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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 19-29

Early mobilization following gastro-intestinal and gynecological cancer surgeries: A clinical trial


Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission07-Jul-2020
Date of Decision30-Sep-2020
Date of Acceptance22-Oct-2020
Date of Web Publication31-Jul-2021

Correspondence Address:
Dr. Renu Pattanshetty
Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Nehru Nagar, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_17_20

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  Abstract 


Context: There has been an increase in the incidence of gastrointestinal and gynaecological cancers and advancement in surgeries has made surgical treatment more for these participants more feasible.
Aim: To evaluate the effect of structured early mobilization programs in postoperative gastrointestinal and gynaecological cancer patients on 30second chair stand test, functional assessment of cancer therapy-general (FACT-G) and length of hospital stay.
Settings and Design: This was a clinical trial conducted at tertiary care hospital on gastrointestinal and gynecological cancer patients.
Materials and Methods: Participants diagnosed with gastro-intestinal (n = 23) and gynaecological (n = 17) cancers who underwent surgery were included in the study. Lower extremity strength was assessed using 30 s chair stand test and the quality of life (QOL) was assessed using the FACT-G Scale. Length of hospital stay was noted from the postoperative day 1 till the day of discharge.
Statistical Analysis Used: Wilcoxon Test and Spearman's rank correlation coefficient test were used for analysis.
Results: Early mobilization program in postoperative gastro-intestinal and gynecological surgery participants showed improvement in the lower extremity strength in terms of 30 s chair stand test (P = 0.001). Moreover, improvements were also observed in the components of QOL viz., physical (P = 0.004), social (P = 0.041) and functional (P = 0.004) components.
Conclusion: The study findings demonstrate improvement in lower extremity strength in terms of 30 s chair stand test and QOL according to FACT-G.

Keywords: Thirty seconds chair stand test, early mobilization, gastro-intestinal cancer, gynaecological cancer, length of hospital stay


How to cite this article:
Rayani M, Pattanshetty R. Early mobilization following gastro-intestinal and gynecological cancer surgeries: A clinical trial. Indian J Phys Ther Res 2021;3:19-29

How to cite this URL:
Rayani M, Pattanshetty R. Early mobilization following gastro-intestinal and gynecological cancer surgeries: A clinical trial. Indian J Phys Ther Res [serial online] 2021 [cited 2021 Oct 21];3:19-29. Available from: https://www.ijptr.org/text.asp?2021/3/1/19/322914




  Introduction Top


Cancer is the leading cause of death globally in the 21st century, with variation in the frequency of tumor occurrence with respect to location and histology.[1],[2] Indian males present with low rates of gastric cancer and the females are positioned at the 9th rank.[3]

Gynecological cancers have shown to account for 19% of the recently predicted new cancer cases globally. In the year 2002, 2.9 million deaths had occurred among women. In the developing countries, 80% of females suffered from cervical cancers, whereas two-third of females suffered from cancer of the uterus in the developed world.[4] Cancer of uterine-cervix presents with major health problems among females, with it being the number one in India and the second commonly occurring malignant tumor in the world.[5] In gynecological cancers, surgery is often preferred as the first treatment option and it is not only used for diagnostic purposes, but in many cases, it is the most essential therapy for these gynecological cancer patients and also for patients having gastro-intestinal cancers. Surgery plays a very important role in deciding the prognosis of patients in terms of duration and quality of the continuity of the patient's life. Intra-operative and postoperative complications of a surgical procedure have an important effect on the immediate postoperative duration and quality.[6]

Surgery for gastric cancer patients has shown to have high-risk due to stresses and complications caused following the surgery. Morbidity among radical gastrectomy patients ranges from 20%–46% to 0.8%–10% of mortality is observed in these patients.[7]

The readmission rates of patients who have undergone gastrointestinal operations are much higher than those with other types of medical conditions or nongastrointestinal operations. A much greater understanding now exists in the pathogenesis of the disease, thus adding to more compelling prevention strategies over the years. One such cost-effective strategy for disease prevention is the incorporation and maintenance of regular physical into individual's day-to-day routines.[8]

Patients are not always mobilized early since there are no specific guidelines which are specifically performed in patients who have undergone such surgeries. Failure to commence early mobilization leads to inadequate pain management and other problems leading to a lack of motivation to perform any physical activity. All these factors lead to a lack of follow-up by increasing patients' length of hospital stay. There are minimal guidelines available to postoperative patients during their hospital stay, which can be a contributing factor to their sedentary state, resulting in increased deconditioning and prolonged their recovery phase.[9] The present study hypothesized that early mobilization will help in reduction in hospital stay and improvement in the quality of life (QOL) in such postoperative patients.[7]


