The impact of inpatient rehabilitation on outcomes for patients with cancer
Background Patients with cancer have challenges around mobility, activities of daily living, and self-care.
Objective To report outcomes of patients who received radiation therapy while on an inpatient rehabilitation facility (IRF).
Methods 61 patients admitted to an IRF with either a primary malignant brain tumor, tumor metastatic to the brain, tumor metastatic to the spine with spinal cord injury, or tumor metastatic to bone. Each patient required radiation therapy. The study notes the outcomes of 69 patients admitted with stroke and 23 patients admitted with a traumatic spinal cord injury. Each patient was offered therapy in accordance with the Center for Medicare and Medicaid Services guidelines. Level of function was assessed using Functional Independence Measure. Outcome measures were improvement in function, functional level at discharge, length of stay, and percent discharged to home.
Results The patients in the cancer group had significant improvement in function. More than 75% of the patients with cancer returned to their homes. The functional level achieved by patients with primary malignancies of the brain or tumors metastatic to the brain was not significantly different than that of patients with stroke. The functional level achieved by patients with cancer metastatic to the spine was not significantly different than that of patients with a traumatic spinal cord injury. The percent of patients with cancer discharged to home was not significantly different than that of patients without cancer.
Limitations The study reports outcomes from only 1 IRF.
Conclusions Comprehensive care that includes radiation and rehabilitation at the IRF level benefits appropriately selected patients with cancer.
Accepted for publication June 12, 2018
Correspondence George Forrest, MD; georgemcv78@gmail.com
Disclosures The authors report no disclosures/conflicts of interest.
Citation JCSO 2018;16(3):e138-e144
©2018 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0409
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We report improvement in total FIM, motor FIM, and cognitive FIM scores and were able to identify all 18 of the items of the FIM score on 60 of the 61 patients in the cancer group. Improvement in total FIM of the 61 patients in the cancer groups was significant at P P P = .05. Just over 75% of the patients in the cancer group had sufficient enough improvement in their level of function that they were able to return to their homes (Table 1). The average FIM score at the time of discharge was 83.08. This was not significantly different than the level of function of patients discharged after stroke (87.52) or traumatic spinal cord injury (89.13).
The patients with primary brain tumors were younger than the patients with cancer metastatic to the brain (P = .013). The patients with a primary brain tumor had lower admission FIM scores than patients with tumors metastatic to the brain (P = .027). The patients with a primary brain tumor had a greater increase in FIM score than patients with metastasis to the brain (P = .043; Table 2). There was not a significant difference between these 2 groups in FIM score at discharge or in the likelihood of discharge to home (Table 1). The FIM efficiency score was 1.12 for the patients in the primary brain tumor group and .80 in those with metastasis to the brain. This difference was not significant P = .96.
There were 69 patients in the stroke group. We compared the 39 patients with primary or metastatic brain lesion to the stroke group. The patients with primary or metastatic cancer of the brain were younger than the patients with stroke, 60.4 years old versus 69.1 years old (P = .004). The patients in the combined cancer group had a higher admission FIM score compared with the stroke patients (68.4 vs 63.12; P = .05). The discharge FIM scores were 83.3 in the combined cancer group and 87.5 in the stroke group (Table 1). This difference was not significant, but the improvement in the combined cancer group (14.6) was less than the improvement in the stroke group (24.40; P = .002) (Table 3).
The average LoS in the IRF was 18.7 days in the combined cancer group and 16.8 days in the stroke group. This difference was not significant. An average of 82% of the patients in the primary tumor or brain metastasis group and 85.5% of the patients in the stroke group were discharged to home. This difference was not significant. The FIM efficiency score of the patients in the stroke group was 2.0. This was significantly greater than the score for the patients in the metastasis to the brain group (0.80; P = .044) but not significantly greater than the primary brain cancer group (1.19; P = .22).
There were 23 patients in the traumatic spinal cord injury group. A comparison of the patients with tumors metastatic to the spine and patients with traumatic spinal cord injury showed that the patients in the cancer group were older (60.27 and 42.70 years, respectively; P = .001). In all, 80% of patients with tumors metastatic to the spine were men. This was not significantly different from the percentage of men in the traumatic spinal cord injury group (82.6%; Table 1). The admission FIM score of the patients with cancer was 66.5 (standard deviation [SD], 13.3) and 58.03 (SD, 15.1) in the patients with a traumatic spinal cord injury (Table 1). The FIM score at discharge was 80.4 (SD, 19.1) in the patients with cancer and 89.1 (SD, 20.3) in the patients with a traumatic spinal cord injury (Table 1). Neither of these were statistically significant. The improvement in patients with cancer was 13.9 (SD, 12.2) and 31.1 (SD, 13.9) in the traumatic spinal cord injured patients. This difference was significant (P
The median LoS was 18.98 days in the cancer metastasis to spine group (interquartile range [IQR] is the 25th-75th percentile, 12-30 days). In the traumatic group the median LoS was 23 days (IQR, 16-50 days). This difference was not significant (P = .14 Mann-Whitney test). The mean FIM efficiency score was 1.46 in the traumatic spinal cord injury group and .78 in the group with cancer metastatic to the spine. This difference was not significant (P = .72). Sixty percent of the patients in the cancer group were discharged to home, and 87% of patients in the traumatic spinal cord group were discharged to home. This difference was not significant (P = .12; Fisher exact test).
As far as we can ascertain, this is the first paper that has looked at the outcomes of patients receiving rehabilitation concurrent with radiation of the long bones. The average improvement in FIM was 12.4 (Table 1). The LoS was 11.6 days, and the FIM efficiency was 1.25. In all, 71.4% made enough progress to go home.
Of the total number of cancer patients, 18% were transferred to the acute medical service of the hospital (Table 1). Neither age, sex, type of cancer, nor admission FIM score were associated with the need for transfer to acute hospital care. Change in FIM score was inversely associated with transfer to acute hospital care (P = .027). Patients whose function did not improve with rehabilitation were most likely to be transferred back to acute hospital care.
