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Physical therapy and other rehabilitation issues in the palliative care setting
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Physical therapy and other rehabilitation issues in the palliative care setting
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Oct 21, 2016.

INTRODUCTION — For patients with a broad range of serious life-threatening illness, loss of function and independence is a common struggle and a significant contributor to diminished quality of life (QOL) [1-4]. Rehabilitation, even in the advanced phases of an illness, can help to maintain or restore function, permit patients to retain mobility and independence, and improve symptoms, all of which can contribute to a reduced burden on families and caregivers, and better QOL [5]. The main rehabilitation modalities are physical therapy, occupational therapy, and speech and swallowing rehabilitation. Rehabilitation of palliative care patients requires a multidimensional approach to meet the physical, emotional, social, and spiritual needs of patients and their families. All members of the interdisciplinary team should work toward common goals, which are dependent on the patient’s preferences and goals of care.

This topic will cover the indications for and benefits of rehabilitation in the palliative care setting. We will also discuss tools to evaluate patients who are appropriate for rehabilitative services, and specific issues related to the delivery of rehabilitation services in palliative care. An overview of issues related to rehabilitation for geriatric patients, cardiac rehabilitation programs, pulmonary rehabilitation for patients with COPD, and issues related to physical rehabilitation for cancer survivors are presented elsewhere. (See "Overview of geriatric rehabilitation: Program components and settings for rehabilitation" and "Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation" and "Cardiac rehabilitation programs" and "Cardiac rehabilitation in patients with heart failure" and "Cardiac rehabilitation in older adults" and "Pulmonary rehabilitation in COPD" and "Physical rehabilitation for cancer survivors".)

OVERVIEW OF REHABILITATION IN PALLIATIVE CARE — Rehabilitation in palliative care is often overlooked. However, patients with a serious life-threatening illness experience high levels of functional loss, with increased dependency for their activities of daily living (ADLs) and mobility. Among the factors that can contribute to loss of function are prolonged hospitalization, deconditioning, pain, fatigue, depression, undernutrition, organ failure (eg, heart failure), neurologic injury, and musculoskeletal problems. Patients with cancer can additionally experience sarcopenia from direct tumor effects and fatigue from cancer treatment [1,2,6-13].

Progressive debility, decline of physical function, and the perception of being a burden to others can have a major impact on most aspects of life in a palliative care patient [14]; for some, it may prompt the desire for a hastened death and requests for physician-assisted death [15-17]. (See "Responding to requests for physician-assisted death", section on 'Who asks about assistance in dying?'.)

Many of the physical and functional impairments that arise in these patients are potentially modifiable through physical therapy and rehabilitation, yet these services are typically underutilized [18,19]. (See 'Underutilization of rehabilitation' below.)

The concept of rehabilitation in patients with palliative needs would seem to be a paradox, but in reality rehabilitation is highly appropriate for patients with complex, progressive illness, depending upon the patient’s goals. However, there are clear differences between rehabilitation in palliative care and the traditional rehabilitation approach within general medical care:

For patients without life limiting or serious illness, rehabilitation is generally performed for a disability that has occurred at one point in time, and there is an expectation that further deterioration is unlikely. The aim of traditional rehabilitation is to maximize recovery, and the emphasis is on physical needs. (See "Overview of geriatric rehabilitation: Program components and settings for rehabilitation".)

In contrast, patients with life limiting or serious illness may not only have a disability but they also have a condition where further deterioration is not only likely, but inevitable. The scope of rehabilitation in this context goes beyond physical needs and emphasizes a coordinated multidisciplinary approach to management of all symptoms whether physical, spiritual, or emotional. The goals are to reach the fullest physical, psychological, social, vocational, and educational potential consistent with his or her physiological or anatomical impairment in the context of environmental limitations, preferences, and goals of care, to maintain the highest possible quality of life and enable individuals to cope and manage their illness [2,13].

Modalities — The main rehabilitation modalities are physical therapy, occupational therapy, and speech and swallowing therapy, each provided by specialists in their field. However, rehabilitation of palliative care patients requires a multidimensional approach that also addresses the emotional, social, and spiritual needs of patients and their families. As a result, rehabilitation in this context includes psychologists, dieticians, nurses, chaplains, and case managers/social workers as well. All members of the interdisciplinary team should work toward common goals, which are defined by the patient’s preferences and goals of care.

Types of rehabilitation — The type of rehabilitation depends upon the patient’s disease stage, function, and goals.

Defined categories or “classifications” of rehabilitation that were initially defined for cancer patients [20,21] can be applied to patients with other life limiting disease processes:

Preventive rehabilitation – Begins after the diagnosis of the potentially life limiting illness, and attempts to mitigate functional morbidity caused by the disease or its treatment.

Restorative rehabilitation – Attempts to return patients to their premorbid functional status when little or no long-term impairment is anticipated and patients have remaining functional activity.

Supportive rehabilitation – Attempts to maximize function by augmenting self-care ability and mobility for patients whose disease has been progressing, and whose functional impairments are increasing and may not be reversible.

Palliative rehabilitation – Attempts to maintain as high a level of quality of life (QOL) as is feasible in terminally-ill patients by relieving symptoms (eg, pain, dyspnea, edema) and preventing complications (eg, contractures, decubitus ulcers). Aims to reduce dependence in mobility and self-care activities in association with the provision of comfort and emotional support.

