Medical Manuscript

American Journal of Hospice

& Palliative Medicine®
The Value of Rehabilitation Medicine for 1-8
ª The Author(s) 2017
Reprints and permission:
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DOI: 10.1177/1049909117742896
journals.sagepub.com/home/ajh

Sarah A. Wittry, DO1,2 , Ny-Ying Lam, MD1 ,

and Thomas McNalley, MD3

Abstract
Background: Rehabilitation medicine is a multidisciplinary field aimed at improving patients’ quality of life by improving function.
Patients receiving palliative care frequently share common symptoms including fatigue, decreased functional independence, mood
disorders, pain, and breathlessness. Many rehabilitation interventions can improve these symptoms. Objective: To evaluate the
scope and effectiveness of rehabilitation interventions and exercise programs in improving quality of life and distressing symptoms
in patients receiving palliative care. Methods: We conducted a literature review of cancer rehabilitation topics and techniques
specifically applied to patients with life-limiting conditions. Exercise and other rehabilitation interventions were analyzed for their
effects on common symptoms and disabilities experienced by this patient population. Conclusion: Current available literature
supports the use of exercise programs and rehabilitation interventions to improve fatigue, mood, functional independence,
breathlessness, and pain. Rehabilitation and palliative care practitioners share many goals in their approach to patient care and
augment one another well. Palliative care providers should consider referral to physiatry (physical medicine and rehabilitation) to
help optimize patients’ quality of life.

Keywords
fatigue, dyspnea, pain, rehabilitation, mood, exercise, mobility

Introduction therapy (PT), including reasons such as lymphedema, incon-

Similar to palliative care, rehabilitation medicine employs an
interdisciplinary approach to improve quality of life (QOL). By
optimizing functional mobility, self-care, self-efficacy, and
cognition, physiatrists and other rehabilitation providers aim
to help patients maintain as much independence as possible.
These interventions can also reduce family or caregiver burden.
Physiatrists prescribe appropriate adaptations, assistive
devices, and equipment to increase functional independence.
Patients with terminal illnesses are often managed by a pallia-
tive care team, which focuses on decreasing symptom burden
as a means to improve QOL for patients. Palliative care provi-
ders may also handle more psychosocial issues and family
dynamics in coping with a significant illness. The most com-
monly reported symptoms in patients with advanced illness
(cancer, cardiopulmonary, and neurologic) include fatigue,
pain, weakness, dyspnea, cognitive changes, and mood disor-
ders (Table 1). Much of available research is among patients
with cancer, but many similar principles and symptoms are
seen in other life-limiting diagnoses. In this review, we hope
to address symptoms that are experienced by patient popula-
tions receiving palliative care services and discuss rehabilita-
tion interventions that may be useful in their treatment plans.
In a recent study, 65% of patients with cancer (inpatient and
outpatient settings) were found to have indications for physical
tinence, musculoskeletal issues or pain, and mobility issues.
However, only 12.8% of patients actually received therapy.1
Many oncologists do not have experience or comfort working
with patients’ functional needs in more advanced stages of
cancer. Palliative care providers are often not as experienced
in specific rehabilitation approaches to improve symptom bur-
den. However, physical function is a very important determi-
nant of QOL and survival. Exercise programs for patients with
cancer have been shown to increase cardiovascular capacity,
improve immune function, reduce reports of insomnia and fati-
gue, and promote a more positive sense of well-being and
respect for self.1
The Eastern Cooperative Oncology Group (ECOG) and
Karnofsky Performance Scale (KPS) are often utilized in
patients with cancer or terminally ill individuals to characterize
1
Department of Rehabilitation Medicine, University of Washington, Seattle,
WA, USA
2
Department of Palliative Care, University of Washington, Seattle, WA, USA
3
Kaiser Permanente, Oakland, CA, USA
Corresponding Author:
Sarah A. Wittry, DO, Department of Rehabilitation Medicine, University of
Washington, 1959 NE Pacific Street, Seattle, WA 98105, USA.
Email: sarahannewittry@gmail.com
2 American Journal of Hospice & Palliative Medicine® XX(X)

