PTA 2750 Term Research Project: Physical Therapy in Hospice

Written by: Rebekah Sanborn

Statement of Purpose: This research project is aimed at presenting the role of physical therapy in
hospice care, particularly by describing common physical therapy (PT) goals with hospice patients
(articles 1, 4, 6), common PT interventions delivered (articles 2, 3, 4, 5), common diagnoses treated
(articles 2, 3, 4, 5), and common outcomes in the hospice population (article 4, 5). Also included is a
discussion of the professional skills needed before considering becoming involved in delivering physical
therapy in the hospice setting (articles 5, 6, 7).
Content:
After reviewing seven articles of how physical therapy fits in the hospice setting, I learned of 1) current
research studies performed to identify the effectiveness of physical therapy in hospice care, 2) common
interventions provided in the hospice setting, 3) the difference between physical rehabilitation and
rehabilitation in reverse, and 4) gained an appreciation for the skill set of those individuals who work
as healthcare professionals in the hospice setting.
The word hospice is defined in the Webster dictionary as a place of refuge for a weary traveler. I
found no better way to think of a patient receiving hospice care as anyone other than a weary traveler.
In thinking this way, we can wrap our minds around the fact that a hospice patient is ending his/her life
journey; they are weary but still living the journey. Their most recent travels may have included
multiple visits to various healthcare appointments and treatments to try and heal their condition, but
they now have come to the place where they know they will soon meet their journeys end.
What role can physical therapy have at the end of a persons life? Improving quality of life, increasing
mobility, and supporting family/caretakers with education on how to transfer or encourage exercise in
their loved one are some of the primary roles. Research tells of the benefits, effective
interventions/techniques used, and common diagnoses encountered in the hospice setting.

Discussion:
Article #1 points out the stages of disease including 1) Preventative, 2) Restorative, 3) Supportive, and 4)
Palliative (Hospice). It summarizes the primary goal of physical therapy in hospice care to be reducing
the dependence in mobility and self-care activities in association with the provision of comfort and
emotional support. Article #5 states it well in that hospice care is directed primarily at symptom control,
not disease control. The common symptoms of the progression of a disease lead to 1) high levels of
functional loss, 2) dependency for ADLs, and 3) mobility dysfunction. These factors then lead to
deconditioning, fatigue, complications from other medical therapies, under-nutrition, neurological and
musculoskeletal problems, pain, bowel/bladder dysfunction, depression, and coexisting morbidities.
Quality of life has been found to directly relate to the physical strength a person maintains, the number
of hours spent daily in bed, and whether one has the ability to do what one wants. Maintaining the
highest level of functional ability, particularly mobility, for as long as possible is one benefit physical
therapy can offer. The article lists twelve common tests used in the hospice setting for assessing
patients physical abilities. A description of exactly what each test measures and what the score
indicates is also presented. The tests include:
Physical Function Measurement Tools

Balance/Fall Risk Measurement Tools

Karnofsky Performance Scale (KPS)measures

Palliative Performance Scale (PPS)
Eastern Cooperative Oncologic Scale
(ECOG)
Edmonton Functional Assessment Tool
(EFAT)
Katz Activities of Daily Living
Lawton Instrumental Activities of Daily
Living
Barthel Index
Functional Independence Measure
(FIM)

Berg Balance Test

Tinetti Assessment of Balance and Gait
Timed Up and Go Test

Endurance Measurement Tool

6-minute Walk Test (6MWT)