The intensity of rehabilitation changes according to disease progression (table 1) [21]. Even at the very end of life as the disease advances to its terminal phase, it is still possible to perform rehabilitative interventions at the patient’s bedside such as range of motion exercises for patients’ limbs, massage for swollen limbs, or patient positioning to relieve cough or dyspnea.

Goals

Regular and open communication with patients and their families regarding the goals of rehabilitation is critical in designing the rehabilitation plan. Even in the advanced phases of a disease, rehabilitation can help maintain function or slow down functional decline and improve mobility and ability to perform ADLs through such means as strengthening, ambulation, range of motion exercises, and relief of pain and other symptoms [21]. However, deciding upon appropriate goals for rehabilitation during the advanced stage of disease (particularly for patients with advanced terminal cancer) requires interaction among patients, families, and rehabilitation staff so that realistic goals can be identified in the context of the disease trajectory and the patient’s goals and wishes for care. The rehabilitation plan must also consider the patient’s environment, existing functionality, and available resources. (See "Discussing goals of care".)

An important point is that for palliative care patients, the measure of success of a rehabilitation program should not focus on length of survival but rather on QOL, function/independence, and psychosocial well-being [22]. Objective outcome measures of rehabilitation in palliative care patients may involve patient-reported parameters, such as improvement in mobility, pain scores, anxiety levels, and satisfaction with care, as well as caregiver-related outcomes, such as caregiver burden and QOL.

It must also be emphasized that these are patients with serious life-threatening illnesses, and patient condition and goals of care can shift dramatically from day to day. Fluctuations in functional status are therefore expected, and therapists must maintain some flexibility allowing for respect for patient choices and for frequent interruptions in the rehabilitation treatment plan. During each session, rehabilitation therapists should reassess and reevaluate each patient and modify/adapt treatment plans as needed.

Indications and benefits — There is a growing body of evidence that the application of rehabilitation in hospice and palliative care settings is feasible, safe, and provides numerous benefits, both with cancer and noncancer patients [13,23].

Cancer — Some of the most common indications for referral to rehabilitation in patients with advanced cancer are refractory pain, fatigue, dyspnea, deconditioning after a prolonged hospitalization, and the need to recover from disabilities (eg, swallowing disorders) that have resulted from the effects of the cancer or its treatment. Often, cancer patients are referred to rehabilitation services in order to improve their performance status and eligibility for additional treatment. Many of these conditions are discussed in detail elsewhere. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Rehabilitation and physical medicine interventions' and "Cancer-related fatigue: Treatment", section on 'Exercise' and "Assessment and management of dyspnea in palliative care", section on 'Pulmonary rehabilitation and respiratory therapy' and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)

Retrospective series and a small number of uncontrolled prospective studies comparing outcomes pre and post rehabilitation intervention show that general rehabilitation can improve function and QOL, and reduce symptom burden (without worsening fatigue) in patients with cancer, even if the illness is at an advanced stage [6,8-10,24-32]. In addition to enabling independence in ADLs despite physiologic and anatomic restrictions, and reducing the sense of being a burden to one’s caregivers, therapeutic interventions such as physical therapy may also be perceived as giving patients hope and a feeling of relief and general well-being [23,33,34]. As examples:

A landmark 1994 study of 301 terminal cancer patients who received rehabilitative services in the hospice facility over a six-month period prior to death concluded that rehabilitation (which included therapeutic exercise, ADL training, bed exercises, bed training, chest physiotherapy, swallowing exercises, thermotherapy, intermittent pneumatic compression, acupuncture, relaxed positioning with pillows, and use of brace, sling, and splints) was associated with improved QOL, mobility, and symptoms such as pain, dyspnea, and leg edema [6]. Sixty-three percent of patients considered the rehabilitation procedures to be effective. Perhaps more importantly, with an improvement in the level of ADL, it was possible for 46 patients to be discharged to return home for a period of time.

A 2013 study evaluated the effect of an interdisciplinary palliative care oncology rehabilitation program on function, symptoms, and well-being [26]. Of the 173 patients with advanced cancer who were referred to the program, 116 were eligible to participate. The patients underwent a three-hour initial assessment in which they met with each member of the team (physiotherapist, occupational therapist, social worker, dietician, nurse, and physician) for about 30 minutes. After the initial assessments, the team jointly formulated an individualized plan for each patient which included medical and nursing assessments, physical exercise, and occupational, dietary, and psychosocial interventions. Measures of physical, nutritional, social, and psychological functioning were evaluated at entry into the program and at completion. For the patients who completed eight weeks of palliative rehabilitation, there were significant improvements across multiple outcomes including nutrition, depression, overall well-being, fatigue, general activity, and functional measures, including Eastern Cooperative Oncologic Group performance status, the Timed Up and Go test, functional reach test, Berg Balance test, grip strength, and walking (table 2). (See 'Patient assessment for rehabilitation planning' below.)

Few randomized trials have explored the benefit of rehabilitation in cancer patients. A systematic review including 13 randomized trials published between 2009 and 2014 (1169 participants) evaluated the benefits of general rehabilitation among patients with advanced cancer; seven were limited to physical exercise alone [35]. The authors concluded that physical exercise was associated with a significant improvement in general well-being and QOL. Rehabilitation had positive effects on fatigue, general condition, mood, and coping with cancer. Physical function was not addressed.