Table 1. Common Impairments Amenable to Rehabilitation helpful to determine how best to improve a patient’s overall
Interventions. function. Although KPS or ECOG scores may not change sig-
Cancer Fatigue, treatment-related complications
nificantly with intervention, QOL and functional mobility can
(neuropathy, radiation fibrosis, myelopathy, etc), improve with appropriately directed therapies, exercise, or
pain, lymphedema, encephalopathy, cognitive treatment.
impairment, amputation, dysphagia, dysarthria, As Desai et al argued, palliative care must support QOL.4
range of motion restrictions, mood disorders, The fundamental question to ask a person whose time is short
bowel/bladder complications is, “how do you define quality of life?” The clinician then asks
COPD Fatigue, breathlessness, decreased endurance, pain, herself how she can marshal resources to optimize the patient’s
mood disorders
Advanced heart Fatigue, breathlessness, mood disorders, functional
time. In both palliative care and rehabilitation, clinicians must
failure decline come with an openness to their patient’s personal and some-
Neuromuscular Fatigue, motor weakness, breathlessness, bulbar time unique views of what they most value.
disease symptoms (dysphagia, dysarthria, dysphonia), Exercise and increased physical activity can help improve
scoliosis, medical equipment needs, mood pain by improving sense of self-efficacy, reducing muscle ten-
disorders sion, and increasing motor efficiency. In palliative care, exer-
Alzheimer Fatigue, cognitive impairment, mood disorders, cise and therapy prescriptions must align with patient goals.
disease dysphagia
Further, clinicians must guard against the misuse of exercise to
Abbreviation: COPD, chronic obstructive pulmonary disease. “get the patient stronger” for last ditch therapies. These aggres-
sive approaches at end of life risk shortening or even reducing
QOL. Functional assessments must be conducted regularly to
Table 2. Clinic Screening Tools to Assess Common Symptoms/ assist in modifying shared functional goals so they continue to
Decrease in Physical Function. be realistic and achievable in patients with advancing disease.
ECOG Performance Status2 Karnofsky Performance Status3 Goals may shift from increasing endurance, maintaining
strength, and reducing fall risk with ambulation to bed mobility
0—Fully active, able to carry on all 100—Normal, no complaints; no and wheelchair/transfer training to allow patients to interact
predisease performance evidence of disease more easily with their loved ones near the end of life if they
without restriction
desire to spend some time out of bed.
1—Restricted in physically 90—Able to carry on normal
strenuous activity but activity; minor signs or Even in patients with terminal cancer, over 85% report the
ambulatory and able to carry symptoms of disease desire to ambulate or use wheelchair mobility.5 Utilizing reha-
out work of a light or sedentary80—Normal activity with effort, bilitation interventions and physical activity may be a bridge
nature, eg, light housework, some signs or symptoms of that can complement palliative care and provide more optimal
office work disease care across the stages and progression of illness. Patients can
2—Ambulatory and capable of all 70—Cares for self but unable to receive both types of services simultaneously, and specific
self-care but unable to carry carry on normal activity or to
goals can be adapted throughout the course of disease. Appro-
out any work activities; up and do active work
about more than 50% of waking 60—Requires occasional priate integration of rehabilitation and palliative care can
hours assistance but is able to care for improve focus on patient-centered outcomes, including physi-
most of personal needs cal function, QOL, psychological function, and overall satis-
3—Capable of only limited self- 50—Requires considerable faction with care.6
care; confined to bed or chair assistance and frequent medical
more than 50% of waking hours care
40—Disabled; requires special
care and assistance Functional Mobility
4—Completely disabled; cannot 30—Severely disabled;
carry on any self-care; totally hospitalization is indicated Functional decline is common for patients coping with
confined to bed or chair although death not imminent advanced or end-stage systemic diseases. Evaluation by a phy-
20—Very ill; hospitalization and siatrist may be helpful to assess for mobility impairments and
active supportive care caregiver needs. Impairments including weakness, decreased
necessary endurance, depressed mood, pain, and fatigue all contribute
10—Moribund to reduced mobility. Comorbid medical conditions as well as
5—Dead 0—Dead
cancer-related treatments can further exacerbate or cause
Abbreviation: ECOG, Eastern Cooperative Oncology Group. impairments that affect balance, gait, and endurance. Potential
underlying etiologies for functional decline include treatment
and disease-related processes such as chemotherapy-induced
a patient’s level of disability (Table 2). These functional scales neuropathy, radiation fibrosis, anemia, critical-illness neuro-
are often inadequate in characterizing patient’s true functional myopathy, and central nervous system spread of disease. Iden-
impairments or therapy needs. In these cases, evaluation by a tifying the cause of new or progressive functional decline is
physical medicine and rehabilitation (PM&R) physician can be useful for determining prognosis for functional recovery.
Wittry et al
There are several clinical markers for mobility that can be
easily tested in the clinical setting, including the timed up and
go test, 6-minute walk test (6MWT), and gait speed (10-m
walk test). One study looking at the mobility of older patients
with advanced cancer demonstrated reduced 6MWT distance
compared with age-adjusted norms. 7 In a population of
