkers, having two or more co-morbidities, previous hospitalization in the last 12 months, and taking five or more medication are strong predictors of functional decline [115117].

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.

Compliance with Ethical Standards

16.

Conflict of Interest Venkadesan Rajendran and Deepa Jeevanantham


declare that they have no conflict of interest.

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.

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