Article #2 provides a critical review of hospice care with a focus from symptom control to quality of life
of the patient. This articles purpose is to explain the role of physical therapy in a hospice care team by
providing a detailed view of physical therapy treatment methods and evidence in support of applying
them into conditions requiring hospice care. It reports 30% of total cancer deaths are related to poor
exercise and nutrition, which contributes to as many as 250,000 premature deaths per year. Physical
therapy can help through hosting group exercise therapy, energy conservation techniques, and effective
maintenance strategies for cancer related fatigue. Additional treatment avenues by physical therapy
can target ambulation and musculoskeletal disorders, neurological issues, respiratory issues,
decongestive therapy, pain decrease through use of electrophysical and/or mechanical agents, massage,
thermal modalities, and TENS can be useful for cancer patients.
Evidence of the application of physical therapy in different capacities with the diagnoses of multiple
sclerosis, ALS, Alzheimers, brain injury, spinal cord injury, and AIDS/HIV are also presented. In MS
patients, physical therapy is the mainstay in the management of spasticity besides drugs. Physical
activity in these patients is indirectly associated with improved QOL by effecting fatigue level, pain,
social support, and self-efficacy with reduced functional limitations. Regular physical activity in
Alzheimers patients showed benefits overall on the patients QOL. SCI patients reported less pain,
depression, stress, and increased QOL with a better physical self-concept after a program of aerobic and
resistance exercise training. Music therapy showed significant positive effect on mood and social
interaction in TBI and CVA patients. In stroke rehab, the most recent therapeutic advance is the use of
motor imagery and mental practice techniques. People living with AIDs or HIV benefitted from
therapeutic massage while cognitive behavioral interactions had a positive effect on mental functioning
and also immune function.
Article #3 reports on a study conducted in Michigan examining the utilization of PT in hospice care as
reported by hospice care unit administrators via survey questionnaire. The article was presented at the

APTA CSM meeting in February 2008. Unfortunately, of the 133 surveys e-mailed to administrators in
this study, only 31 were completed and returned. The questions on the survey, including both
structured and free response, were asked to determine 1) the number of individuals who received PT
care at the unit, 2) medical diagnoses of those patients, 3) most common diagnoses treated with PT, 4)
PT interventions used, and 5) the treatment outcomes of those patients. The result of the study
concluded that 2.4-3.0% of individuals in hospice care settings received PT care. This is in stark contrast
to the results from other articles which found referral rate for PT in the hospice setting to be 65%
(article #5), 26% (*Yoshioka), and 37% (*Montagnini) of patients. The most common diagnoses referred
to PT included stroke, cancer, MS, and heart disease. The least common included osteoporosis, kidney
disease, diabetes, and liver disease. The most common PT problems treated were decreased mobility,
fall risk, decreased balance/coordination, and gait training. Other less reported problems included
caregiver lack of knowledge, caregiver physical/emotional stress, foot drop, and decreased ability to
transfer. The most common PT interventions utilized were caregiver education, fall prevention, range of
motion exercises, patient education, and strength training. The least common were traction and
breathing techniques. The most common reported treatment outcomes in this study included increased
confidence in caregiver, improved QOL/well-being, increase patient safety, improved mobility,
improvement in depression/anxiety, increased endurance, and decreased pain. These reports coincide
with those found in article #5.
Article #4 presents a case study of a 68 year-old male hospice patient referred to physical therapy after
suffering from a fall that resulted in the patient being bed ridden for 5 weeks due to an increased fear of
falling. The patient was referred for strengthening and transfer training. This case study is a prime
example of a very positive outcome in the treatment of a hospice patient. As mentioned in previous
articles, QOL was greatly enhanced through physical therapy intervention with this individual. The
patients treatment goals were 1) the caregiver was to safely transfer the patient using appropriate