patients with cancer receiving palliative care, increased self-
reported physical activity and walking over 30 minutes daily
were associated with an improved QOL.8 Simple interven-
tions such as recommending and helping implement daily
walking in patients with advanced disease can positively ben-
efit their daily function.
Impaired mobility increases risk of falls, which are a major
source of morbidity in elderly and frail individuals. Complica-
tions from falls, such as fractures, intracranial bleeding, or skin
breakdown, can lead to further decline. Therefore, fall preven-
tion is a key component of rehabilitation interventions. Patients
receiving palliative care services are at even more risk of falls
than their peers. In 1 study, adults aged 65 years or older with a
cancer diagnosis were found to be more likely to fall than those
without cancer (odds ratio [OR]: 1.16).9 In a prospective study of
ambulatory adults with advanced cancer, half (50.3%) of the 185
participants fell at least once over a 6-month period.10 Another
study of 302 adults with solid tumors showed that moderate–
high fall risk patients were more likely to be readmitted to the
hospital than those with low fall risk (OR: 1.79). Interestingly,
risk of hospital readmission for patients with metastatic
advanced disease was equally increased (OR: 1.71).11
A meta-analysis of interventions to prevent falls in the
elderly assessed 40 randomized controlled trials (RCTs) and
showed a reduction in fall risk for patients who underwent a fall
risk assessment followed by a management program or exer-
cise. Commonly assessed fall risks included medications,
visual impairment, orthostasis, balance, cognition, and envi-
ronmental hazards. Mitigation or management of these risks
resulted in an adjusted risk ratio (ARR) of 0.82 (0.72-0.94)
of falling and improved adjusted incidence rate ratio of falling
monthly to 0.63 (0.49-0.83).12 Exercise also improved fall risk
(ARR: 0.86; 0.75-0.99). Types of exercise programs varied but
included general aerobic or endurance activities as well as
targeted training of balance, gait, and strength.13 Other factors
contributing to falls in patients with advanced cancer or on
hospice include mood disorder, brain tumor or metastasis,
cancer-related pain, and history of falls.10,12
Summary/Recommendations
In patients with advanced disease, functional mobility should
be assessed early and often in the context of a patient’s current
living environment, activity goals, and treatment goals. By
establishing the functional goals of care, physiatrists can then
appropriately refer patients for therapies and determine the
necessary level of caregiver support. Reducing fall risk is an
important rehabilitation intervention which can be initially
addressed with fall risk assessment followed by PT and/or
exercise. Physiatry consultations may be helpful in elucidating
3
Table 3. When to Consider Referral to Physiatry/PM&R.
Frequent falls at home
Neurocognitive changes affecting daily life
Multifactorial pain limiting activity and function
Interest in establishing a long-term guided exercise program
Caregivers or family members reporting increased burden of care
Fatigue limiting activity and quality of life with desire to be more active
Recent exacerbation of illness requiring hospitalization and decline in
functional status
Abbreviation: PM&R, physical medicine and rehabilitation.
the etiology for and appropriate treatment of functional impair-
ments (Table 3). Patients with motor weakness, coordination
difficulties, decreased balance, or gait abnormalities should
receive individualized skilled PT in order to optimize their
functional mobility. Physical therapies can determine the
appropriate assistive devices or orthotics needed, provide gait
and balance training, and educate caregivers on how to safely
assist with mobility. In patients with functional decline due to
reduced cardiopulmonary reserve, PT may focus more on
energy conservation, pacing, and activity tolerance.
Fatigue
Fatigue is a disabling symptom experienced by patients suffer-
ing from several chronic and life-limiting conditions, including
cancer, advanced heart failure, chronic obstructive pulmonary
disease (COPD), and neuromuscular disease.[ The incidence of
cancer-related fatigue (CRF) has been reported as one-third to
100% of patients. It has been cited as the single most distres-
sing cancer symptom by many patients.14
The treatment with the most supportive evidence for
improving CRF is currently exercise, and the setting of delivery
does not seem to be a critical factor in effectiveness.15 Fatigue
can be addressed with therapeutic exercises, energy conserva-
tion techniques, and education.16 Rehabilitation programs have
shown significant improvements in general well-being and pos-
itive effects on fatigue and coping with cancer, regardless of
age, stage of cancer, or prognosis.16 Patients’ perceived bene-
fits of regular physical exercise include weight management,
distraction from cancer, sense of control despite disease, and
enhancing strength and emotional well-being.5
Patients with advanced heterogeneous cancer who partici-
pated in an ambulatory PT program reported significantly less
generalized fatigue.17 Schuler et al showed improvements in
fatigue after an exercise program for patients with cancer with a
limited 3- to 12-month life expectancy. Many patients pre-
ferred walking or a home-based program, starting after their
treatments were finished.18
Patients with breast cancer who participated in a 6-week
walking program showed improvement in sleep quality and
fatigue.19 In a systematic review of patients with breast cancer
and survivors, exercise programs significantly reduced fatigue
severity after treatments were completed, but not during adju-
vant treatment.20 Grade A evidence has been cited to reduce
4 American Journal of Hospice & Palliative Medicine® XX(X)
