Original Article

Impact of inpatient rehabilitation services on the

functional levels of cancer patients at King Fahad Medical
City, Riyadh, Saudi Arabia

Amani AlJohi, MSc, Sherwynn Javison, MSc, Suzan Lubbad, BSc, Yara Bashawri, MPH, Abdullah Bany Hamdan, MSc.

ABSTRACT improved more than the cognitive. The LOS was less
(30 days) in patients requiring minimal assistance,
‫ حتدد هذه الدراسة تأثير مدى خدمات التأهيل على املستويات الوظيفية‬:‫األهداف‬
at the time of admission, compared to the LOS in
.‫ملرضى السرطان‬
patients with moderate and low levels of independence.
‫ مدينة‬،‫ كانت هذه دراسة بأثر رجعي للبيانات من مستشفى إعادة التأهيل‬:‫املنهجية‬ The level of significance was set at p≤0.05
.‫م‬2018 ‫م إلى‬2012 ‫ اململكة العربية السعودية من‬، ‫ الرياض‬، ‫امللك فهد الطبية‬
‫) لتقييم التغييرات الوظيفية من‬FIM( ‫مت استخدام أداة قياس االستقالل الوظيفي‬ Conclusions: In patient cancer rehabilitation service
.‫القبول إلى اخلروج لتحديد تأثير إعادة التأهيل للمرضى الداخليني‬ demonstrated statistically significant functional gains
during rehabilitation at King Fahad Medical City. This
‫ كان متوسط مدة اإلقامة في‬.‫ سجل مؤهل‬81 ‫ مت مراجعة ما مجموعه‬:‫النتائج‬ study may help the policymakers to provide similar
‫ ومت إخراج‬،25±15.3 ‫ كانت‬FIM ‫ يعني أن مكاسب‬،‫ يو ًما‬50 ‫املستشفى‬ rehabilitation services to all cancer patients as well as
‫ على الرغم من وجود مكاسب‬.‫ فقط‬4.9% ‫ في حني مت إعادة‬،‫ إلى املنزل‬91.4% in other health care hospitals to improve the functional
‫ فقد حتسنت‬،‫ذات داللة إحصائية في كل من الدرجات احلركية واإلدراكية‬ status of cancer survivors.
‫ يو ًما) في املرضى‬30( ‫ كان مدة اإلقامة أقل‬.‫الدرجات احلركية أكثر من اإلدراكية‬
‫ مقارنة بـمدة‬،‫ في وقت القبول‬،‫الذين يحتاجون إلى احلد األدنى من املساعدة‬ Keywords: cancer survivors, FIM scale, inpatient
.‫اإلقامة في املرضى الذين يعانون من مستويات معتدلة ومنخفضة من االستقاللية‬ rehabilitation
.p≤0.05 ‫مت حتديد مستوى األهمية عند‬
Saudi Med J 2020; Vol. 41 (9): 984-989
‫ أظهرت خدمة إعادة تأهيل مرضى السرطان الداخليني مكاسب وظيفية‬:‫اخلالصة‬ doi: 10.15537/smj.2020.9.25309
‫ قد تساعد‬.‫ذات داللة إحصائية أثناء إعادة التأهيل في مدينة امللك فهد الطبية‬
‫هذه الدراسة واضعي السياسات على تقدمي خدمات إعادة تأهيل مماثلة جلميع‬ From the Physical Therapy Department (AlJohi), Rehabilitation Hospital,
‫مرضى السرطان وكذلك في مستشفيات الرعاية الصحية األخرى لتحسني احلالة‬ King Fahad Medical City; from the Comprehensive Cancer Center (Javison,
.‫الوظيفية للناجني من السرطان‬ Bany Hamdan); from the Physical Therapy Department, Rehabilitation
Hospital (Lubbad); from the Biostatistical Department, Research Center
Objectives: To identify the impact of inpatient (Bashawri), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
rehabilitation services on the functional levels of cancer
Received 31st May 2020. Accepted 29th July 2020.
patients.
Address correspondence and reprint request to: Amani AlJohi, Department
Methods: This was a retrospective study of data from of Physical Therapy, Rehabilitation Hospital, King Fahad Medical City,
the Rehabilitation Hospital, King Fahad Medical Riyadh, Kingdom of Saudi Arabia. E-mail: a_aljohi@yahoo.com
City, Riyadh, Saudi Arabia, from 2012 to 2018. The ORCID ID: https://orcid.org/0000-0001-5619-3559
functional independence measure (FIM) tool was used
to assess functional changes from admission to discharge
to determine the impact of inpatient rehabilitation.