Two of the trials included in this review specifically evaluated the benefits of physical therapy:

One was a small randomized controlled trial evaluating the clinical and cost-effectiveness of a mixed rehabilitation intervention for patients with advanced cancer; the trial enrolled 41 patients, and 36 completed the trial [36]. The intervention arm (services were selected according to patient need; the actual number who received physical therapy or nutrition interventions was not reported) showed significant improvements in the psychological, physical, and patient care subscales of the Supportive Care Needs Survey (SCNS [37]), and self-reported health state.

The second was a pilot randomized trial of massage, mobilization, and local and global exercises (six sessions of 30 to 35 minutes each over a two week period) in 24 patients with terminal cancer [38]. After two weeks, the intervention group had significantly less pain and better mood, and parameters of physical distress were no greater in the intervention group.

A randomized controlled trial (RCT) of outpatient CAncer REhabilitation for older adults with functional impairment (the CARE program) is currently underway in the United States [39]. This study is one of the first RCTs aimed at examining the effect of occupational and physical therapy (OT/PT) in older adults with cancer. Patients aged 65 years or older, with a diagnosis of cancer within five years, with at least one functional deficit and not eligible for hospice care will be randomized in two groups: (1) the CARE (CAncer Rehabilitation) Program consisting of outpatient OT/PT and (2) standard of care. The primary outcome is change in ADL scores from baseline to three months between CARE and control. If positive, findings from this study will suggest the potential for outpatient OT/PT to improve the functional ability and QOL of older adults with cancer.

Other diseases — For patients with a variety of noncancer diseases such as chronic obstructive pulmonary disease (COPD), heart failure, and amyotrophic lateral sclerosis (ALS), there is convincing evidence that rehabilitation plays a pivotal role in managing symptoms and improving overall quality of life. Most of the supporting data come from retrospective series and uncontrolled prospective studies in which outcomes were compared prior to and following rehabilitation; few clinical trials have been undertaken.

Chronic respiratory disease — Palliative care and pulmonary rehabilitation are both important components of integrated care for patients with chronic respiratory disease such as COPD and interstitial lung disease that can substantially improve dyspnea and exercise tolerance, reduce anxiety [40], and reduce healthcare utilization [40-42]. (See "Palliative care for adults with nonmalignant chronic lung disease" and "Assessment and management of dyspnea in palliative care", section on 'Psychological and social impact'.)

The American Thoracic Society defines pulmonary rehabilitation as a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy [43]. It listed four essential components:

Exercise training – Upper extremity endurance training, lower extremity endurance training, strength training, and respiratory muscle training

Education – Breathing exercises, energy conservation, work simplification, end of life education

Psychosocial and behavioral intervention – Coping strategies, stress management

Outcome assessment

In addition, for patients with copious or tenacious sputum production, nebulized normal or hypertonic saline and airway clearance techniques (also known as bronchial hygiene or chest physiotherapy) may help to clear the secretions and mucous plugs that frequently complicate bronchiectasis. Methods of airway clearance include forced exhalation, postural drainage, positive expiratory pressure (PEP), oscillatory PEP (eg, flutter valve acapella device), and high-frequency chest wall compression (table 3). (See "Treatment of bronchiectasis in adults", section on 'Airway clearance techniques'.)

A general overview of pulmonary rehabilitation for COPD, including a discussion of the benefits, components, and duration, is presented elsewhere. (See "Pulmonary rehabilitation in COPD".)

The benefits of pulmonary rehabilitation in patients with severe chronic respiratory disease can be illustrated by the following reports:

In one report of 40 patients with severe COPD, 16 weeks of inpatient pulmonary rehabilitation (mainly breathing retraining and exercise) resulted in clinically significant improvement in the Six-Minute Walk Test, dyspnea, fatigue, emotional function, and the psychological domains of depression, anxiety, and symptom distress [44].

A subsequent small controlled trial of nine weeks of a home-based pulmonary rehabilitation in 29 patients with severe COPD found significant improvements in exercise tolerance and QOL that were maintained at six months, as well as improvement in dyspnea [45].

Patients with interstitial lung diseases such as idiopathic pulmonary fibrosis (IPF) can also benefit from pulmonary rehabilitation, although the evidence base is more limited than it is for COPD. In a randomized controlled trial of exercise-based pulmonary rehabilitation (eight-week exercise training program two days per week consisting of stationary cycling and treadmill walking) versus weekly telephone support in 57 patients with interstitial lung disease (including 34 with IPF) [46], exercise tolerance was assessed using a Six-Minute Walk Distance (6MWD) test and a symptom-limited cycle ergometer test. The 6MWD increased following training (mean difference to control 35 m, 95% CI 6 to 64 m), and this was accompanied by significant improvements in dyspnea and fatigue. However, the benefits were not maintained at six months.

Advanced heart failure — Advanced heart failure (HF) typically leads to recurrent hospitalization which, in turn, impacts physical function. Inactivity leads to muscle atrophy which leads to exercise intolerance and deconditioning; skeletal muscle dysfunction can also involve the respiratory muscles which contribute to fatigue and dyspnea on exertion. Deconditioning is usually not adequately addressed with medical management alone, resulting in further inactivity to avoid symptoms. (See "Cardiac rehabilitation in patients with heart failure", section on 'Rationale'.)

Cardiac rehabilitation can be an appropriate option for patients with stable class II to III HF (table 4) who do not have advanced arrhythmias and who do not have other limitations to exercise (table 5 and table 6). There are insufficient data that recommend cardiac rehabilitation for patients with class IV HF. (See "Cardiac rehabilitation in patients with heart failure", section on 'Indications' and "Cardiac rehabilitation programs", section on 'Risk stratification for exercise'.)