Table 4. General Physiatry Recommendations for Managing
Common Symptoms.
Fatigue Graded aerobic exercise program; resistance
exercises; pacing and energy conservation
strategies
Depressed mood/ Pharmacologic treatment, psychotherapy/
anxiety counseling, aerobic and resistance exercises,
complementary/alternative treatments
(yoga, Pilates, etc)
Pain Aerobic exercise, physical modalities (heat,
ice), biofeedback, complementary/
alternative treatments, mind–body therapy
Decreased physical Fall assessment, home evaluation, equipment
functioning evaluations, physical therapy, and/or
occupational therapy
Breathlessness Pulmonary rehabilitation, supplemental oxygen,
pacing techniques, opioids as needed
fatigue in patients with prostate cancer, particularly with home-
based programs including resistance training.21 Fewer studies
exist assessing exercise in patients with hematologic malignan-
cies, but in those undergoing stem cell transplants, exercise
during their hospitalization led to less fatigue and higher QOL
at discharge.22
Patients with chronic heart failure can also benefit from a
structured exercise program. Those who participated in an
aerobic exercise program had improved levels of fatigue as
well as improved exercise tolerance, increased ability to per-
form activities of daily living (ADLs), decreased hospital read-
missions, and decreased cardiac mortality.22
Fatigue is frequently cited as a barrier to physical activity by
patients with cancer, despite over half of patients desiring sup-
port to increase their level of physical activity.5 However,
physical activity and exercise can be viewed as a treatment for
fatigue. Programs should be modified based on patients’ goals,
preferences, current and dynamic level of functioning, and
other comorbidities. Even bed mobility exercises can be effec-
tive to improve physical function and fatigue.
Typically, benefits of exercise interventions on fatigue are
more pronounced with moderate or vigorous intensity exercise
programs (Table 4).15 Supervised high-intensity cardiovascular
and heavy resistance training along with relaxation and body
awareness training for 6 weeks may significantly reduce CRF
in patients actively undergoing chemotherapy.23 A multidisci-
plinary, home-based, tailored intervention with optional
weekly gym attendance is often acceptable to patients.24 Exer-
cise prescriptions should suggest activity at least 3 times per
week at 60% to 85% heart rate in accordance with American
College of Sports Medicine.15 With such programs, patients
may show significant improvements in upper and lower body
strength, fatigue, blood pressure, and 6MWT.25
Summary/Recommendations
Evidence suggests that fatigue is a multifactorial issue that
impacts all facets of life and adversely affects function, mood,
QOL, and even survival. Despite fatigue being cited as a fre-
quent barrier to physical activity, we suggest exercise be used
as a therapeutic strategy to combat fatigue. When physiatrists
are involved in the overall care plan of patients with advanced
cancer, there is a greater chance of successful treatment that
addresses physical and psychosocial aspects and improves
patient and family satisfaction with care. We recommend that
patients with cancer are given an appropriate and individua-
lized exercise prescription during and after their treatment to
optimize their strength, safe physical mobility, and ADLs, as
well as to offset their sense of fatigue over time. A home-based
rehabilitation program should also be considered for all
patients with chronic or advanced heart failure. Further
research is needed for patients with COPD and neuromuscular
disease.23,26
Mood
Mood is another critical component of attaining a better QOL
across patient populations with serious or life-limiting diag-
noses. Mood disorders are frequently associated with fatigue
and other somatic symptoms. Older patients with advanced
cancer having more severe depression have an increased risk
of falling.10
In a meta-analysis of 37 RCTs, depressive symptoms were
experienced by up to 60% of cancer survivors.27 Rehabilitation
care providers can be an essential support to help sustain hope
in patients and families, as the ability to maintain or improve
ADLs is often linked to joy and an increased desire to live.28
Cancer rehabilitation has positive effects on mood for patients
with cancer regardless of age, stage, or prognosis.16
In a review by Barawid et al, palliative care patients
achieved alleviation of psychological suffering through reha-
bilitation, including decreasing anxiety, stress, and depressive
symptoms with exercise interventions.23 A systematic review
found overall evidence supporting the utilization of PT in pal-
liative care settings to improve the emotional well-being of
patients.28 Patients described involvement with PT as motivat-
ing, confidence-building, and providing hope for future phys-
ical activity. Additionally, combining music with PT
interventions showed significant improvement in patients’ rat-
ings of depression and anxiety.29
In 13 RCTs, exercise consistently had positive effects on
mood and coping with the diagnosis of advanced cancer.30
Reviewing a meta-analysis, exercise interventions were com-
monly prescribed during curative therapy, with average treat-
ment course of 3 sessions per week for 12 to 13 weeks.27
Exercise provided a small overall reduction in depressive
symptoms compared to standard of care, which was more pro-
nounced in breast cancer survivors. Larger decreases in depres-
sive symptoms were seen in patients exercising at least 3 hours
per week. Overall, patients preferred supervised exercise pro-
grams over self-directed programs.27 Studies of patients with
lung cancer participating in pulmonary rehabilitation (PR) have
shown decreased rates of depression, anxiety, improved self-
Wittry et al 5