Results: A total of 81 eligible records were reviewed.

T he majority of cancer patients have some degree
of physical impairment. Approximately one-third
of them are limited in their basic activities of daily
The median hospital length of stay (LOS) was 50 days, living (ADL) and have difficulty walking because
mean±SD of the FIM gain was 25 (15.3), and 91.4% of disease progression or treatment.1-3 The physical
were discharged home, while only 4.9% were readmitted.
Although statistically significant gains were observed and psychological impairment of cancer survivors
in both motor and cognitive scores, motor scores negatively affects their quality of life (QOL).4,5 In 2018,
the Global Burden of Disease Cancer Collaboration

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 Inpatient cancer rehabilitation ... AlJohi et al

reported that there were 17.2 million people living concept of rehabilitation has led to reduced referrals.17
with cancer worldwide between 2006 and 2016, and Furthermore, the complexity of cancer patient
the incidence of cancer has increased by approximately conditions and the lack of healthcare providers who
28%.6 Fortunately, the number of cancer survivors specialize in cancer rehabilitation may negatively impact
continues to increase, primarily as a result of advances their acceptance of cancer patients as inpatients in their
in cancer treatment and early diagnoses. While this facilities. ‘Providing proper attention and services to
is positive news, it comes with a heavy burden of cancer patients is undoubtedly a significant challenge
disability for survivors who account for a total of 213.2 nationwide when facilities are limited in terms of
million disability-adjusted life years.6 Therefore, this inpatient rehabilitation. Indeed, there have been no
high disability rate has increased the demand for early studies regarding the influence of inpatient rehabilitation
physical rehabilitation. services on cancer patients in Saudi Arabia. Therefore,
The importance of rehabilitation referrals among the purpose of this study was to identify the impact of
cancer patients has already been recognized, since inpatient rehabilitation services on the functional levels
they are an integral part of care coordination among of cancer patients at a tertiary health care hospital, with
healthcare providers. Inpatient rehabilitation services the hopes of facilitating opportunities for more cancer
play a significant role in overall QOL improvement patients and survivors to receive similar services in the
and affect many patients’ ability to cope with their future.
disabilities.7,8 Previous studies have reported that
cancer patients benefit from inpatient rehabilitations.1-4 Methods. The study used a retrospective chart review
However, functional impairments related to cancer are of related data gathered between January 2012 and
often not referred for specialized rehabilitation services December 2018. It was conducted at the Rehabilitation
as the main focus of oncologists remains the treatment Hospital, King Fahad Medical City, Riyadh, Saudi
of the disease rather than the functional deficits it causes. Arabia. The King Fahad Medical City-Rehabilitation
In addition, specialists in rehabilitation medicine and Hospital (KFMC-RH) is one of the main and largest
rehabilitation facilities where they practice are keenly Ministry of Health tertiary inpatient rehabilitation
aware of the burden and escalating costs that accompany facility (IRF) and provides services to referred patients
the special care requirements of cancer patientss.6 in Riyadh free of cost. This facility provides a holistic
Functional improvement achieved through inpatient rehabilitation approach by an interdisciplinary team led
rehabilitation is associated with prolonged survivorship by a physiatrist. Based on the patients’ activity limitation,
among cancer patients.10 The functional independence all patients receive multidisciplinary management
measure (FIM) is widely used in the context of inpatient including nursing, physical therapy, occupational
cancer rehabilitation. This is a valid and reliable tool to therapy, speech or swallowing, and other services. In
assess the level of independence in basic ADL. It has addition, patients receive support services such as art
been found to be a reliable tool not only for cancer therapy, social support, and recreation therapy.
survivors but also in stroke and other neurological All adult cancer patients (≥14 years old) who were
disorders and has been widely used in many countries, admitted for rehabilitation at this facility from the year
including Europe, the UK, and Australias.11-15 2012 to 2018 were included. Patients’ prognosis more
However, cancer patients with functional than 6 months and were not receiving any chemo or
impairment are rarely referred for rehabilitation radiotherapy. Records were excluded if there were
services. In Saudi Arabia, there were 16,210 cancer missing FIM scores, if cancer was a secondary diagnosis,
cases in 2015, and the number has increased yearly.16 any metastasis, and when the patient had already received
The major barriers to optimizing the delivery of rehabilitation services in other facilities or at home. This
oncology rehabilitation are the lack of proper study was approved by the Institutional Review Board
identification of patients’ functional impairment and of King Fahad Medical City. The patients’ level of
gaps in multidisciplinary communication. Moreover, functional independence at the time of admission and
oncologists and hematologists are unfamiliar with the at discharge was noted.
Social demographic information, comorbidity, and
length of stay were collected from patient records.
The FIM tool is widely used to identify physical
Disclosure. Authors have no conflict of interests, and the and cognitive limitations that indicate the level of
work was not supported or funded by any drug company. independence, and to assess functional gain during
inpatient cancer rehabilitation. The FIM consists of