A comprehensive cardiac rehabilitation program includes aerobic training (continuous and interval), physical activity counseling, psychosocial support, and risk factor education for weight control and smoking cessation [47]. There are no set guidelines; the individual program must be individualized. (See "Cardiac rehabilitation in patients with heart failure", section on 'Components'.)

Exercise can improve clinical and prognostic outcomes in patients with heart failure. Multiple studies of exercise demonstrate improved exercise tolerance, dyspnea, fatigue, QOL, ability to perform ADLs, decreased anxiety and depression, reduced rates of hospital readmission, and cardiac mortality without an adverse impact on left ventricular function, as long as patients are appropriately selected. (See "Cardiac rehabilitation in patients with heart failure", section on 'Evidence on effects of exercise'.)

The two methods of aerobic training typically used for patients with heart failure are continuous and interval training. No set guidelines exist and the program must be individualized. A comprehensive cardiac rehabilitation program also includes physical activity counseling, psychosocial support, and risk factor education for weight control and smoking cessation [47].

Neurodegenerative disorders — A variety of neurodegenerative conditions, including ALS, Parkinson disease and other movement disorders, and Alzheimer disease are characterized by progressive and inexorable loss of neurologic function, which usually culminates in loss of mobility and independence.

ALS – ALS is a progressive and degenerative neurologic disease affecting motor neurons disrupting muscle control characterized by lower motor neuron defects (muscle atrophy, axial muscle weakness, respiratory muscle weakness, loss of arm strength and dexterity, weakness of speech and swallowing) and upper motor neuron loss (incoordination). On top of their motor impairment, patients have high burdens of pain, fatigue, dyspnea, and sialorrhea. The natural history of ALS is characterized by a relentlessly progressive course that is characterized by diffuse weakness and skeletal muscle wasting, and frequently accompanied by dysarthria, dysphagia, and failure of the muscles that support respiration. The main focus of palliative care as the disease progresses is proactive management of symptoms such as pain, shortness of breath, and dysphagia.

ALS Centers have been developed to facilitate multidisciplinary care which includes rehabilitation at every phase of the illness [48], and American and European guidelines emphasize the preference for multidisciplinary care for all people affected by ALS. The focus is to prolong and maintain independence, maximize quality of life, and avoid complications. Over the spectrum of the disease’s natural history, patients can benefit from individualized rehabilitation interventions with the goal of optimizing independence, function, and safety [49], although the evidence base to support benefit from multidisciplinary rehabilitation and physiotherapy is of low quality [50,51]. (See "Symptom-based management of amyotrophic lateral sclerosis", section on 'Multidisciplinary care'.)

For patients with ALS, physical therapists may initially intervene using gait and balance training [52]. As the disease progresses, recommendations for a manual or power wheelchair will be offered and fitted for appropriate patients. Among patients with swallowing dysfunction, assessment by a speech language pathologist may identify compensatory swallowing strategies, behavioral changes, and dietary modifications that may increase the safety of swallowing. (See 'Speech and language pathology therapist' below and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)

Dementia – Among patients with Alzheimer disease, data from randomized trials and meta-analyses suggest that physiotherapy interventions can improve QOL as well as cognitive and physical skill [53-56]. This subject is discussed in detail elsewhere. (See "Treatment of dementia", section on 'Rehabilitation'.)

Among patients with Alzheimer disease, data from randomized trials and meta-analyses suggest that physiotherapy interventions can improve QOL as well as cognitive and physical skill [54-56].

Parkinson disease – Among the benefits of multidisciplinary rehabilitation in patients with Parkinson disease (PD) are improved sleep quality and physical performance, including gait and balance [57-61].

In a retrospective study by Frazzitta et al, a 28-day multidisciplinary intensive rehabilitation program consisting of three one-hour sessions of cardiovascular warm-up, relaxation, muscle stretching, balance, and gait training, and occupational therapy improved Parkinson Disease Sleep Scale (PDSS) scores for sleep quality, motor symptoms, and daytime somnolence [57].

In a 2016 randomized cross-over trial involving 23 PD subjects who were randomly allocated to three months of active balance exercises versus usual care, the intervention resulted in a 37 percent decline in the rate of falls per month [58]. A second randomized controlled trial comparing the effects of power training and high-speed yoga programs on the physical performance of PD patients showed that both training groups can significantly improve physical performance of older PD patients except in the areas of functional reach and postural sway [58,59].

There is growing evidence that suggests that exercise-dependent plasticity constitutes the main mechanism underlying the effects of physiotherapy. Exercise increases synaptic strength and influences neurotransmission, thus potentiating functional circuitry in Parkinson disease. A pooled analysis of 39 randomized trials of physiotherapy intervention on PD revealed that physiotherapy results in short term improvement (<3 months) in gait outcomes for speed, two or six minute walk tests, functional mobility and balance outcomes of Timed Up and Go test, Functional Reach test, Berg Balance Scale, and the clinician-rated disability using the Unified PD Rating Scale (UPDRS) [60,61].

Other — Other populations who might conceivably be managed by palliative care include geriatric patients with organ failure (eg, heart failure and end-stage lung disease), in whom there is frequently a progressively downward, irregular, and protracted trajectory of dying with unpredictably timed yet repeated exacerbations often requiring hospitalizations. There may be a short window of opportunity, during and immediately after acute hospitalization, to provide rehabilitation services in order to regain lost ADL capabilities [62]. Issues specific to rehabilitation for geriatric patients are discussed in detail elsewhere. (See "Overview of geriatric rehabilitation: Program components and settings for rehabilitation" and "Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation".)

