Rehab and Pall Med. What we ll go over. Rehabilitation 11/13/2014. Chirag Patel, MD Palliative Medicine

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1 Rehab and Pall Med Chirag Patel, MD Palliative Medicine What we ll go over Rehab needs in pall care patients Disability Assessment Interventions Rehab in different settings What patients find helpful Rehabilitation Multidisciplinary process that aims to maximize physical and emotional well being, enhance social participation, and minimize caregiver distress Wang and de Jong Improve quality of life Helps people regain function Live independently Facilitates adaptation to disability Psychosocial wellbeing 1

2 Rehab and palliative care Goals are broadly congruent Maintain an optimal quality of life holistic approach physical psychosocial spiritual Differences in emphasis Rehab: actively promote function and independence Palliative Care: more concerned with managing deterioration and the dying process Rehab needs in pall med Pall care patients have high levels of functional loss dependency on ADLs mobility dysfunction Disability is related to deconditioning fatigue therapy complications malnutrition neuro/msk problems pain bowel/bladder dysfunction thromboembolic disease depression other comorbidities Rehab needs in early pall med General oncology service inpatients 35% of cancer patients experienced functional loss due to physical weakness 32% required assistance with ADLs 23% experienced difficulty with ambulation 7% had deficits in transfers Lehmann 2

3 Rehab needs in late pall med Physical function deteriorates during last 2 months of life Dependence in self care increases Leisure and household/working activities Impacts ability to derive pleasure from daily activities Elmqvist Disability s effects Disability affects many aspects of life Depression Increased caregiver needs Increased healthcare utilization Increased need for institutionalization Predictors of QOL for cancer patients and spouses Physical strength Hours spent in bed Ability to do what one wants Disability is concerning Multiple papers support findings that loss of ability to manage daily activities is a matter of concern for palliative patients 3

4 Disability is concerning Deteriorating function Among patients most distressing concerns Unwanted dependency Threatens dignity Loss of ability to participate in daily activities Disability is concerning 5 most prevalent problems in palliative care population Not being able to continue usual routines 51% Experiencing physically distressing symptoms 48% Not being able to carry out important roles 38% No longer feeling like who I once was 36% Not being able to perform tasks of daily living 30% Chochinov Disability is concerning Reasons for desiring death and interest in physician assisted suicide Progressive debility Being a burden to others Perception of increasing dependency is a strong predictor of patient s interest in physician assisted suicide 4

5 Minimizing disability Patients express desire to remain physically independent during course of disease Nursing home patients views on dignity Hall independence was prized maintaining pride in oneself sense of normalcy feeling valued by others Minimizing disability Survey of families of patients who died in a pall care unit in Japan Problems during hospital stay included Pain Impaired mobility ADL impairment 85% of patients wanted to be able to walk or move about with a wheelchair Okamura Minimizing disability Rehabilitation can help reduce the burden of care for caregivers improve overall QOL increase satisfaction of care increase functional status reduce pain reduce anxiety 5

6 Identifying rehab indications Up to 65% of inpt/outpt cancer pts show rehab indications pain lymphedema incontinence respiratory problems musculoskeletal problems mobility problems Only 12.8% receive PT Identifying rehab indications Poor congruence b/w pt report & clinical records discrepancy b/w patient reports on questionnaire and physician documentation of functional problems symptoms: 49% functional problems: 6% walking problem: 23% difficulty getting in/out of bed and ADLs: 0% Identifying rehab indications Why? patients reluctance to raise functions concerns may be deemed ineligible for therapy oncologists have limited time Similar to pain patients desire to be a good patient wishing to deny possible evidence of disease progression lack of an easily available rehab referral and treatment infrastructure 6

7 Physician barriers Differences in attitudes b/w fields can be a barrier to advanced cancer patients receiving rehab services Survey of oncologist and physiatrists regarding cancer patients whose prognosis was 6-12 months Spill 2012 Physician barriers Referrals and admissions for acute rehab oncologists: more likely to refer patient to rehab for emotional/psych benefit of pt/family physiatrists: more likely to accept a patient for family education tightened admission standards for inpt rehab still need patient to participate (example: to direct care) Spill 2012 Physician barriers Referrals and admissions for acute rehab physiatrists were less likely to use prognosis to determine eligibility for inpt rehab instead shortened time in rehab facility numerous studies on rehab of cancer patients have shown shorter LOS than pt with similar impairments of other diagnosis Poor cross training between fields Spill