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 Inpatient cancer rehabilitation ... AlJohi et al

18 items and is subdivided to a motor and cognitive and 54.3% of the patients were female. Out of 81 files,
components. Motor component is assessed on 4 38 (46.9%) were retrieved from the Comprehensive
domains of function: i) self-care (6 items) ii) sphincter Cancer Center (CCC), while 43 (53.1%) were brain
control (2 items), iii) mobility/transfers (3 items), and tumor cases from the neurosurgery ward. Most of the
iv) locomotion (2 items). Communication (2 items), cases (n=20; 24.4%) from CCC were hematologic
and social cognition (3 items) are cognitive function malignancies, and 18 (22%) were other solid tumors.
domains. All the items are scored on a 7 point ordinal The majority of participants (58%) were diagnosed
scale; 1- total assistance and 7-complete independence. with brain tumors. The participants’ characteristics are
This functional measure has a total score range from shown in Table 1.
18-126, a greater score indicates a higher level of At admission. At the time of admission, 53.1% of
independence.15 patients required moderate assistance, while only 37%
Statistical analysis. Demographic and clinical required maximal assistance for their activities. The
characteristics of the study patiens were reported as mean of the total FIM scores at the time of admission
mean (SD), median (25th percentile, 75th percentile) or was 63.52 (SD 21.61), mean of the total motor scores
counts (percentage, as appropriate. Differences between was 3.25 (SD 15.80), and mean of the total cognitive
admission and discharge FIM scores were compared scores 28.27 (SD 9.51).
using Wilcoxon signed-rank test. All statistical analyses At discharge. At the time of discharge, only 29.6%
were conducted using Statistical Package for Social of patients required moderate assistance, and only
Sciences version 25.0 (SPSS Inc., Chicago, IL, USA). 12.3% required maximal assistance, as measured by
A 2-tailed test with a p-value of 0.05 was considered the FIM. The mean total FIM score was 89.35 (SD
significant. 25.59), mean FIM motor score 59.26 (SD 20.87), and
mean cognitive score 30.09 (SD 8.13). There was a
Results. A total of 86 medical records of cancer significant improvement in FIM scores from admission
patients admitted for inpatient rehabilitation at King to discharge (Table 2; Figure 1). The median scores at
Fahad Medical City were included. Five records were 25th and 75th percentiles are also presented in table 2.
excluded because of inadequate data, leaving the total Hospital length of stay (LOS). The median patient
sample at 81. The mean age was 47.38 years (SD 17.18) length of stay (LOS) was 50 days and ranged from 4
to 333 days. Patients requiring minimal assistance had
a median LOS of 26.50 days, and their FIM efficiency
Table 1 - Summary of patient demographics and medical characteristics.
was 0.69 (0.48). All patients with a high level of
independence were discharged home. Patients with
Characteristics n (%)
a moderate level of independence had a median LOS
Age (years) (mean±SD) 47.38 (17.18) of 43 days, and FIM efficiency was 0.69 (0.44). The
Gender majority of patients (93%) were discharged home, while
Males 37 (45.7) 7% were readmitted to an acute facility. Patients with a
Females 44 (54.3)
Referral source
Table 2 - Comparison of functional independence measure (FIM) scores
Comprehensive Cancer Center 38 (46.9) from admission to discharge.
Neurosurgery Ward 43 (53.1)
Diagnosis FIM scores Admission Discharge P-value