Underutilization of rehabilitation — In general, rehabilitation is underutilized in palliative care patients [18,19,63,64]. In one institution-based registry of 529 older adults with cancer, 111 had functional deficits that were potentially modifiable, yet only 10 (9 percent) received physical or occupational therapy with 12 months of a noted deficit [18]. Undertreatment of remediable physical impairments may be particularly prominent among minority and socioeconomically disadvantaged groups [19].

It is often thought that physical therapy and rehabilitation are not cost-effective, particularly for patients approaching the end-stage phase of their illness. However, limited evidence from randomized trials suggest that rehabilitation is cost-effective, at least for patients with advanced cancer [36,65,66]. The evidence base for cost-effectiveness in other palliative care populations, including patients with ALS, is very limited [48,50]. In patients with COPD, several uncontrolled studies suggest that pulmonary rehabilitation decreases total hospital stay and recurrent hospitalization rates but the benefits have been less clear in controlled studies. (See "Pulmonary rehabilitation in COPD", section on 'Health care utilization'.)

Risks of rehabilitation — It is widely maintained that exercise and physical activity exacerbates fatigue, however, there is little, if any, evidence to support this assertion. In fact, several studies affirm the observation that physical exercise improves fatigue, even in dying patients, and that the provision of physical therapy does not worsen physical distress in patients with advanced cancer [38,67,68]. However, this issue has not been studied systematically.

Other potential risks of physical therapy include aggravation of pain from manipulation or exercise, straining bones with metastatic disease that have impending fractures, cardiovascular risk, and falls. The magnitude of these risks and how best to avoid them has not been systematically studied. However, individualization of the rehabilitation regimen, especially for patients with metastatic bone disease or central nervous system metastases, is essential to ensure the safety and appropriateness of the rehabilitation program.

Patient assessment for rehabilitation planning — A thorough patient assessment for rehabilitation potential involves gathering information on disease location and stage, previous and current therapies, estimated life expectancy, comorbidities, pain and non-pain symptoms, medications, cognition, mood, nutritional status, and physical function. A complete physical examination with special attention to the neurologic and musculoskeletal system is essential to evaluate motor strength, sensory deficits, joint flexibility, gait pattern, and fall risk. An evaluation of the home environment, the availability of community resources, and financial resources should also be carried out [13].

Using a systematized evaluation process will help to determine the patient's current level of disability, previous level of functioning, and potential to regain function, which are all important components of rehabilitation planning. Ideally, patient evaluation and planning for rehabilitation should be performed by an interdisciplinary team led by a physiatrist experienced in hospice and palliative medicine along with clinicians specializing in physical therapy, occupational therapy, speech therapy, nursing, nutrition, psychology, respiratory therapy, recreation therapy, and case management.

A variety of functional assessment tools may be utilized to assess function during the planning process for rehabilitation therapy palliative care (table 2). The choice of the specific tool will depend on the goal of the rehabilitation process and the functional capacity of the individual.

DELIVERY OF REHABILITATIVE SERVICES

Setting — Settings for delivery of rehabilitation services for palliative care patients include the acute care hospital, freestanding rehabilitation hospitals, skilled nursing facilities, outpatient clinics, hospice settings (acute inpatient, long term care, and home with hospice), and home. The intensity and scope of services differ across care settings, and the choice of the setting depends on a number of factors including the type of illness, the overall disease course and the specific goals of care and wishes/preferences of the patient. In addition, similar to non-palliative care patients, the choice of the setting is dependent on medical stability, cognition, therapy tolerance and motivation, types of needed medical services, psychosocial factors, and at least in the United States, insurance. Many of these issues, including issues related to reimbursement, are discussed in more detail elsewhere. (See "Overview of geriatric rehabilitation: Program components and settings for rehabilitation", section on 'Optimal level of postacute rehabilitation'.)

The following is a brief description of the major settings in which rehabilitation therapy can take place for palliative care patients.

Acute inpatient rehabilitation — Inpatient rehabilitation facilities (IRFs) are dedicated, free standing facilities designed for patients who have the potential for significant functional improvement or adaptation to permanent impairments within a prescribed period of time. There is emphasis on an intensive and coordinated interdisciplinary approach. Patients suitable for inpatient rehabilitation should be able to tolerate three hours of daily therapy five times per week, and need active and ongoing rehabilitation intervention from multiple disciplines, at least one of which is physical therapy or occupational therapy. Inpatient rehabilitation programs are supervised by a rehabilitation physician (a physiatrist) with face-to-face visits at least three days per week. Acute inpatient rehabilitation is generally covered by Medicare Part A, Medicaid, and private insurers.

Subacute rehabilitation — Subacute rehabilitation, which is typically carried out in a skilled nursing facility (SNF) with rehabilitation services, offers coordinated interdisciplinary services to patients who can tolerate at least one hour of therapy each day. Subacute rehabilitation may also serve as a transitional program prior to discharge from a medical or surgical unit, and for respite care.

For patients in the United States, reimbursement issues must be considered. For patients covered by Medicare Part A in the United States, there are specific criteria for eligibility for subacute rehabilitation. The beneficiary must have been a hospital inpatient with a medically necessary stay of at least three consecutive calendar days; time spent in an emergency department or hospitalized with observation status does not count toward the qualifying three days. The beneficiary must also have been transferred to a participating skilled nursing facility (SNF) within 30 days after discharge from the hospital.