equipment and technique, 2) reduce the risk and fear of falling, 3) ambulate 20 feet, to the patio, with a
walker and minimal assist, and 4) independence with a HEP for strength and flexibility. The result after
10 physical therapy treatments over 8 weeks were that patient met every goal. The initial goal of safety
with transfers was achieved by the 5th visit. After intervention completion, the Tinetti balance score
improved 9 points to 16/28, the MQOL score changed from 66 to 100, and the patient ambulated 40
feet with contact guard assistance, use of a walker, and gait belt. The patient stated, The benefits were
immeasurable. He had more confidence after the intervention and his quality of life returned. The
patients caregiver, his wife, stated that physical therapy made all the difference. Without PT
instruction, someone was going to get hurt. It took away the fear.
Article #5 presents a study conducted in Limerick, Ireland at a specialist hospice care inpatient unit
aimed at informing the international community of hospice physical therapy practice and to providing a
comparison for future research. A validated palliative care tool, the Edmonton Functional Assessment
Tool (EFAT-2), was used to measure patient outcomes. This tool measures 10 domains that may affect
function: communication, pain, mental status, dyspnea, balance, mobility, locomotion, daily activities,
fatigue, and motivation. The study design consisted of a retrospective chart audit over 6 months
covering 195 persons. End-of-life care was provided for 54% of the patients, while the remaining 46%
received symptom control and/or rehabilitation. Of the 195 persons, 162 were referred to
physiotherapy; 8% deteriorated clinically before assessment; therefore, 58% (n=144) were assessed and
included in the audit. The most common diagnoses referred to physical therapy in this setting were
cancer diagnoses (92.3%) including lung, bowel, gynecological, other GI, breast, prostate, and brain
making up the majority. Heart failure, motor neuron disease, and multiple sclerosis were the most
common non-malignant diagnoses.
The referral rate to physical therapy in this hospice setting was high (65%) compared with previous
literature for referral rate percentages. *Yoshioka and *Montagnini showed rates of 26% and 37%

respectively. An even starker contrast is found between the referral rate from my third article in the
Michigan study of a 3% referral rate for physical therapy in palliative care units. The article suggests this
may be due to the necessity for treatments to conform to insurance company criteria, which may impact
negatively on utilization rates. Interventions used for treatment included gait re-education (prescription
of walking aids, walking practice), transfer training ( patient training, advice to staff), exercise (aerobic,
resistance, balance exercises, passive movements, positioning), respiratory (breathlessness,
management, pulmonary rehabilitation), pain relief (heat, ice, manual therapy, electrical modalities),
psychological support (supportive discussions, relaxation), patient education, education of
family/caregivers, and lymphedema treatments. The most common interventions used in this setting
were gait training (67%), transfer training (58%), and exercise (53%) which is in common with the
findings in article three at the Michigan hospice care units and *Yoshiokas findings in his 1994 research.
The median therapy program lasted 11 days, but was frequently suspended because of sudden clinical
changes, priority given to other therapies, and conflicting desires of the patient, such as visitors and
social activities. One in three attempted treatments were not possible. Average fluctuation was six
points on the EFAT-2 scale throughout the therapy program due to variations in function due to a
patients often progressive declining condition. Physical therapy goals, therefore, change constantly and
treatments are adjusted on a daily basis. Respecting patient choice and allowing for interruptions
requires considerable flexibility.
Article #6 was by far my favorite article I found that describes the role of physical therapy in hospice
care. It describes hospice care as necessary when an individual has an illness for which curative
measures are no longer possible, and for which a physician has determined the patient has a life
expectancy of about 6 months or less. At this time, a hospice team can support the process of death
and dying in a compassionate way. This article points out that one of the cornerstones of a hospice
program is a dedicated team of care providers. The hospice team is described in articles #1 and #5 as