management, self-efficacy, and greater enjoyment of leisure Table 5. General Activity/Exercise Recommendations.
activities.31
General
Alternative and complementary treatments involving move- Recommendations Special Considerations
ment and exercise have also shown beneficial effects on mood
in patients with cancer. Specifically, Pilates exercises in Cancer Prescribe during and Thrombocytopenia,
women who had undergone axillary dissection and radiation (nonhematologic) after treatments neutropenia,
for breast cancer showed improvements in mood and shoulder Aerobic and resistive pathologic fractures,
exercises neuropathy (skin
range of motion.32 Patients with cancer and survivors who
breakdown),
participated in a regular yoga program showed significant shoulder range of
reductions in distress, anxiety, and depression and found yoga motion restrictions
beneficial, enjoyable, and confidence-building.33 (breast cancer)
In patients with chronic heart failure, poor adherence to Cancer Start after treatments; Fatigue may be more
therapy due to depression or cognitive disorder has been asso- (hematologic) aerobic > resistive difficult to overcome
ciated with worse management of congestive heart failure Neuromuscular Focus on fitting May have rapidly
diseases equipment, declining function,
(CHF).34 Medically supervised cardiac rehabilitation (CR) pro-
caregiver training, carefully assess
grams have been documented to decrease anxiety and depres- respiratory needs, specific functional/
sion in patients with CHF.23 positioning, communication
swallow, etc. goals; early referral
Summary/Recommendations Exercise changes as to palliative care to
function/strength discuss noninvasive
Overall, literature suggests that mood disorders are common declines; bed positive pressure
among patients with chronic, severe illnesses including cancer. mobility, patient- ventilation, feeding
Prehabilitation (defined as the time between diagnosis of can- specific goals tube
(communication,
cer to the start of acute treatment) is the ideal time to assess
wheelchair mobility,
baseline psychological functioning and focus on interventions accessing
to promote psychological health and resiliency during treat- community, etc)
ment. A variety of exercise interventions, including therapeutic COPD Pulmonary Smoking cessation
exercise programs, yoga, and Pilates, have been shown to be rehabilitation counseling, cachexia,
helpful in many populations of patients with terminal illnesses. supplemental oxygen
Additional research is needed in noncancer populations to fur- needs
Advanced heart Cardiac rehabilitation Clearance from
ther elucidate specific benefits of exercise on mood. Early and
failure cardiologist prior to
frequent assessment and discussion of the impact of mood dis- beginning, angina,
orders on function and pain is integral. Exercise and movement hemodynamic
prescriptions should be used as a tool concurrent with pharma- responses
cologic and psychotherapeutic efforts to address mood disor-
Abbreviation: COPD, chronic obstructive pulmonary disease.
ders on an individualized basis.