8 Patient assessment for rehab Disease information location, stage, therapies, life expectancy, comorbidities, symptoms, medications, nutrition, physical function Home and community support systems Physical exam neurological and musculoskeletal exam Patient assessment for rehab Health related quality of life incorporates physical health, psychological state, personal beliefs, interpersonal relationships, and social participation aspects common to pall med and rehab Measures of physical function used in rehab to identify intervention outcomes also muscle strength and independence (FIM) Patient assessment for rehab Functional assessment scales can help Karnofsky Performance scale Palliative Performance scale Eastern Cooperative Oncologic Scale Edmonton Functional Assessment Tool Katz Activities of Daily Living Lawton Instrumental Activities of Daily Living Barthel Index Functional Independence Measure 8

9 Patient assessment for rehab Difficulties with identifying functional issues PE findings and FIM scores don t correlate FIM is highly weighted to functional activities Rather than individual components of the functions like finger strength Need to develop better function based physical exam Patient assessment for rehab International Classification of Function, Disability, and Health commonly used in rehabilitation not much use in palliative care Patient assessment for rehab Dietz Classification for cancer rehab Preventative prevent deconditioning and contracture Restorative return to premorbid level of function Supportive return home, remain active even with lower function Palliative hospice level 9

10 Patient assessment for rehab: Dietz 1. Rehab before and after surgery early postoperative ambulation improvement of physical function goal to return to lives as prior to surgery 2. Rehab during chemotherapy encourage ambulation/prevent disuse make movement a habit, no matter how much Patient assessment for rehab: Dietz 3. Rehab during recurrence/advanced stages less movement due to malaise/fatigue disuse syndrome develops 4. Rehabilitation during terminal stage teach family members how to assist with ADLs environmental modifications ROM, massage Rehab interventions Underdeveloped research into effective ways of helping patients manage declining physical function and disability Hampered by familiar methodological challenges in end of life research Vulnerable population, difficulty with recruitment, attrition, and outcome measurement 10

11 Rehab interventions Need for rehab has been identified Few reports demonstrating effectiveness studies have incomplete reporting and methodological flaws Minimal studies on outcomes in palliative medicine rehabilitation Variation in specific interventions Rehab interventions Lack of guidance most common barrier by PT in recommending or using exercise in clinical practice optimal type intensity mode of exercise Rehab interventions PT evidence is underdeveloped OT evidence is almost near absent Cancer nutrition rehab program initially envisioned self care deficits interventions actually ended up intervening more on leisure (54%) productive activities (employment, housework) (32%) ADLs (14%) 11

12 Rehab interventions Specific exercise interventions vary 28 day inpatient multidisciplinary program outpatient PT led sessions self managed home program guided by written information patients naturally occurring physical activity Choice of program is driven by resources available Rehab interventions Models for therapy in pall med Traditional rehabilitation daily to several times/week moderate to high intensity goals to achieve improved function SNF or inpatient rehab or home PT Rehab Light similar but more gradual weekly or biweekly greater emphasis on home exercise program clinic, home health, or hospice setting Rehab interventions Models for therapy in pall med Rehabilitation in Reverse progressive decline causes increased dependency backwards progression independence cane walker wheelchair bed Case Management supervise a care plan which is followed by unskilled caregivers follow up visits Functional assessment caregiver assist techniques updating home exercise programs monthly/bimonthly visits in hospice programs fit this model 12

13 Rehab interventions Models for therapy in pall med Skilled Maintenance infrequently used model of care for therapy occasional patient with therapy needs due to complexity of assistance required despite not making progress towards independence Supportive Care primary model in hospice therapy physical and emotional support gentle ROM, massage, edema management Role of PT, OT, and Speech Role of PT, OT, and Speech 13

14 Role of PT, OT, and Speech Acute inpatient rehab Goals of inpatient rehab for cancer patients Goal of d/c home Revised goals for dynamic lesions Family training prioritized Acute inpatient rehab Mean length of stay 11.1 days Discharge destinations Home 76% Acute care service 17% 33% of leukemia patients 50% of bone marrow transplant patients SNF 4% Palliative Care 2% LTAC 1% Shin