  Materials and Methods Top


Study design and setting

This experimental study was conducted in a tertiary care hospital. Ethical clearance was obtained by the Institutional Ethical Review Committee before the commencement of the study. Participants were then screened as per the inclusion and exclusion criteria. All male and female participants in the age group of 18–60 years diagnosed with gastrointestinal and gynecological cancers (Stage 1, 2, or 3 as per TNM staging) and who had undergone surgeries, willing to participate in the study were included. Participants with any comorbid medical illness or psychiatric illness that would impede completion or interfere with the treatment protocol, evidence of distant metastasis, and currently undergoing radiotherapy treatment were excluded from the study [Figure 1].
Figure 1: CONSORT flow chart of participant recruitment process for the study

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Description of the participants

Forty adult male and female participants who had undergone surgery for gastro-intestinal (n = 23) and gynecological (n = 17) cancer were included in the study.

Procedure

Each participant was explained the purpose of the study in vernacular language and a consent was taken from them. The demographic data of all participants were noted.

All participants were administered the functional assessment of cancer therapy-general (FACT-G) Questionnaire and the number of hospitalization days and 30 s chair stand test were assessed on day 1 and at the time of hospital discharge.

Intervention protocol/exercise protocol

The intervention or the exercise protocol was administered to all the participants till the day of the discharge [Annexure 1].

Outcome measures

Number of days of hospitalization after surgery

It was termed as the time spent in the hospital from the date of surgery up to the date of discharge.

Thirty-seconds chair stand test

The participants had to sit at the back of their chair, with both feet in contact with the ground and with arms across their chest. They were then instructed to perform sit to stand and vice versa for 30 s.[10]

Functional assessment of cancer therapy-general questionnaire

QOL was assessed using FACT-G questionnaire. This questionnaire consists of 33 questions under four sub-domains, i.e., Physical, Social, Emotional, and Functional well-being. The FACT-G Questionnaire demonstrates high coefficients of reliability and validity with the Cronbach's alpha of the total scale is 0.89, and subscales range from 0.82 to 0.69.[11]

Statistical analysis

Statistical analysis was performed using SPSS version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Nominal data, including demographic data of all participants, were analyzed for simple frequency and percentage. With a study power of 80%, probability values of <0.05 (P ≤ 0.05) were considered statistically significant Comparison of 30 s chair stand test and FACT-G in all participants was made using the Wilcoxon Test and comparison of the two cancer groups in terms of QOL using the individual components of FACT-G Scale was done by Spearman's rank correlation coefficient.


  Results Top


The present study included 40 participants, including both male and female participants who underwent surgery for gastro-intestinal and gynecological cancers [Table 1]. All of them received structured early mobilization program following surgery till their discharge. The comparison of 30 s chair stand test and QOL among all the participants showed statistical significance with P = 0.001 [Table 2]. The 30 s chair stand test showed a significant improvement (P = 0.001) after the study. All components of QOL showed statistical improvements (P = 0.001) except for the emotional component [Table 3].
Table 1: Demographic profile of all the participants (n=40) in the study

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Table 2: Comparison of 30 s chair stand test and functional assessment of cancer therapy-general in participants with gynecological (n=17) and gastro-intestinal (n=23) cancers in the study

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Table 3: Comparison of the two cancer groups in terms of quality of life using individual components of functional assessment of cancer therapy-general scale

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  Discussion Top


The impact of prehabilitation on the recovery of functional exercise capacity in patients undergoing colorectal resection for cancer have been well documented. It is believed that the preoperative period may represent a more appropriate time than the postoperative period for intervention. The intervention of moderate aerobic and resistance exercises, nutritional counseling, and relaxation exercises initiated either 4 weeks before the surgery or immediately after surgery has proved to be beneficial. A decrease in hospital stay with a structured early mobilization program has also proved to be. However, using a large sample size would provide a piece of better evidence to prove the same.[12]

Surgical stress responses increase cardio-vascular demands is a known fact.[13] Regaining physically in the postoperative cancer population is important since their independence and QOL are essential for surgical recovery and physical function. Treatments after chemo or radiotherapy are largely dependent on the functional status of the patient.[7] The result of the present study is consistent with the results of the above-mentioned study, which included structured early mobilization protocol.

