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Original Investigation
April 4, 2019

Effect of Collaborative Telerehabilitation on Functional Impairment and Pain Among Patients With Advanced-Stage Cancer: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
  • 2Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
  • 3Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
  • 4Center for Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
JAMA Oncol. 2019;5(5):644-652. doi:10.1001/jamaoncol.2019.0011
Key Points

Question  Does collaborative telerehabilitation with or without pharmacological pain management for patients with functional impairment and late-stage cancer improve function, lessen pain, and reduce requirements for inpatient care?

Findings  In this 3-arm randomized clinical trial of 516 patients, telerehabilitation with physical therapy–directed pain management modestly improved function, pain, and quality of life, and reduced hospital length of stay and use of postacute care facilities. Telerehabilitation with nurse-directed pharmacological pain management also improved pain and reduced use of postacute care facilities.

Meaning  Collaborative telerehabilitation that integrates impairment and pain management may be considered a viable component of comprehensive cancer care for patients with advanced-stage cancer experiencing mild disability.


Importance  Most patients with advanced-stage cancer develop impairment and pain-driven functional losses that jeopardize their independence.

Objective  To determine whether collaborative telerehabilitation and pharmacological pain management improve function, lessen pain, and reduce requirements for inpatient care.

Design, Setting, and Patients  The Collaborative Care to Preserve Performance in Cancer (COPE) study was a 3-arm randomized clinical trial conducted at 3 academic medical centers within 1 health care system. Patient recruitment began in March 2013 and follow-up concluded in October 2016. Participants (N = 516) were low-level community or household ambulators with stage IIIC or IV solid or hematologic cancer.

Interventions  Participants were randomly assigned to the (1) control arm, (2) telerehabilitation arm, or (3) telerehabilitation with pharmacological pain management arm. All patients underwent automated function and pain monitoring with data reporting to their care teams. Participants in arms 2 and 3 received 6 months of centralized telerehabilitation provided by a physical therapist-physician team. Those in arm 3 also received nurse-coordinated pharmacological pain management.

Main Outcomes and Measures  Blinded assessment of function using the Activity Measure for Postacute Care computer adaptive test, pain interference and average intensity using the Brief Pain Inventory, and quality of life using the EQ-5D-3L was performed at baseline and months 3 and 6. Hospitalizations and discharges to postacute care facilities were recorded.

Results  The study included 516 participants (257 women and 259 men; mean [SD] age, 65.6 [11.1] years), with 172 randomized to 1 of 3 arms. Compared with the control group, the telerehabilitation arm 2 had improved function (difference, 1.3; 95% CI, 0.08-2.35; P = .03) and quality of life (difference, 0.04; 95% CI, 0.004-0.071; P = .01), while both telerehabilitation arms 2 and 3 had reduced pain interference (arm 2, −0.4; 95% CI, −0.78 to −0.09; P = .01 and arm 3, −0.4; 95% CI, −0.79 to −0.10; P = .01), and average intensity (arm 2, −0.4; 95% CI, −0.78 to −0.07; P = .02 and arm 3, −0.5; 95% CI, −0.84 to −0.11; P = .006). Telerehabilitation was associated with higher odds of home discharge in arms 2 (odds ratio [OR], 4.3; 95% CI, 1.3-14.3; P = .02) and 3 (OR, 3.8; 95% CI, 1.1-12.4; P = .03) and fewer days in the hospital in arm 2 (difference, −3.9 days; 95% CI, −2.4 to −4.6; P = .01).

Conclusions and Relevance  Collaborative telerehabilitation modestly improved function and pain, while decreasing hospital length of stay and the requirement for postacute care, but these outcomes were not enhanced with the addition of pharmacological pain management.

Trial Registration  ClinicalTrials.gov identifier: NCT01721343