15 Acute inpatient rehab Rehab unit stays benefit patients with cancer significant functional gains in cancer patients at freestanding rehab hospital spinal cord tumor patient make significant functional gains Maintain those gains over 3 months Acute inpatient rehab Rehab unit stays benefit patients with cancer brain tumor vs stroke patients functional outcome is similar rate of discharge to community is similar shorter rehabilitation length of stay brain tumor vs TBI daily functional gains were similar Hospital unit based rehab Consult team with physiatrist, PT, OT, social services rep, chaplain seen twice a day (PT and OT) Functional improvements occurred in short period of time less for those with metastatic disease differs from other studies Sabers

16 Pall care unit rehab Japanese unit in 1994: 26% Ireland unit in 2012: 65% Wisconsin unit in 2003: 37% Michigan unit in 2009: 3% Cobbe 2012 Pall care unit rehab--ireland Referral rate to PT was 65% Wide functional variation Fully independent to bedbound Education and psychologic support was likely under documented Cobbe 2012 Pall care unit rehab--wisconsin Referral rate was <40% influenced by patients functional status at admission more functional more likely to get PT Increasing weakness was reason for d/c from PT program in 70% of patients 56% of patients who received PT showed functional improvement by week 2 Higher albumin was correlated to more likely to improve As was presence of underlying dementia Montagnini

17 Rehab for hospice patients Studies suggest rehab unit stays benefit hospice patients survey of caregivers at a hospice rehab program 78% were satisfied with the rehab program 63% found rehab to be effective Yoshioka inpatient rehab benefited weak/elderly cancer patients transitioning from curative to palliative Scialla care Rehab for pall med patients Studies suggest rehab unit stays benefit our patients improvement in Barthel Mobility Score in 63% of hospitalized cancer patients Sabers patients judged by oncologist as able to achieve more aggressive treatment goals tend to make larger FIM-motor gains than those with less aggressive treatment goals Cole Rehab for pall med patients Inpatient rehab for severe COPD inpatient pulmonary rehabilitation decrease psychosocial concerns Guell exercise capacity and quality of life Home rehab for severe COPD exercise tolerance and quality of life lasted 6 months Hospital based rehab for CHF patients supervised exercise/rehab program functional and hemodynamic parameters Resqueti Freimark 17

18 Do patients complete rehab Review of patients with active/prior cancer: 63% of patients started a rehab program adherence (84%) and completion (87%) were high ~1/2 of patients offered a program completed one may need to consider modifying existing programs Maddock Willingness to participate in rehab Patients with <3month life expectancies were willing/able to do a 6wk group exercise program 63% were willing to participate others: lack of energy and mobility, burdensome getting to hospital Supporting patients during rehab Important to involve patients in setting goals of therapy counterbalance feeling of lack of control External motivation when tired/down Staff behaviors encourage independence promote sense of pride and not being a burden avoid reinforcing disabled identity support view of worthwhile, resourceful individual 18

19 Not a smooth transition to disability Adjusting to disability patients appreciated equipment to maintain functional well being also concerned about self image and negative connotations of dependence and disability patients noted support was concentrated around time of diagnosis and treatment consequences of disability became more apparent after this phase Malassiotis What pall med patients like about rehab Themes noted by interviewers Routines of everyday life something to do being together with others in similar situation Less fatigue Professional guidance therapist as a teacher therapist as a motivator Hope Patient priorities for rehab goals What do you need most from rehab therapists? Schleinich

20 Patient priorities for rehab goals What do you need most from rehab therapists? Schleinich 2008 Patient priorities for rehab goals What do you need most from rehab therapists? Schleinich 2008 Patient priorities for rehab goals What do you need most from rehab therapists? Schleinich

21 Patient priorities for rehab goals What do you need most from rehab therapists? Schleinich 2008 Pall care patient s preferences Pall care patient survey preference for home based ambulation programs that could be completed alone Lowe 2010 What we touched on Rehab needs in pall care patients Disability Assessment Interventions Rehab in different settings What patients find helpful 21

22 Questions/Comments 22