Hi everyone! I am Emmeline and this is Zhuting and we are both your presenters for today. Before we start proper, let us take a moment to imagine. Imagine the day when u step into the ward and flip open your patient’s case notes. The very first thing you see is your patient’s quality of life score and immediately you know that this patient just needs a walking stick and your supervision. So our project is somewhat related to this and its title is:
What is the relationship between Quality of Life and Physical Function of Patients undergoing palliative care?
And these are the content that we are covering today.
A brief introduction and some literature reviews that we have found.
As the various key words of our title suggest, our group is working with cancer patients undergoing palliative care. Look around you and think about this, that in every 4 of us, 1 will be diagnosed with cancer and eventually die of it. However , with the advancement of medical technology, early screening and detection of cancer is possible. Early treatment can be given to more and as a result the number of cancer survivors and patients receiving palliative care has been increasing. Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. In 2008, Ministry of Health says that singapore hospices are expecting to take in more of such patients in the next 5-7 years. And the focus of treating these patients is no longer just extending their lives but to improve their quality of life as well. Quality of Life is described as being multifactorial by WHO and is commonly measured through questionnaires.
WHO defines it as a broad ranging concept affected by the person's social relationships, personal beliefs, psychological state, environmental factors, level of independence, and physical functioning. Many questionnaires measure a person’s quality of life through asking these various components. In other words, they are measured subjectively, through the person’s opinions. However, one of the factors, physical functioning can be measured objectively too. By physical tests like six minute walk test, timed up and go test and many more depending on what aspects of physical functioning are to be measured.
The various aspects of physical functioning, according to Reuben et al are, strength, endurance, agility, flexibility and balance. It has been shown that a decline in physical functioning increases the risk of distress and psychological problems. Often than not, the quality of life will decrease as well. Hence, it is important to be able to measure a person’s physical functioning. And what better way to measure it, than through objective tests that tangibly and accurately quantify the person’s physical ability. Since physical functioning is a part of quality of life, many studies have seek to find if results of physical functioning objective measures are related to the quality of life scores tabulated in questionnaires.
We have found in 4 studies during our literature reviews that: The physical scores of SF-36(another QOL questionnaire) have a strong correlation with the distance walked in the six-minute walk test. And also the dyspnoea, fatigue, emotion and total QOL scores of the Chronic Heart Failure Questionnaire correlated strongly with the six-min walk distance.
Lee et al showed that there was a strong correlation between the physical scores of SF 36 and the six-min walk distance in respiratory patients. And lastly, it was found that the EORTC-QLQ-C30 physical functioning scores have strong relationships with the six minute walk test.
Hence, our project seeks to find out the relation shared between QOL questionnaire scores and even more objective measures other than the six minute walk test. And if there is a strong correlation between them, clinicians will then be able to predict the physical functioning of palliative care patients through QOL questionnaires. Subsequently, as healthcare professionals tangibly work on these patient’s physical functioning through exercises and other interventions, they are improving their QOL as well. And the aim of all these is for the overall wellness of patients undergoing palliative care.
So when considering patients that have language, cognitive and physical barriers that do not allow them to answer the questionnaires independently, we wanted to find out if caregivers are able to answer on their behalf. So on some studies done in different patient populations and questionnaires we have found that,
on the EORTC-C30, the correlation between the QOL ratings of patients and their caregiver was of moderate strength. Especially in the physical functioning domain, a high correlation of 0.74 was found.
In other questionnaires like the SF-12 and CES-D, a moderate correlation was found between the patient and their caregiver’s ratings. Fair to moderate agreement was found in the patient caregiver scores in the older adult with cognitive impairments.
So our group wishes to find out if a strong correlation is shared between the patient’s and caregiver’s ratings of quality of life in the palliative patient population as well.
And hence these 2 aims have led to the derivation of our hypotheses. The primary null hypothesis is that there is NO relationship between Quality of Life Questionnaire Score and Physical Objective Measures among terminally ill cancer patients undergoing palliative care . And the alternate hypothesis is as follows.
The secondary null hypothesis is that there is NO agreement between the Quality of Life Questionnaire answers of the caregivers and the patients. The alternate hypothesis is as follows.