Postoperative patients are at high risk of long periods of bed rest, which has been associated with poor pain management, insulin resistance, loss of lean muscle mass, and amelioration of surgical stress response, which is detrimental for their health status, slowing down the recovery process. To initiate strategies for minimizing bed rest in postoperative phase, an early mobilization program favouring enhanced recovery after surgery is always beneficial. The benefits offered to the patients immediately postoperatively, a structured early mobilization program that initiated immediately within 24 h after the surgery was implemented in the present study. Reducing complications after surgery and improving overall outcomes including QOL.[8]

Core strengthening exercises have shown to greatly influence the exercise prescription in many ways. Core strengthening exercises not include only a single body segment but involves the body as the centre of all functional movements of the upper as well as lower extremities.[14] This was the reason for including core strengthening exercises in the present. Improvement in the muscle strength was observed in the lower extremity in the present study suggesting that resistance training using thera band has shown to be beneficial in improving muscle strength and maintaining body composition in cancer patients undergoing neoadjuvant and adjuvant therapy in the early rehabilitation phase.[15] Using 30 s chair stand test as an outcome measure for lower limb strength has proved beneficial in community-residing older adults.[11]

Measuring QOL is gaining importance in cancer care. The functional assessment of cancer therapy questionnaire with the colorectal module FACT-Colorectal and EuroQol (EQ-5D) questionnaire has demonstrated that higher the TNM stage of the tumor, greater is the association with an increased state of postoperative anxiety and poorer emotional well-being.[13] These results are in consistence with results of the present study as well.

The improvements in the individual components of QOL viz., physical, social, and functional components have demonstrated statistical significance. This could be the effect of early mobilization on the removal of the indwelling catheter, which is inserted postoperatively to prevent postoperative urinary retention. The urinary catheter is known to causes discomfort, pain, and anxiety to the patient. Interfering with the physical functioning of the patient.[16]

Contradictory to the results of the present study, the effect of early mobilization and diet after laparoscopic colon surgery has shown no improvement in the length of hospital stay after the rehabilitation program. The length of hospital stay was not a significant post structured early mobilization program in gastro-intestinal and gynecological patients. This may be explained within the time to discharge vary among countries because of differences in the health-care services, including Indian set up. However, in a country like India, patients may wish to get discharged sooner due to a lack of medical insurance coverage.[17] However, in a developing country like India, there is a focus on reducing postoperative stay and hence the medical costs to optimize the utilization of health care resources.

In the present study, the maximum distribution was seen in the age group of 59–68 years (32.5%) that. The age-specific incidence rate for gynecological cancers increases from 35 years of age and reaches a peak between the ages of 55 and 64.[18] Similar age trend was noticed among a study conducted in the gastro-intestinal cancer population in which the mean age group was between 50 and 70 years, suggesting gynecological and gastro-intestinal cancers are more common among the older age group.[19] In addition, treatment for the older population is frequently discontinued as the physicians feel that the older population will not be able to tolerate the side effects of cancer treatment therapies.[20]

One of the reasons for low body mass index (BMI) could be cancer cachexia, which is associated and most commonly seen in gastrointestinal, lung, and prostate cancer patients.[8] Most of the participants in the present study had a BMI of ≤25, suggesting cancer cachexia as a common symptom in such patients.

Due to late diagnosis, the absence of highly curative chemotherapy and a high degree of molecular heterogeneity in ovarian tumors, there has been a steady rise in these tumors. A similar observation was made in the present study in which the ovarian cancer participants were the highest in number (n = 11).[21] Within the gastro-intestinal group, majority of the participants suffered from cancer of the stomach (n = 9). Cancers of the stomach are mostly related to diet and food preservation, such as high intake of salt-preserved foods and dietary nitrate or low intake of fruit and vegetables.[22] Diet has also been shown to play a major role in gastric carcinogenesis. In India, the risk factors for stomach cancers include Helicobacter pylori infection, salted tea, pickled food, rice intake, spicy food, soda, tobacco, and alcohol as risk factors for gastric cancer.[23] Although the risk factors of the same were not studied, the above-mentioned risk factors may be the causative factors for the same. Majority of participants in the present study were in the cancer Stage III. Studies have shown that in India, two-thirds of the patients are affected with cancer, usually presenting in its advanced stages. This is largely due to the scarcity of infrastructure, lack of health-care providers, illiteracy, and lack of awareness among the general population regarding the effects and use of tobacco and leading to a delay in seeking medical attention.[24],[25]


  Conclusion Top


To conclude, the results of the present study have demonstrated significant improvements in terms of improved lower extremity strength and QOL using a structured early mobilization program implemented immediately postoperatively in gynecological and gastro-intestinal Cancers. Although the study included a small sample size with a heterogeneous population, similar studies may be carried out in a larger population with different cancer populations in a similar clinical setting.