consisting of some or all of the following members: Physical Therapist, Occupational Therapist, Speech
Therapist, Psychologist, Nursing, Nutritionist, Respiratory Therapist, Recreational Therapist, Art/Music
Therapist, Social Worker, Chaplaincy, and Case Management.
Physical therapy has four vital roles in hospice according to this article: 1) maximizing functional ability
and comfort to enhance QOL, 2) assuring patient and caregiver safety, 3) helping people redesign their
lives and life goals, and 4) providing support around physical, emotional, and spiritual issues at the end
of life. Steve Gudas, PT, PhD with a 35-year career dedicated to oncology physical therapy and has been
the namesake of the APTA Oncology Section says, There is always something that physical therapy can
do to provide function or comfort to the patient who is terminally ill. We assist patients in maintaining
their self-identity, while waiting actively for death, achieving a comfort level and confidently using
their remaining abilities as the gradual reduction in functional abilities, roles, and expectations.
According to Gudas, the physical therapists role on the hospice care team is to provide 1) pain
management and relief, 2) positioning to prevent pressure sores, decrease pain, help to prevent
contractures, and aid in breathing and digestion, 3) Endurance training and energy conservation
techniques, 4) gait training, stair climbing, transfers, and safety instruction, 5) therapeutic exercise, 6)
edema management, 7) equipment recommendation, modification, and training, and 8) home
modification recommendations. The hospice physical therapist must also be ready to educate the
patient-family care unit and fellow health professionals, function as a team member, enhance the
patients overall dignity and QOL, provide psychosocial support, and provide self-care as appropriate in
dealing with the therapists own personal life.
As for the rewards of being a PT on a hospice care team, Gudas says, The spirit, the strength, the
courage, the resiliency, and the determination that people have toward the end of life is amazing to
witness. And, it is a privilege to play a role in the process. It is actually life-affirming.

Article #7 comes from APTAs Perspectives magazine as look into whether or not a physical therapy
career in the hospice setting is for you? It states much of the same information found in article #6
regarding the rewards of hospice care and the reverse process of therapy to maintain function in a
declining individual. One major addition this article contributes to the topic of physical therapy in
hospice is a rundown on the professional skills necessary to be good at the job. Rich Briggs, PT, MA who
works in the hospice and home health setting and is an advocate for PT in hospice says you need a fairly
broad clinical background and a solid grounding in acute care and rehabilitation. Many people in
hospice have more than one diagnosis. Therapists need to understand related diagnoses and the end
result of those diagnoses. The therapist may need additional skills to learn about the population and
understand the medications the patients are taking. You have to be comfortable knowing that your
patient may be declining and that its not due to failure on your part. Briggs says, We help our patients
get the best function at all points on the spectrum.
Conclusions:
There is a way to help patientsand their familiesadjust to the change in lifestyle when a terminal
illness takes over ones body. Independence can be held onto for a longer period of time and quality of
life can be maximized by the effects physical therapy has to offer when applied for optimal benefit of
the patient and caretakers involved. The hospice approach is often a tight-knit team of health
professionals who work together with the patient and family to make improvements with mobility,
emotional support, achieving goals in lifes final events, and decreasing reliance on pain medications,
thus improving overall function.
Physical therapy research in the hospice arena has not been researched widely, but its positive impact
on the lives of the patients treated and their families cannot be denied with what existing research is
available on the subject. Many people may not be aware of the benefits of physical therapy in hospice
care and fail to seek it out because of their ignorance.

As far as financial benefits to cover hospice care bills, Rich Briggs, PT, MA states hospice services are
bundled. Like an HMO, you get a certain per diem to care for this patient, and it covers professional
services, equipment, and medications. Physical therapy can be cost saving because it manages pain
without medication, and it may bring some independence to the patient. By increasing their ability to
move, patients may be less likely to develop other medical issues such as bed sores. Or it may take
fewer people to help them walk to the bathroom. As Briggs points out so well, there are multiple
positive results when applying physical therapy in hospice care. I will surely share what I have learned
from this project with anyone in need of it.

Annotated Bibliography
1)

Javier N, Montagnini M. Rehabilitation of the Hospice and Palliative Care Patient. Journal Of
Palliative Medicine [serial online]. May 2011;14(5):638-648. Available from: Academic Search
Premier, Ipswich, MA. Accessed July 31, 2014.
Contribution to project: Article contains the concept, benefits, and role of physical therapy in
the hospice setting. Also, provides the twelve tests used to measure physical function in
hospice patients, and outlines 13 research studies supporting the benefits of physical therapy in
hospice.