So the method in which we have done our study consisted of choosing the Quality of Life questionnaire and the objective measures to find out their relationship in palliative care patients.
So the questionnaire we’ve chosen is the EORTC-QLQ-C15 PAL which is directly derived from C30. C30 that some might be more familiar with is a reliable and valide test used widely all over the world. It contains 30 questions that ranges from “Do you have any trouble taking long walks?” to “ Did you feel depressed?” However, mainly due to its length, C30 is not suitable for the use in palliative care as patients may fatigue before finishing the questionnaire.
Hence, the choice for C15, the shortened version of C30 which has proven to have good content validity for palliative care settings.
This is a copy of the C15
and the questions are categorised into these 10 domains. And out of the 30 questions from C30, 15 was directly plucked out to make up C15 which were decided to be most essential in determining the QOL.
Moving on to the physical objective measures that we’ve chosen. The 6 minute walk test measures the subject’s muscular and cardiovascular endurance.
The handheld dynamometer measures the upper limb strength and the ability to carry out ADL.
5 time sit to stand test measures the lower limb strength.
Functional reach that measures the dynamic balance.
And lastly the timed up and go that measures the agility and speed of the subject.
So how did we conduct our study? First, 5 subjects have been chosen through judgment sampling from a pool of clients at Assisi Hospice. The inclusion criteria were as follows and they included palliative care patients with less than a year prognosis and that they or their caregiver could understand conversational english or chinese. Subjects were also excluded if they are unable to follow instructions and had conditions that limited their physical ability and function. We then proceeded on to performing screening tests and took their baseline blood pressure, heart rate and SP02. The C15 questionnaire was administered to the subjects verbally. The viva questionnaire was given to their caregivers later on through phone interviews. After the questionnaire, the subjects then performed the 5 physical objective measures. Their blood pressure, heart rate and SPO2 was monitored throughout the procedures and after they had performed all of them.
We used the subject’s and caregiver’s C15 answer to tabulate their scores through the EORTC scoring formula. And the results of the 5 objective measures were compared against the different domains of the subject’s C-15 questionnaire answers to find their correlations. The relationship between the subject’s and their caregiver’s ratings of the C15 was also analysed. All these, we used the Pearson’s correlation test.
So moving on to the results part, Zhuting will share with you what we had found out!
Insufficient components of QOL taken into consideration in EORTC QLQ – C15 – PAL Global QOL in EORTC QLQ – C15- PAL is computed based on 1 question – “How would you rate your overall quality of life during the past week?” Includes Characteristics of Environment & Non-medical factor , Spiritual Well-being (Wilson IB, Cleary PD, 1995; Ferrans, 2010)
What is the Relationship between Quality of Life and Physical Functions of Patients Undergoing Palliative Care?
Introduction Cancer <ul><ul><li>1 out of 4 Singaporeans will die of cancer (Hock 2002) </li></ul></ul><ul><ul><li>Early screening and treatment </li></ul></ul>Palliative Care <ul><ul><li>Singapore Hospice to increase beds by 20% in 5 to 7 years (Ministry of Health, Channel Newsasia, 14 th Oct 2008,) </li></ul></ul><ul><ul><li>Improve QOL (Granda-Cameron et al., 2008) </li></ul></ul>QOL <ul><ul><li>Multi-factorial (World Health Organisation, 2002) </li></ul></ul><ul><ul><li>Measured by QOL questionnaire </li></ul></ul>
(World Health Organisation, 1997) Quality of Life Social Relationship Physical Functioning Level of Independence Environmental Factors Psychological State Personal Beliefs
Correlation of QOL to Physical Objective Measures <ul><li>Physical Component score SF-36 correlated strongly (r=0.766) with distance walked in 6-minute walk test in liver transplant patients. </li></ul><ul><li>(Hsieh et al., 2010) </li></ul><ul><li>Strong correlations (r>0.7) between 6-minute walk distance and Dyspnoea, Fatigue, Emotion and Total QOL scores of Chronic Heart Failure Questionnaire. </li></ul><ul><li> (O'Keeffe et al., 1998) </li></ul>
<ul><li>SF-36 physical scores has a strong relationship with 6-minute walk distance in bronchiectasis patients (r=0.71, p < 0.001). </li></ul><ul><li>(Lee et al., 2009) </li></ul><ul><li>EORTC QLQ-C30 physical functioning strongly correlates with 6-minute walk distance in palliative patients (r2=0.70). </li></ul><ul><li>(Nicklasson et al., 2007) </li></ul>Correlation of QOL to Physical Objective Measures
AIM: Determine the correlation of physical objective measures and questionnaire scores for the overall wellness of patients undergoing palliative care
<ul><li>Moderate levels (r=0.68) of correlation in patient-caregiver mental health scores of SF12 and CES-D (depression questionnaire) </li></ul><ul><li>(Fleming et al., 2006) </li></ul><ul><li>Fair to moderate levels of agreement in patient-caregiver QOL scores of older adults with cognitive impairments. </li></ul><ul><li>(Logsdon et al., 2002) </li></ul>Caregiver’s Rating of Patient’s QOL
AIM: To determine the correlation of the ratings of palliative patient’s QOL by themselves and their caregivers.