Acknowledgment

The authors are grateful to the Medical Director, tertiary care hospital, for granting us permission to conduct the study, Mr. Javali, for helping us out with the statistical analysis of the data. The authors wholeheartedly thank all the participants for agreeing and giving consent for being a part of the early mobilization protocol without whom the study would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexure Top


Annexure 1: Early mobilization protocol


  First Phase Top


This phase included routine chest physiotherapy postoperatively, which consisted of nebulization and airway clearance techniques (including the active cycle of breathing techniques).

Supervised exercises were performed 2 times/day.

(POD 1).

Stretching (neck, shoulder, wrist, ankle).

Triceps stretching

Position of the participant: Sitting.

Procedure: In sitting with the opposite side hand elbow and shoulder extension was performed by the participant to stretch the triceps. The stretch was held for 15–30 s.

Flexor compartment muscles of forearm stretching

Position of the participant: Sitting.

Position of the therapist: The therapist stood beside the participant.

Procedure: The therapist grasped the participants left arm to prevent shoulder movement after which she grasped participant's right hand and fingers. Participants elbow was extended along with the hand and fingers, which provided a stretch to the whole flexor compartment. The stretch was held for 15–30 s.


  Sternomastoid Stretchhing Top


Position of the participant: Sitting.

Position of the therapist: Therapist was standing behind the participants head.

Procedure: The therapist held the participants head with both the hands (one below the occiput and other below the chin) and performed the opposite action of the sternomastoid, i.e., opposite side flexion and same side rotation and extension of the neck. The stretch was held for 15–30 s.

Tendo-achilles stretching

Position of the participant: Supine lying.

Position of the therapist: The therapist stood beside the patient.

Procedure: The therapist held the lower thigh region of the participant with her left hand and flexed the knee. The therapist's right hand held the heel in the neutral position and slowly extended the participants knee with the left hand and dorsiflexed with the right hand. The stretch was held for 15–30 s.

Dorsiflexors stretching

Position of the participant: Supine lying.

Position of the therapist: The therapist stood beside the patient.

Procedure: Therapist placed her left hand and held the leg. The right hand held the foot and stretch was applied to the dorsiflexors. The stretch was held for 15–30 s.

Core exercise (pelvic tilt: Isometric contraction).

Pelvic tilt

Position of the participant: crook Lying.

Procedure: Participant attained a crook lying position, with hands placed at the side of the bed. The participant was asked to pull the pelvis towards the bed while isometrically contracting it. Participant had to hold this position for 10 s.

10 repetitions × 1 set was performed.

Resistance exercise using yellow theraband.

Resistance to the shoulder, arm, thigh and calf was provided using the theraband and the participant had to perform movement against the resistance of the theraband. Initially, a yellow theraband was used and was gradually progressed.

(12 repetition × 3 sets using yellow theraband and progressing gradually).


  The Second Phase Top


This phase included routine chest physiotherapy post-operatively, which consisted nebulization and airway clearance techniques (including the active cycle of breathing techniques).

Supervised exercise (twice/day).

(POD 1 ~ 3).

Stretching (neck, shoulder, wrist, ankle).

Triceps stretching

Position of the participant: Sitting.

Procedure: In sitting with the opposite side hand elbow and shoulder extension was performed by the participant to stretch the triceps. The stretch was held for 15–30 s.

Flexor compartment muscles of forearm stretching

Position of the participant: Sitting.

Position of the therapist: The therapist stood beside the participant.

Procedure: The therapist grasped the participants left arm to prevent shoulder movement after which she grasped participant's right hand and fingers. Participants elbow was extended along with the hand and fingers, which provided a stretch to the whole flexor compartment. The stretch was held for 15–30 s.

Sternomastoid Stretching

Position of the participant: Sitting.

Position of the therapist: Therapist was standing behind the participant's head.

Procedure: The therapist held the participants head with both the hands (one below the occiput and other below the chin) and performed the opposite action of the sternocleidomastoid, i.e., opposite side flexion and same side rotation and extension of the neck. The stretch was held for 15–30 s.