Additional criteria for a skilled nursing level of care must also apply, including that the patient requires skilled services on a daily basis. Skilled services include: medication management, catheter changes, or wound care.

Outpatient rehabilitation — Outpatient rehabilitation offers comprehensive interdisciplinary or single rehabilitation services for patients living in the community. Outpatient rehabilitation can be delivered in private offices of rehabilitation therapists, physician offices, outpatient hospital departments including critical access hospitals, rehabilitation agencies (also called other rehabilitation facilities [ORFs]), comprehensive outpatient rehabilitation facilities (CORFs), and skilled nursing facilities (SNFs) when Medicare Part A does not apply.

In the United States, Medicare law limits how much it pays for medically necessary outpatient therapy services in one calendar year. These limits are called "therapy caps" or "therapy cap limits” [69]. After patients pay their yearly deductible for Medicare Part B (Medical Insurance), Medicare pays its share (80 percent), and patients pay their share (20 percent) of the cost for the outpatient therapy services. Medicare will pay its share for therapy services until the total amount paid by both patient and Medicare reaches a therapy cap limit. Amounts paid by the patient may include deductibles and coinsurance.

Home-based rehabilitation — Home-based rehabilitation may be appropriate for patients whose rehabilitation needs are not extensive, or whose performance or functional status precludes them from more intensive rehabilitation programs. Home-based rehabilitation is usually offered through home care and home hospice programs, and most can provide physical therapy, occupational therapy, speech therapy, social work, and skilled nursing care on an intermittent basis to home-confined patients who are not necessarily bedridden. Rehabilitation therapies are not offered on a daily basis, and the services provided are contingent upon the skilled need of the patient and the goals to be attained. A physician must certify a skilled nursing or rehabilitation need for eligible patients to help them recover from illness, injury, or an acute condition. Medicare Part A, Medicaid, and most private insurances cover this level of service [70,71].

Medicare hospice benefits allow for physical therapy, occupational therapy, and speech and language pathology services to be provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills [72]. All services must be provided in accordance with professional standards of practice [73]. These services are offered in a variety of hospice settings to include home hospice, acute inpatient hospice, and long-term care with hospice. The American Physical Therapy Association Code of Ethics for the physical therapist and Standards of Ethical Conduct for the physical therapy assistant state that physical therapists and their assistants shall act in the best interests of their clients/patients in all practice settings, including hospice [74].

Roles of the specific specialists — Ideally, the rehabilitation plan should be developed by an interdisciplinary team led by a physiatrist with experience in hospice and palliative medicine. The team may be comprised of a physical therapist, occupational therapist, speech therapist, psychologist, nurse, nutritionist, respiratory therapist, recreational therapist, pharmacist, prosthetist-orthotist, and case manager/social worker [75]. The primary roles and functions of the members of the multidisciplinary rehabilitation team are outlined in the table (table 7), and specific roles that pertain to palliative care patients for the physiatrist and occupational, physical, and speech-language pathology therapists are discussed in more detail below.

Some cancer outpatient rehabilitation programs have additional members such as an enterostomal therapist, vocational counselor, sex therapist, dentist, psychiatrist, dental hygienist, and maxillofacial prosthetist.

Physical therapist — The prominent role of the physical therapist cannot be overemphasized in palliative care [76,77]. Physiotherapists view their role as helping maximize independence and improve quality of life; these views are consistent with the overall philosophy of palliative care. The input of the physical therapist is invaluable in determining the correct level of rehabilitative care and setting for a patient after discharge from the hospital. (See 'Delivery of rehabilitative services' above.)

Physical therapists treat common functional disabilities such as deconditioning, pain, imbalance, and localized weakness. Functional tasks that are appropriately addressed by physical therapy in a rehabilitative program include [13]:

Bed mobility – Rolling, positioning for comfort and/or pressure relief, bridging (lifting pelvis off the bed), moving supine to sit and sit to supine

Transfers – Set up (ie, positioning of wheelchair in relation to bed), sit to stand, pivot (or slide), stand to sit

Ambulation or gait – Gait assessment, assistive device placement, foot placement  

Specific interventions — Specific interventions utilized by physical therapy include physical modalities for pain control, provision of adaptive and assistive equipment, environmental modification, education on energy conservation/preservation, therapeutic exercises, and work simplification techniques [78]:

Examples of physical modalities used by physical therapists to treat pain include massage, heat, cold, ultrasound, diathermy, manual lymphatic drainage (which when used in combination with compression therapy is referred to as complete decongestive therapy), soft tissue mobilization, and transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) devices [79]. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Physical modalities' and "Breast cancer associated lymphedema", section on 'Complete decongestive therapy' and "Clinical staging and conservative management of peripheral lymphedema", section on 'Physiotherapy'.)

Modifications to lymphatic massage therapy that may be necessary for palliative care patients are discussed in detail separately. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Modifications for patients in palliative care'.)

In addition to massage, other pain-relieving techniques for manual physical therapy include myofascial release, trigger point therapy, traction therapy, and compression therapy. (See "Clinical staging and conservative management of peripheral lymphedema" and "Breast cancer associated lymphedema".)