Primary Hypothesis <ul><ul><li>H o : There is NO relationship between Quality of Life Questionnaire Score and Physical Objective Measures among terminally ill cancer patients undergoing palliative care . </li></ul></ul><ul><ul><li>H a : There is A relationship between Quality of Life Questionnaire Score and Physical Objective Measures among terminally ill cancer patients undergoing palliative care . </li></ul></ul>
Secondary Hypothesis <ul><ul><li>H o : There is NO agreement between the Quality of Life Questionnaire answers of the caregivers and the patients. </li></ul></ul><ul><ul><li>H a : There is AN agreement between the Quality of Life Questionnaire answers of the caregivers and the patients. </li></ul></ul>
EORTC QLQ – C15 PAL <ul><ul><li>Derived from EORTC QLQ – C30 </li></ul></ul><ul><ul><ul><li>EORTC QLQ-C30 is a reliable and well-validated tool of measuring QOL. (Nicklasson et al., 2007) </li></ul></ul></ul><ul><ul><ul><li>Similar trend observed between overseas and local population (Luo et al., 2005) </li></ul></ul></ul><ul><ul><ul><li>EORTC QLQ - C30 questions are not relevant to palliative care setting (Fredheim et al., 2007) </li></ul></ul></ul>
EORTC QLQ – C15 PAL <ul><ul><li>Shows good content validity for palliative care (Groenvold et al., 2006) </li></ul></ul>
<ul><li>Global Quality of Life </li></ul><ul><li>Physical function </li></ul><ul><li>Emotional function </li></ul><ul><li>Fatigue </li></ul><ul><li>Dypsnoea </li></ul><ul><li>Constipation </li></ul><ul><li>Pain </li></ul><ul><li>Nausea </li></ul><ul><li>Insomnia </li></ul><ul><li>Loss of appetite </li></ul>EORTC QLQ – C15 PAL * Questions are directly plucked out from C30
Physical Objective Measures - Endurance <ul><li>The six-minute walk test , which has been found to reflect activities of daily living better than other walk tests, measures of walking capacity (Solway et al., 2001) . </li></ul>
Physical Objective Measures – Upper Limb Strength <ul><li>Handheld dynamometer test has been shown to correlate with gold standard methods of strength testing, such as repetition maximum testing (Lippincott et al., 2006) . </li></ul>
Physical Objective Measures – Lower Limb Strength <ul><li>5 times Sit-To-Stand Test measures the ability to stand from a chair by testing lower-extremity strength and balance (Lord et al., 2002) . </li></ul>
Physical Objective Measures - Balance <ul><li>Functional reach , a well-known clinical measure of balance, has shown to correlate with activities of daily living (Duncan et al., 1990) . </li></ul>
Physical Objective Measures - Agility <ul><li>The Timed Up and Go Test is a measure of the subject’s mobility and balance which are crucial for those who are home or community ambulant. The test is also used to assess fall risk (Overcash et al., 2008) . </li></ul>
Method <ul><li>Experimental Procedure </li></ul>5 subjects recruited by judgment sampling from Assisi Hospice EORTC QLQ C15-PAL(VERBAL) administered to subjects and caregivers 5 Physical Objective Measures performed on subjects <ul><li>Inclusion Criteria: </li></ul><ul><li>Palliative care cancer patient with <1 year prognosis </li></ul><ul><li>21 years and above </li></ul><ul><li>understands or have a caregiver who understands conversational English or Chinese </li></ul><ul><li>home ambulant with or without walking aid </li></ul><ul><li>meet PAR-Q standards or recommended by hospice healthcare professionals </li></ul><ul><li>Exclusion Crieria: </li></ul><ul><li>Inability to follow simple instructions </li></ul><ul><li>Other conditions which limit physical ability and function (blindness, deafness, etc) </li></ul>
