Development of a Method for Transferring Paraplegic Patients with Advanced Cancer from Bed to Wheelchair

Introduction

The number of patients with cancer continues to increase worldwide. Increasing interest has been directed at the maintenance and improvement of the quality of life (QOL) of patients with cancer, especially with the recent prolongation of survival of these patients. Attention is now focused on the rehabilitation of patients with cancer. ¹ Previous studies have reported that transfer/movement is the primary treatment goal at the start of rehabilitation in patients with advanced cancer.^2–5 Until now, methods for transferring or moving paraplegic patients have been developed for those patients with paraplegia caused by traumatic spinal cord injury. Specifically, the transfer methods for these patients mainly involve use of the upper limb functions and require that the patient be able to push up. ⁶

However, the ability to push up, which is generally encouraged during the transfer of paraplegic patients, may be harmful in patients with advanced cancer for the following two reasons. First, bone metastases can cause severe pain thus discouraging any movements. Even if the pain is relieved by drug therapy during rest, it may recur during movement and these patients often cannot move by themselves. Second, even if the patients ignore the pain and move, pathologic fractures may occur because of reduced bone strength caused by the bone metastases. ⁷

For these reasons, moving patients with advanced cancer and paraplegia requires approaches that differ from the long-established approaches for patients with paraplegia caused by traumatic spinal cord injury. However, few studies have focused on the transfer approaches for patients with advanced cancer and paraplegia. ⁸ We report here a method that we developed for transferring paraplegic patients taking into consideration the unique characteristics of patients with advanced cancer. Furthermore, the usefulness of this method was investigated from the standpoint of provision of support, as much as possible, of the patients' independence.

Methods

This study was conducted at the palliative care unit of a comprehensive cancer center, with the approval of the ethical review board of the institution.

Development of the transfer method

A horizontal movement system was developed to enable the transfer of patients from bed to wheelchair without needing the patient to push up. The principle of this system was functional compensation, and the horizontal movement system was constructed by introducing pieces of a safety apparatus. A transfer board was used for movement in the horizontal direction, basically with the patient in the sitting position, without pushing up. No generation of muscle force was required as the power source for transfer, with the potential energy arising from a difference in height between the bed and the chair being used instead. Therefore, a bed vertically movable by an electric motor was used. A 24-hour pressure ulcer prevention-type cushion was used to prevent the development of pressure ulcers while on the wheelchair, because of the inability of the patients to push up.

The transfer procedure is shown in Table 1 and Figure 1. An occupational therapist stood behind the patient, checked the positions of the pieces of the safety apparatus, and the patient's movement procedures to prevent accidental falls.

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FIG. 1.

Steps to deliver a transfer method.

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Table 1.

Transfer Procedures

1. The patient assumes a sitting position at the edge of the bed on the side of movement.

2. A wheelchair is placed at an angle of 45 degrees to the bed.

3. The height of the bed is adjusted so that the surface of the bed is 5 to 6 cm higher than the seat of the wheelchair.

4. The trunk is inclined to the side opposite to the direction of transfer to raise the ischial tuberosity on the side of transfer from the surface of the bed.

5. A transfer board is inserted between the the bed and ischial tuberosity.

6. The trunk is returned to the midline position after confirming that the ischial tuberosity is on the transfer board.

7. The opposite edge of the transfer board from which the ischial tuberosity is placed on the center of the cushion on the wheelchair.

8. The upper limb on the side of movement is extended, and if possible, the patient grasps the wheelchair armrest on the distal side to use it as a direction guide.

9. When the patient inclines the trunk to the side of movement, the difference in height allows the patient to slide from the bed to the wheelchair.

10. A staff member stands behind the patient, checks the positions of the elements of the safety apparatus, and the patient's movement procedures to prevent accidental falls.

Results

The characteristics of the subjects and the results of the intervention are shown in Table 2.

Transfer from bed to wheelchair became possible for 23 of the 25 patients (92%); 16 (64%) eventually became able to transfer both from the bed to the wheelchair and from the wheelchair to the bed unassisted, while 7 (28%) could be transferred with assistance. In 2 of the 25 patients, the horizontal movement approach was unsuccessful: in the first case (case 4), the patient could maintain the sitting position at the edge of the bed for only 1 to 2 seconds and was actually unable to transfer himself in the sitting position. In the second case (case 13), the patient had severe ascites and the distended abdomen pressed against the diaphragm when the patient assumed the sitting position at the edge of the bed, causing dyspnea.