Physical therapists can make recommendations for the type of equipment that patients may benefit from based upon their level and type of physical impairment. There are two types of devices – assistive and adaptive. Assistive equipment pertains to devices that may help with ambulation, mobility, balance, pain, fatigue, muscle weakness, joint instability, excessive skeletal loading, and elimination of weight bearing on an affected extremity (eg, crutches, canes, walkers, wheelchairs, scooters, lifts, ramps, and transfer boards). Adaptive equipment, on the other hand, pertains to devices used to improve performance in activities of daily living (ADLs, eg, functional reachers, one-handed cutting boards, rocker knives, and sandwich holders for cooking and eating). Further discussion of specific assistive and adaptive devices, including reimbursement guidelines in the United States, is provided elsewhere. (See "Overview of geriatric rehabilitation: Program components and settings for rehabilitation", section on 'Assistive technology'.)

Physical therapists also provide recommendations for orthotic devices as appropriate for joint stability and safety, especially in patients with motor deficits. Examples include upper extremity orthotics to assist with manipulation of objects, lower extremity orthotics such as splints to promote joint stability and muscle function, and truncal orthotics for osseous instability. Phantom limb pain or stump pain may be ameliorated by a well-fitting prosthesis or the use of an assistive device such as a cane or walker to help in ambulation.

In addition, physical therapists can work with patients, families, and caregivers in providing strategies for safe environmental manipulation or modification to allow for a suitable living or working environment for patients [80]. Examples include placing a recliner on a platform to assist with transfer, having a high stool in the kitchen to reach a cupboard, and adjusting the height and arms of the chair to assist in transfer. (See "Overview of geriatric rehabilitation: Program components and settings for rehabilitation", section on 'Environmental modification' and "Overview of geriatric rehabilitation: Program components and settings for rehabilitation", section on 'Prosthetics and orthotics'.)

Another major role for physical therapy is providing education. For patients with fatigue, energy conservation and management strategies may be taught (table 8 and table 9). (See "Cancer-related fatigue: Treatment", section on 'Nonpharmacologic interventions'.)

Education may also be provided to patients and caregivers regarding good body mechanics to promote balance and safety, and prevent falls.

Physical therapists can often help put together a home exercise program for patients to follow at home. Therapeutic exercise comprises a range of techniques that can be applied in anatomical planes or as functional movement direction. The types of movement include active movement, assisted active movement, resistive movement, assisted-resistive active movement, and passive movement. Examples of therapeutic exercise techniques include relaxation, massage, muscle reeducation, floor aerobics, suspension therapy, progressive resisted exercise, breathing exercise, postural training, work simulation, work conditioning, work hardening, proprioceptive neuromuscular facilitation using facilitation and inhibition techniques, graded activity program, and cognitive behavioral training [81]. Therapeutic exercise may improve body mechanics through its beneficial effects on muscle strength, joint flexibility, range of motion, and balance. Reconditioning programs for patients with advanced illness such as cancer or other serious illnesses generally include graded aerobic and stretching exercises. Examples of equipment that promote aerobic exercise are treadmills, ergometers, and rowing machines.

Mechanical modalities of therapy include traction therapy, compression therapy, therapeutic taping, and continuous passive motion.

Occupational therapist — The occupational therapist (OT) screens for and monitors performance deficits to modify and meet the changing needs of palliative care patients. OT assesses and provides treatment programs in the functional areas such as ADLs, work tasks, employment and role-related tasks, recreation, use of adaptive equipment, and discharge planning. Functional tasks addressed by OT include [13]:

Self-care – Bathing; dressing; grooming; toileting; self-feeding

Transfers as they relate to ADLs and home management – Shower or tub transfers; toilet transfers; retrieving objects from the floor, cupboards, or high shelves; carrying objects

Home management – Food preparation; managing faucets, lights, doors, drawers; use of remote controls, phone, home appliances; food management (grocery list compilation, shopping); social management (transportation, calendar, communications); money management

The effectiveness of OT for promoting feeding independence was shown in a study of 36 patients with terminal cancer who were receiving palliative care [82]. Through the use of positioning, feeding aid support, and upper limb support, self-feeding improved significantly after only one week, and improvements were maintained through week three.

Speech and language pathology therapist — For patients with serious life-threatening illness, speech language pathologists can help communication and swallowing function. Their goal is to optimize the patient’s ability to communicate effectively, and to assist in optimizing function and patient satisfaction that emphasizes the safest way to eat [83,84].

The functional tasks that are addressed by speech and language therapy include [13]:

Receiving information – Auditory, visual, and reading comprehension by the patient

Communicating information (expressing needs) – Verbal expression; nonverbal and graphic expression; speech intelligibility; voice quality and volume; prosody (change in pitch, stress, intensity, and duration of sound); latency of response

Feeding/swallowing disorders – Tongue coordination; lip closure; bolus control; transit time; food management (eg, pocketing); swallow reflex; cough or choke during swallow or change in voice quality following intake; consistency of foods or liquids tolerated; presence of regurgitation

The functional activities supervised by speech and language therapists overlap with occupational therapists insofar as eating or feeding is a part of ADL. The clear delineation is that occupational therapists specifically address the ability to get the food into the mouth while speech and language pathology therapists address what occurs between the lips and the stomach.

Assessment and management of swallowing disorders in palliative care patients are addressed separately. (See "Swallowing disorders and aspiration in palliative care: Definition, consequences, pathophysiology, and etiology" and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)

DISCONTINUATION OF SERVICES — Discharge planning is an integral component of any rehabilitation program across various settings. This dynamic interdisciplinary process should consider the patient's progress toward meeting the preestablished rehabilitation goals, whether goals of care have changed that affect the decision to continue the rehabilitation program, the degree of caregiver support needed after the rehabilitation program, or the setting in which the patient will receive subsequent care.