Breast cancer 5 (6.2) Total FIM scores

Multiple myeloma 6 (7.4) Mean ± SD 63.52 ± 21.61 89.35 ± 25.59

<0.0001
Lymphoma 14 (17.3) Median (25 , 75 )
th th
65 (49, 80) 96 (73, 110)

Brain tumor 47 (58.0) FIM motor score

Others (endometrial, leukemia) 9 (11.1) Mean ± SD 35.25 ± 15.80 59.26 ± 20.87

<0.0001
Discharge Median (25 , 75 )
th th
34 (20, 48) 62 (41, 77)
Home 74 (91.4) FIM cognitive score
Readmission to acute inpatient facility 4 (4.9) Mean ± SD 28.27 ± 9.51 30.09 ± 8.13
<0.0001
Transfer to long-term facility 3 (3.7) Median (25th, 75th ) 35 (23, 35) 35 (29, 35)

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 Inpatient cancer rehabilitation ... AlJohi et al

Figure 1 - Level of independence from admission to discharge.

Table 3 - Participants’ level of independence, hospital length of stay, and FIM efficiency at discharge.

FIM Scores Minimum Moderate Maximum

assistance (n=8) assistance (n=43) assistance (n=30)
FIM admission
Mean ± SD 98.13 ± 6.6 73.16 ± 8.76 40.47 ± 12.2
Median 97.5 72 42.5
25th 92.5 65 29
75th 102.5 82 50
FIM discharge
Mean ± SD 114.38 ± 7.56 100.19 ± 15.17 67.13 ± 24.55
Median 117.5 104 68.5
25th 108.5 94 48
75th 120.5 112 84
P-value 0.012* <0.0001* <0.0001*
FIM efficiency
Mean ± SD 0.69 ± 0.48 0.69 ± 0.44 0.48 ± 0.41
Median 0.64 0.57 0.34
25th 0.24 0.33 0.16
75th 1.13 1.03 0.69
Length of stay (days)
Mean ± SD 29.88 ± 14.86 52.49 ± 36.63 73.93 ± 53.81
Median 26.50 43 62.50
25th 21.50 30 51
75th 40.50 62 83
Discharge location
Home n (%) 8 (100) 40 (93) 26 (86.7)
Readmission n (%) 0 (0) 3 (7) 1 (3.3)
Other facilities n (%) 0 (0) 0 (0) 3 (10.0)
*Wilcoxon signed-rank test, admission compared to discharge