The BI scores increased after the intervention in all patients, and the median value increased significantly from 10.0 to 40.0 (p < 0.001).

Fifteen of the 25 patients (60%) had successful overnight stays outside the hospital. The primary reason why the remaining 10 patients could not stay was because they were not able to transfer from the wheelchair to the bed. On the other hand, only 12 patients (48%) could be discharged from the hospital. In most cases, the reason why the patient could not be discharged from the hospital was death from the primary disease. In addition, there were additional reasons other than the movement ability for the patients to be kept in the hospital, such as lack of acceptance by the family.

There were no adverse events associated with this intervention. When the transfer method using the transfer board was explained at the beginning of the intervention, half of the subjects expressed anxiety because they were unfamiliar with this method. However, they no longer expressed anxiety after the method was actually demonstrated to them. In addition, none of the patients complained of pain or developed pathologic fractures associated with the intervention.

Discussion

In recent years, the goal of maintenance and improvement of the environment for the treatment of patients with cancer has expanded the use of palliative care, and interventions with the aim of maintaining and improving the environment for treatment have also received attention in patients with advanced cancer.

Factors that prevent transfer movement from bed to wheelchair and vice versa in patients with advanced cancer include the pain associated with bone metastases ¹⁰ and risk of pathologic fractures caused by the physical stress caused by movement. ¹¹ All 25 patients included in this study had well-controlled pain at rest and did not complain of pain before the start of the training for transfer. Pain in these patients is known to increase during body motion compared with that at rest, necessitating the use of rescue doses of analgesics. ¹² However, such use of rescue doses may increase lightheadedness and sleepiness, making it difficult to perform the transfer movements. In the present method, none of the patients complained of pain or required rescue doses of analgesics during the intervention. Furthermore, none of the patients developed pathologic fractures in this study. This seems to be because the physical stress on both humeri, which are frequent sites of bone metastases, posed by pushing up was avoided, and furthermore, the body weight was dispersed by supporting the trunk on the two ischial tuberosities. Namely, it is likely to be because physical stress was decreased by provision of support at multiple points including the upper limbs and ischia, thereby decreasing bone distortion.

When a patient in the sitting position at the edge of the bed moves to a wheelchair, a horizontal plane has to be established to fill the difference in the height and the gap between the bed and the wheelchair. For this purpose, a transfer board that was developed in Sweden to transfer frail elderly was used.^13–-15 Use of this board allows the patients to slide horizontally while maintaining the sitting position. Furthermore, because the horizontal plane of the board is smooth, frictional resistance is low during the horizontal movement, necessitating use of only a low level of energy for the transfer. Use of this horizontal movement system, the development of which took into consideration the unique characteristics of patients with advanced cancer, enabled transfer from bed to wheelchair for 23 of the 25 patients (92%) in this study. The patients got used to the movement method and no longer expressed anxiety after approximately three sessions, including the first that explained the transfer method. Of these, 28% could be transferred with the assistance of the staff during hospitalization, and 64% became able to transfer unassisted while the staff was only supervising them. The mean BI score for the item “transfer between wheelchair and bed” significantly increased from 10.2 before the intervention to 39.2 after the intervention. Furthermore, of the 23 patients who could be moved successfully with the use of the horizontal movement system, 60% were able to have successful overnight stays outside the hospital.

These results suggest that this method may improve the mobility and transfer of patients with cancer-related paraplegia who often express a desire to leave the bed, even at an advanced stage of the disease. Furthermore, the cost of the equipment is low, and it is also appropriate for home use if the patients can become proficient at this method.

There are, however, some limitations. First, one of the prerequisites for success of this transfer method is the patient's own ability to maintain the sitting position. When this method was developed, easy fatigability, which is a characteristic of patients with advanced cancer, could not be fully taken into account. Second, because patients have to learn a new method (i.e., horizontal transfer) that they have not experienced before, this method cannot be applied to patients with low learning ability and those with impaired consciousness. Finally, pieces of the safety apparatus, such as a bed, board, and wheelchair have to be prepared and adequate bedside space is required. Based on such a physical environment, the presence of staff who can educate patients about the transfer method is indispensable. While resolving these limitations, it will be necessary to expand the number of subjects and improve the validity and universality of this transfer method.