2)

Kumar S, Jim A. Physical therapy in palliative care: from symptom control to quality of life: a
critical review. Indian Journal Of Palliative Care [serial online]. September 2010;16(3):138-146.
Available from: CINAHL Complete, Ipswich, MA. Accessed July 31, 2014.
Contribution to project: Article details physical therapy techniques and provides how those
techniques are applied to hospice patients with cancer, neurodegenerative disorders, multiple
sclerosis, Alzheimers disease, spinal cord injuries, brain injuries, respiratory illnesses, HIV/AIDS,
and psychiatric disorders.

3)

Drouin J, Martin K, Onowu N, Berg A, Zuellig L. Physical therapy utilization in hospice and
palliative care settings in Michigan: a descriptive study. Rehabilitation Oncology [serial online].
June 2009;27(2):3-8. Available from: CINAHL Complete, Ipswich, MA. Accessed July 31, 2014.
Contribution to project: This study surveyed hospice care administrators in the State of
Michigan to describe PT utilization patterns. Data gathered provided information on the percent
of individuals who received PT care in these settings, the medical diagnoses most frequently
referred, the most common PT diagnoses treated, the most commonly used PT interventions,
and PT treatment outcomes.

4)

Cobbe S, Kennedy N. Physical Function in Hospice Patients and Physiotherapy Interventions: A

Profile of Hospice Physiotherapy. Journal Of Palliative Medicine [serial online]. July
2012;15(7):760-767. Available from: CINAHL Complete, Ipswich, MA. Accessed August 2, 2014.
Contribution to project: Provision of a positive outcome case-study involving a terminally ill
hospice patient who had remained bed-ridden for 5-weeks after a fall until physical therapy
came in to make all the difference for him. The interventions were focused on transfer
training, strengthening and mobility to help the patient achieve his personal goal of walking to
his patio, and improving overall quality of life with his spouse. The results were that the patient
met each goal including a QOL score improvement from 60 to 100.

5)

Turner F, Seiger C, Devine N. Impact of Patient and Caregiver Transfer Training Provided by a
Physical Therapist in the Hospice Setting: A Case Study. American Journal Of Hospice & Palliative
Medicine [serial online]. March 2013;30(2):204-209. Available from: CINAHL Complete, Ipswich,
MA. Accessed August 2, 2014.

Contribution to project: In-depth research project aimed to inform the international community
practicing physical therapy in hospice care of the rate of referral, functional improvements,
common interventions, outcomes of, and challenges associated with hospice patients. The
study was conducted in Limerick, Ireland at a specialist hospice care unit and involves 195
patients.
6)

Jeyaraman S, Kathiresan G, Gopalsamy K. Hospice: rehabilitation in reverse. Indian Journal Of

Palliative Care [serial online]. September 2010;16(3):111-116. Available from: CINAHL Complete,
Ipswich, MA. Accessed August 2, 2014.
Contribution to project: This article gives a definition of hospice and explains the role of
physical therapy in hospice care within the healthcare hospice team of individuals. It outlines
how physical therapy can specifically intervene to make a difference for the patient and family
care unit. Rewards of being on the hospice care team are also discussed.

7)

Unknown. APTA. Cool Careers: Hospice and Palliative Care. September 2012. Available at
http://www.apta.org/NewProfessionals/CareerManagement/CoolCareers/HospiceandPalliative
Care/. Accessed August 2, 2014.
Contribution to project: This article came from APTAs Perspectives magazine and includes direct
quotes from a hospice PT who has experience and advice for anyone considering working in
hospice care. He describes the role of the physical therapist in hospice care as well as what kind
of goals pursued and results can be expected when working with hospice patients.

*Below are additional references used within the literature review of article #5:
1)

Yoshioka H: Rehabilitation for the terminal cancer patient. Am J Phys Med Rehabil 1994;73:199206.
Contribution to project: Provided past research of physical therapy in hospice care to compare
with more current research in articles #3 and #5.

2)

Montagnini M, Lodhi M, Born W: The utilization of physical therapy in a palliative care unit. J
Palliat Med 2003:6:11-17.
Contribution to project: Provided past research of physical therapy in hospice care to compare
with more current research in articles #3 and #5.