Physiotherapy - Theses
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ItemPhysical function in patients following surgery for colorectal cancer( 2016)Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second most common cancer in females worldwide. Surgery is the usual treatment for CRC, however post-operative morbidity can be high. Post-operative problems can include symptoms such as anxiety, depression, and bowel, bladder and sexual dysfunction, poor functional exercise capacity, and low levels of physical activity. These highly distressing problems can negatively impact patients’ health-related quality of life (HRQoL). Although the current evidence is strong for physical activity for patients with CRC, there is limited evidence for optimal bowel management in patients who have undergone surgical treatment for CRC. In addition, there are no validated instruments for measuring pelvic floor symptoms and functional exercise capacity in both colon and rectal cancer. This thesis aimed to (1) determine the validity and applicability of a bladder and bowel symptom-specific questionnaire and three field walking tests for the CRC population; (2) comprehensively understand the changes in pelvic floor symptoms and physical and psychological outcomes in patients before and six months after surgery for CRC; (3) investigate the feasibility of implementing a general rehabilitation program incorporating the international physical activity guidelines for patients following surgery for CRC; (4) explore changes in patient centred functional and pelvic floor outcomes following the rehabilitation program; and (5) identify and synthesize current evidence for the effectiveness of pelvic floor muscle training for bowel dysfunction in patients who have undergone CRC surgery. Study 1 and Study 2 examined the validity and applicability of instruments/tests used in the measurement of functional exercise capacity and bladder and bowel symptoms of patients with CRC. The studies found that one pelvic floor symptom-specific instrument and two functional exercise capacity field walking tests are suitable (valid and applicable) for use with patients with CRC. The findings from Study 1 and Study 2 support the choice of outcome measures used in the subsequent studies in this thesis. Study 3 examined the pelvic floor symptoms, physical and psychological outcomes of patients undergoing surgery for CRC in a prospective observational study design. Adult patients with stage I-III CRC completed pelvic floor symptom-specific questionnaires (the Australian Pelvic Floor Questionnaire and the International Consultation on Incontinence Questionnaire Bowel module and Urinary Incontinence short form module) and questionnaires on physical activity levels, anxiety, depression, and HRQoL before and six months following surgery. The main findings were that patients experience significant bowel symptoms and persistent low physical activity levels for up to 6 months following CRC surgery. These results suggest the need for interventions such as rehabilitation programs or exercise interventions to increase levels of physical activity and address bowel symptoms in patients following CRC surgery. Therefore, Study 4, a prospective non-randomized quasi-control study, was undertaken to investigate the feasibility of implementing international guidelines within an oncology rehabilitation program in patients following CRC surgery and to explore changes in patient centred functional and pelvic floor outcomes following the rehabilitation program. The findings showed that implementation in the oncology rehabilitation program was feasible, and patients who have undergone the rehabilitation program had improvements in bladder and bowel symptoms, depression and HRQoL. Study 5, a pilot study nested within Study 4, was conducted to further explore the changes in bladder and bowel symptoms and pelvic floor muscle clinical outcomes measured using digital rectal examination, anorectal manometry and transperineal ultrasound in patients following a general oncology rehabilitation program. Findings demonstrated improved bowel symptoms from pre- to post-rehabilitation program in patients following surgery for CRC. This suggests that general exercise may have positive effects on pelvic floor symptoms in patients following surgery for CRC. However, the evidence is stronger for targeted pelvic floor muscle training/exercise than general exercise on pelvic floor symptoms in non-cancer populations, and patients with CRC behave differently to those with non-cancer diagnoses in terms of symptoms and treatment (i.e. surgical approaches and side effects of chemotherapy (CT) and radiotherapy (RT)). Study 6 summarizes the current evidence on the effectiveness of pelvic floor muscle training on bowel dysfunction in patients who have undergone CRC surgery by systematic literature reviews. This review identified eight studies of level III-2 to IV evidence that reported improvements in patient-reported measures of bowel function and the HRQoL of patients who have undergone pelvic floor muscle training following CRC surgery. This systematic review identified gaps in the literature and revealed that there is a need for randomized controlled trials to provide high levels of evidence of pelvic floor muscle training for CRC populations. In conclusion, the studies outlined in this thesis identified the importance of bowel problems following CRC surgery and suggest that an oncology rehabilitation program may be clinically feasible for CRC. Pelvic floor muscle training is widely used in the incontinence population, and the systematic review suggests that randomized controlled trials are needed to confirm the effectiveness of pelvic floor muscle training in CRC population. Given the small sample size, the evidence in this thesis must be regarded as preliminary. Future research should investigate which subgroups of patients with CRC (i.e. low functional exercise capacity or physical activity levels or high levels of comorbidity at baseline) to target with exercise interventions and which intervention (i.e. general exercise, pelvic floor muscle training, or a combination of both) is more effective in improving pelvic floor outcomes in patients with CRC.