Method <ul><ul><li>Pearson’s correlation ( r) </li></ul></ul>Scores generated from EORTC Scoring Formula Physical Objective measures Questionnaire Functional reach EORTC QLQ-C15 PAL (subjects) EORTC QLQ-C15 PAL (caregivers) Hand grip dynamometer 5 times sit to stand Timed up and go 6 minute walk test
EORTC QLQ – C15 vs Physical Objective Measures Correlation Significance Domains of EORTC QLQ - C15 Physical objective measures Physical functioning 6 minute walk test 0.749 0.145 Dyspnoea Functional reach 0.750 0.144 Handheld dynamometer 0.860 0.061 Global QOL Handheld dynamometer -0.826 0.085 Functional reach -0.950 0.013
Negative Correlation for Global QOL “ How would you rate your overall quality of life during the past week?” Global QOL EORTC-QLQ-C15-PAL Emotional Function Physical Function Fatigue Nausea Pain Dypsnoea Insomnia Appetite Loss Constipation
(World Health Organisation, 1997) Recall… Quality of Life Social Relationship Physical Functioning Level of Independence Environmental Factors Psychological State Personal Beliefs
Inability to compute results <ul><li>5 out of 10 domains in correlation of EORTC QLQ – C15 scores and physical objective measures </li></ul><ul><li>7 out of 10 domains in correlation of caregivers’ and subjects’ responses </li></ul><ul><li>Questions are not discriminative enough </li></ul>
Limitations <ul><li>Judgement sampling of higher functioning subjects </li></ul><ul><ul><li>Frail patients undergoing palliative care may not be willing to participate in the physical objective measures </li></ul></ul><ul><ul><li>Homogenous population therefore not representative of entire palliative care population </li></ul></ul>
Suggestions for Future Studies <ul><li>Include subjects of various physical functioning status </li></ul><ul><li>Source for suitable subjects who are not involved in centre activities </li></ul>
Conclusion <ul><li>Only 3 consistent, strong correlation found: </li></ul><ul><ul><li>Subjects’ Physical functioning scores and 6 minute walk test </li></ul></ul><ul><ul><li>Caregiver s’ and subjects’ physical functioning scores of the EORTC QLQ C15 PAL </li></ul></ul><ul><ul><li>Caregiver s’ and subjects’ fatigue scores of the EORTC QLQ C15 PAL </li></ul></ul>
Conclusion <ul><li>Physiotherapists have to encourage patients to maintain active lifestyle despite medical condition </li></ul><ul><li>There is still a need establish patient’s physical functions through physical objective measures </li></ul><ul><li>Quality of Life of patients has to be determined by patients themselves </li></ul>
Special Thanks! <ul><li>Mr Abdul Rashid Jailani </li></ul><ul><ul><li>for his guidance and advice </li></ul></ul><ul><li>Mr Andy Ong </li></ul><ul><ul><li>for his statistical expertise </li></ul></ul><ul><li>Mr Patrick Tan </li></ul><ul><ul><li>for his technical and logistical support throughout out project </li></ul></ul><ul><li>Dr Bala S. Rajaratnam </li></ul><ul><ul><li>for providing us with all the necessary resources needed </li></ul></ul><ul><li>Ms Grace Sim </li></ul><ul><ul><li>for her enthusiasm in assisting us </li></ul></ul><ul><li>Staff and Patients of Assisi Home </li></ul><ul><ul><li>for bringing us much joy during our visits </li></ul></ul>
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