Tendo-achilles stretching

Position of the participant: Supine lying.

Position of the therapist: The therapist stood beside the patient.

Procedure: The therapist held the lower thigh region of the participant with her left hand and flexed the knee. The therapist's right hand held the heel in the neutral position and slowly extended the participants knee with the left hand and dorsiflexed with the right hand. The stretch was held for 15–30 s.

Dorsiflexors stretching

Position of the participant: Supine lying.

Position of the therapist: The therapist stood beside the patient.

Procedure: Therapist placed her left hand and held the leg. The right hand held the foot and stretch was applied to the dorsiflexors. The stretch was held for 15–30 s.

Core exercise (pelvic tilt: Isometric contraction).

Pelvic tilt

Position of the participant: Crook lying.

Procedure: Participant attained a crook lying position, with hands placed at the side of the bed. The participant was asked to pull the pelvis towards the bed while isometrically contracting it. Participant had to hold this position for 10 s.

10 repetitions × 1 set was performed.

Resistance exercise using theraband.

Resistance to the shoulder, arm, thigh and calf was provided using the theraband and the participant had to perform movement against the resistance of the theraband. Initially, a yellow theraband was used and was gradually progressed.

(12 repetition × 3 sets using yellow theraband and progressing gradually).


  The Third Phase Top


This phase included routine chest physiotherapy post-operatively, which consisted of nebulization and airway clearance techniques (including the active cycle of breathing techniques).

One supervised and one unsupervised exercise.

Ambulation (paced plain ground walking) without discomfort (POD 3 ~ discharge).

Stretching (neck, shoulder, wrist, ankle).

Triceps stretching

Position of the participant: Sitting.

Procedure: In sitting with the opposite side hand elbow and shoulder extension was performed by the participant to stretch the triceps. The stretch was held for 15–30 s.

Flexor compartment muscles of forearm stretching

Position of the participant: Sitting.

Position of the therapist: The therapist stood beside the participant.

Procedure: The therapist grasped the participant's left arm to prevent shoulder movement after which she grasped participant's right hand and fingers. Participants elbow was extended along with the hand and fingers, which provided a stretch to the whole flexor compartment. The stretch was held for 15–30 s.

Sternocleidomastoid stretching

Position of the participant: Sitting.

Position of the therapist: Therapist was standing behind the participants head.

Procedure: The therapist held the participant's head with both the hands (one below the occiput and other below the chin) and performed the opposite action of the Sternocleidomastoid i.e., opposite side flexion and same side rotation and extension of the neck. The stretch was held for 15–30 s.

Tendo-achilles stretching

Position of the participant: Supine lying.

Position of the therapist: The therapist stood beside the patient.

Procedure: The therapist held the lower thigh region of the participant with her left hand and flexed the knee. The therapist's right hand held the heel in the neutral position and slowly extended the participants knee with the left hand and dorsiflexed with the right hand. The stretch was held for 15–30 s.

Dorsiflexors stretching

Position of the participant: Supine lying.

Position of the therapist: The therapist stood beside the patient.

Procedure: Therapist placed her left hand and held the leg. The right hand held the foot and stretch was applied to the dorsiflexors. The stretch was held for 15–30 s.

Core exercise (pelvic tilt: Isometric contraction).

Pelvic tilt

Position of the participant: Crook lying.

Procedure: Participant attained a crook lying position, with hands placed at the side of the bed. The participant was asked to pull the pelvis towards the bed while isometrically contracting it. Participant had to hold this position for 10 s.

repetitions × 1 set was performed.

Resistance exercises using yellow theraband.

Resistance to the shoulder, arm, thigh and calf was provided using the theraband and the participant had to perform movement against the resistance of the theraband. Initially, a yellow theraband was used and was gradually progressed.

(12 repetition × 3 sets using yellow theraband and progressing gradually) Walking and sitting activities were continued.

Supervised balance exercise (once/day).

In standing, he following balance exercises were performed in supervision of a therapist and each exercise was performed for 10 repetitions.

One leg standing.

One leg calf raise.

Hip adduction

Hip abduction.

Hip flexion with knee bent.

Hip extension.

The quality of life questionnaire, length of hospital stay and 30s chair stand test were assessed before the beginning of intervention and on the last day of intervention.



 
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Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
Annexure
First Phase
Sternomastoid St...
The Second Phase
The Third Phase
References
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