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 Inpatient cancer rehabilitation ... AlJohi et al

low level of independence had a median LOS of 62.50 rehabilitation benefits, lack of rehabilitation facilities,
days, and their FIM efficiency was 0.48 (0.41). There and lack of cooperation between interdisciplinary
was a significant difference in their FIM scores from team members, and these factors negatively affect the
admission to discharge, and 86.7% of patients were functional recovery of cancer survivors.17 Apart from
discharged home, 3.3% were readmitted, and 10% were the above-mentioned factors, the clinical profile of
transferred to long-term care facilities (Table 3). cancer patients admitted to rehabilitation facilities
may also affect the overall prognosis and duration
Discussion. This study analyzed the functional of hospital stay. Aljohi et al17 reported that barriers
efficiency of patients who received inpatient to admitting patients with cancer are essentially the
rehabilitation at KFMC over a period of 7 years. perceived chances of readmission to an acute setting.17
Our retrospective study found that inpatient cancer Our study reported that only 4.9% were readmitted to
rehabilitation patients showed significant functional an acute care setting. In contrast to our study results,
gain from admission to discharge, and the majority previous studies showed that approximately 18% of
(91%) were discharged home. cancer patients with low functional capacity return to
In our sample, brain tumors accounted for about an acute setting.3,4,19 They also found that FIM scores
58% of inpatient cancer rehabilitation admissions. were associated with the return rate to an acute setting.
Similar results were observed in a study done in a US However, the other factors associated with the return
rehabilitation facility, and they also found that cancer of cancer patients to acute care settings are still unclear.
survivors accounted for only 2.4% of all inpatient Ours was a retrospective study from one health care
rehabilitation admissions between the years 2010 and setting involving a small number of cancer patients and
2012.18 The median LOS in our sample was 50 days, hence lacks sufficient information about the reason why
with a minimum of 4 and a maximum of 333 days. cancer patients were admitted back to an acute setting.
We also observed that the mean FIM gain was 25.8 Hence, further studies to identify the factors associated
(15.3) points and total FIM efficiency 0.61 (0.44), with readmission to acute care are warranted.
and 91.4% were discharged home. In contrast to our Inpatient cancer rehabilitation provides post-acute
findings, FIM efficiency was 2 in a recent 13-year care including medical management, physiotherapy,
study.4 Another study by Forrest and Deike reported and occupational and speech therapy, and this helps to
that LOS was 18.7 days for the cancer patients, and the restore functional ability that allows cancer survivors
FIM efficiency score was 1.12 and 0.80 in patients with to be independent in their daily activities. It also helps
primary brain tumors and those with metastasis to the to manage impairments related to cancer treatment.20
brain, respectively.3 The LOS of cancer patients in our Similar to previous research,21 our study results also
sample was relatively longer compared to the LOS, 14 found that inpatient rehabilitation helps to improve
days, observed in other studies.4 The possible reason for the functional status of cancer patients. Often, the
the observed longer LOS may be due to the presence of impairments in cancer survivors were unnoticed or
an outlier of 333 days, which would have affected the untreated, which leads to physical disability and further
mean LOS in our sample. Furthermore, this may have leads to distress and reduced QOL. Research has shown
also resulted in delayed FIM efficiency in our study. that rehabilitation helps to reduce physical disability
From our findings, it was evident that patients and improve overall QOL of cancer survivors.22
experienced an improvement in their activities as Although our study is the first of its kind to assess
demonstrated by their total FIM scores. Further analysis the impact of inpatient rehabilitation on functional
of our results showed that both motor and cognitive recovery, it is worth mentioning a few limitations. With
FIM scores improved significantly at discharge, motor a retrospective design and small sample size, it was not
gain 24 (14) more so than the cognitive gain 1.8 (3.2). possible to explain the factors related to functional
The impact of rehabilitation was therefore greater on recovery or the reasons for readmission to acute care.
physical function than cognitive ability. The existing It is also not possible to know the functional status of
literature also showed that improvements in FIM scores patients after discharge or how well the patients who
resulted in decreased strain on resources and burden of were not admitted to inpatient rehabilitation performed.
caregivers.3,4 In conclusions, patients with cancer receiving
Common barriers to cancer rehabilitation were inpatient rehabilitation have significantly improved
lack of physician/oncologist knowledge about functional capacity from admission to discharge. One of

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 Inpatient cancer rehabilitation ... AlJohi et al

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