Monday, April 08, 2019 JAMA Oncology: Telerehab Makes a Difference in Patients With Advanced-Stage Cancer "Collaborative telerehabilitation" isn't a regular part of care for patients with advanced-stage cancer, but maybe it should be, say authors of a study recently published in JAMA Oncology (abstract only available for free). They found that the approach, which combines remotely delivered rehabilitation instruction with outpatient physical therapy and regular communication, can reduce pain, improve function, shorten hospital says, and decrease the use of postacute care facilities. The findings are based on results from the Collaborative Care to Preserve Performance in Cancer (COPE) program, a randomized clinical trial designed to address what the JAMA authors describe as a "knowledge gap" in the application of collaborative care models (CCMs) focused on patient function. The COPE trial includes patients with stage III or IV solid or hematologic cancer with a life expectancy of more than 6 months, and who reported moderate functional impairment (a score of 53-60 on the Activity Measure for Postacute Care assessment, or AM-PAC). The 516 participants in the study were divided into 3 groups studied over 6 months: a control group that was encouraged to self-report on pain and function via telephone or web-based surveys (every other week for the first month and monthly thereafter), an "arm 2" group that received a collaborative telerehabilitation program led by 2 physical therapist (PT) fitness care managers (FCMs) with 15 years or more of specialization in cancer rehab, and an "arm 3" group that added pharmacological pain management to the collaborative telerehab model, overseen by a nurse pain care manager (PCM). The collaborative telerehabilitation model put patients in touch with FCMs who provided instruction on "an incremental pedometer-based walking program" as well as the Rapid Easy Strength Training (REST) resistance training program, individualized based on patients' physical impairments. Participants also reported to the FCMs on pain and function, where FCMs "encouraged the use of compensatory strategies and initiated rehabilitative analgesic modalities when indicated," authors write. The participants in the telerehab model also were referred to local outpatient PTs "to further adapt their conditioning and analgesic regimens," with the outpatient PTs and FCMs working together to advance step and REST goals. Participants in arm 2 reported on progress, pain, and function weekly for the first month of the study and were then allowed to drop back to every other week or even once a month. FCMs received an alert if participants reported loss of function or increased pain, or if they failed to achieve the recommended 4 REST sessions per week. The arm 3 participants received the same rehabilitation approach but at the direction of a PCM, with the only real difference being that during the monitoring phase participants could request a call from the PCM, who could recommend the prescription of pharmacological treatments to address pain and function. Among the findings: Physical function, as measured by the AM-PAC, improved for the arm 2 and 3 groups versus control by about 1.3 points—a difference that exceeded the minimum clinically important difference (MCID) threshold of 1 point. Both the arm 2 and arm 3 groups reported clinically significant, albeit similar, reductions in pain compared with control as measured by the Brief Pain Inventory—pain interference dropped by 0.4 for arms 2 and 3, while pain intensity dropped by 0.4 for arm 2 and 0.5 for arm 3. When it came to quality-of-life measures, a slightly different picture emerged: arm 2 telerehab-only participants reported significant improvement over control via the 5-item EQ-5D-3L assessment, but arm 3 participants (telerehab plus pain management) did not. Hospitalization days were on average 57% higher for the control group (7.4 days) than for arm 2 participants (4.2 days), and 18% higher than for arm 3 participants (7.2 days). Authors note that the differences had to do with shorter, not fewer, hospitalizations in arms 2 and 3. Among patients who were hospitalized, arms 2 and 3 were 4.3 times more likely to be discharged home than was the control group. "Although modest, the COPE interventions' effect sizes of 0.23 for mobility and -0.24 for pain are nonetheless notable given the remote, low-touch delivery; the known positive effect of the control condition; and the trial's vulnerable, high-needs participants," authors write. "Furthermore, our findings agree with reports suggesting that surprisingly modest functional losses and gains among individuals with borderline dependency…can profoundly affect their requirement for inpatient care." The researchers were surprised by the data that showed the addition of pharmacological pain management to be less effective than telerehab alone when it came to improving function and about equally effective in decreasing pain. They believe more study is needed but speculate that the greater reliance on nonpharmacological approaches in both arms, as well as a "more seamless integration of pain- and function-directed treatments in arm 2, may have contributed to the outcomes. Authors also note that in addition to reduced pain and improved function, results of the COPE trial shed more light on possible avenues for reining in the costs of care for individuals with late-stage cancer. "Our findings of reduced hospital use among participants in the telerehabilitation arms add to growing evidence that proactively addressing functional impairment among vulnerable patients reduces hospital utilization," authors write "Reducing the requirement for institutional care among patients with late-stage cancer has the potential for high financial return given that hospitalizations account for a large proportion of health care spending in this population, drive regional variation in costs of care, and are not associated with survival or [quality of life]." Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.