In general, rehabilitation facilities have protocols in place for deciding whether and when patients will be discharged from their services. The most common reasons for discontinuation of services in both the inpatient and outpatient rehabilitation venues are as follows [85]:

Patients have reached their maximum rehabilitative potential based upon existing goals.

Treatment services are refused by the patient and/or his or her family.

Needed treatment services are not offered by physical or occupational therapy.

Referral to a different agency or department may meet the patient's needs.

Changes in the patient's condition preclude further rehabilitation services (eg, active dying state).

Patient is discharged from the hospital or inpatient facility.

Patient's goals of care have changed and preclude further continuation of rehabilitation therapy services (no longer contributes to the meaning of quality of life for the patient and/or family).

Guidelines for discontinuation of physical therapy, occupational therapy, and speech language pathology services are available from professional groups such as the American Physical Therapy Association [86], the American Occupational Therapy Association [87], and the American Speech-Language-Hearing Association [84]. However, none of these guidelines specifically addresses indications for discontinuing services in palliative care patients, and they are of limited utility in this setting.

SUMMARY

For patients with a broad range of serious life-threatening illnesses, including advanced cancer, advanced heart failure, chronic obstructive pulmonary disease (COPD), dementia, and chronic neurodegenerative conditions such as amyotrophic lateral sclerosis (ALS), loss of function and independence is a common struggle and a significant contributor to diminished quality of life (QOL). Rehabilitation is an integral component of a holistic palliative care approach that enables people to maintain optimal levels of functioning, regardless of life expectancy. Even in the advanced phases of an illness, rehabilitation can help patients to retain mobility and independence, and improve symptoms, all of which can contribute to a reduced burden on families and caregivers, and better QOL [5]. (See 'Introduction' above.)

Rehabilitation of palliative care patients requires a multidimensional approach to meet the physical, emotional, social, and spiritual needs of patients and their families. Teams are interdisciplinary and can include PT, OT, speech language pathology (SLP), as well as psychologists, dieticians, nurses, chaplains, and case managers/social workers. (See 'Overview of rehabilitation in palliative care' above.)

For patients in the palliative care setting, the goal of rehabilitation can differ, depending upon the patient’s preferences and values, as well as physical needs and availability of social support. (See 'Goals' above.)

The application of rehabilitation in the hospice and palliative care settings is feasible, safe, and provides numerous benefits, both with cancer and noncancer diagnoses. For patients with cancer, rehabilitation can help manage refractory pain, fatigue, dyspnea, deconditioning after a prolonged hospitalization, and swallowing disorders resulting from the effects of the cancer or its treatment. (See 'Cancer' above and "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Rehabilitation and physical medicine interventions' and "Cancer-related fatigue: Treatment", section on 'Exercise' and "Assessment and management of dyspnea in palliative care", section on 'Pulmonary rehabilitation and respiratory therapy' and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)

For patients with noncancer diseases, rehabilitation can help manage symptoms, improve physical performance, and maintain overall quality of life. (See 'Other diseases' above.)

Potential risks of rehabilitation include aggravation of pain and fatigue. The magnitude of these risks and how best to avoid them has not been systematically studied. Individualized decision making about rehabilitation is required. (See 'Risks of rehabilitation' above.)

A thorough patient assessment for rehabilitation potential involves gathering information on disease location and stage, previous and current therapies, estimated life expectancy, comorbidities, pain and non-pain symptoms, medications, cognition, mood, nutritional status, and physical function. A variety of functional assessment tools may be utilized to assess function during the planning process (table 2). (See 'Patient assessment for rehabilitation planning' above.)

Settings for delivery of rehabilitation services to palliative care patients include the acute care hospital, freestanding rehabilitation hospitals, skilled nursing facilities, outpatient clinics, hospice units, and the home environment. The intensity and scope of services differ across care settings, and the choice of the setting depends on a number of factors including the specific goals of care and wishes/preferences of the patient, therapy tolerance and motivation, types of needed medical services, and at least in the United States, reimbursement. (See 'Setting' above.)

Functional tasks that are appropriately addressed by physical therapy in a rehabilitative program include bed mobility, transfers, and ambulation/gait. Specific interventions utilized by physical therapy include physical modalities for pain control, provision of adaptive and assistive equipment, environmental modification, education on energy conservation/preservation, therapeutic exercises, and work simplification techniques. (See 'Physical therapist' above.)

The occupational therapist (OT) screens for and monitors performance deficits to modify and meet the changing needs of palliative care patients. Functional tasks that are appropriately addressed by occupational therapy include self-care, transfers as they relate to activities of daily living (ADLs), and home management. (See 'Occupational therapist' above.)

The role of the speech language pathologist is to provide consultation in the areas of communication, cognition, and swallowing function, optimize the patient’s ability to communicate effectively, and to assist in optimizing function and patient satisfaction that emphasizes the safest way to eat. (See 'Speech and language pathology therapist' above.)

Discharge planning is an integral component of any rehabilitation program across various settings. This dynamic interdisciplinary process should consider the patient's progress toward meeting the preestablished rehabilitation goals, whether goals of care have changed that affect the decision to continue the rehabilitation program, the degree of caregiver support needed after the rehabilitation program, or the setting in which the patient will receive subsequent care. (See 'Discontinuation of services' above.)

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