Pharmacological measures such as bronchodilators and

Breathlessness
Shortness of breath (SOB) is a symptom experienced by many
patients with advanced disease, particularly cardiac and pul-
monary disorders such as COPD, heart failure, and lung cancer.
The prevalence of dyspnea in all stages of lung cancer is 55% to
87%.31 Restrictive ventilatory lung dysfunction arises in the
later stages of neuromuscular disorders such as amyotrophic
lateral sclerosis (ALS) or muscular dystrophy and is often
accompanied by bulbar dysfunction and ineffective cough.
Respiratory insufficiency is one of the leading causes of death
in these latter 2 populations.
Dyspnea can be distressing and anxiety-provoking. A pro-
spective study evaluating elderly adults with varying diagnoses
identified that over half of participants experienced breathless-
ness that restricted activity within the year leading up to
death.35 Exercise often induces exacerbations of SOB, which
can lead to self-imposed restrictions on activity, thus worsening
mobility, endurance, and overall function.
inhaled steroids are often first line in the treatment of breath-
lessness in advanced lung disease. Oxygen may also relieve
dyspnea, but there is a lack of evidence for its use in the
absence of hypoxia.36 Opiates are also useful in reducing
the feeling of suffocation and relieving breathlessness in
end-of-life care.
Rehabilitation interventions for patients with breathlessness
can address functional impairments, increase endurance, and
improve QOL. Pulmonary rehabilitation was initially devel-
oped for patients with advanced lung disease such as COPD
with the goal of restoring functional capacity limited by dys-
pnea. This comprehensive intervention includes education on
breathing techniques, airway clearance techniques, and energy
conservation as well as exercise training. Patients are coun-
seled on smoking cessation, exacerbation prevention, beha-
vioral change, and nutrition (Table 5). Different training
regimens have been proposed that include a mix of strength
training and variable intensity aerobic exercises. Pulmonary
6 American Journal of Hospice & Palliative Medicine® XX(X)
rehabilitation programs are generally group classes meeting 2
to 3 sessions per week for at least 8 weeks.
In a Cochrane review meta-analysis, PR for COPD demon-
strated clinically significant improvement in health-related
quality of life (HRQOL) measures of dyspnea, fatigue, and
emotional function. It was also found to reduce hospital read-
mission and improve exercise capacity as measured by the
6MWT, despite not affecting lung physiology as measured
by pulmonary function tests.37 Small studies have examined
the effect of exercise training in patients with lung cancer. One
study of PR implemented after lung cancer resection demon-
strated improvement in dyspnea on exertion as well as
6MWT.38 Cardiac rehabilitation programs incorporate ele-
ments of PR principles to improve dyspnea and fatigue in their
patient populations.39 A Cochrane review of CR in heart dis-
ease demonstrated primarily improvements in HRQOL and
reduced hospital readmissions.40
Management of dyspnea in patients with advanced neuro-
muscular disease such as ALS is more challenging. As patients
lose independence due to progression of disease, bulbar symp-
toms become more prevalent. Risk of aspiration from dyspha-
gia coupled with reduced chest wall strength and cough reflex
puts patients at high risk of pneumonia. Cardiopulmonary com-
plications are the main cause of death in many of these patients.
The decision to pursue ventilatory support should not be taken
lightly. Pulmonologists should be involved in management of
these patients to discuss ventilatory options when indicated.
Summary/Recommendations
The evidence suggests that regular exercise—structured reha-
bilitation programs in particular—can improve dyspnea and
QOL for patients with advanced cardiopulmonary disease and
lung cancer. Other positive outcomes include improving exer-
cise capacity and fatigue as well as reducing hospital readmis-
sions. Management of breathlessness due to restrictive
neuromuscular lung dysfunction may require involvement of
pulmonary medicine to determine appropriateness and timing
of ventilation options. Rehabilitation interventions should
focus on minimizing secondary complications such as aspira-
tion, while optimizing seating and positioning, minimizing
caregiver burden, and maximizing functional independence for
communication and mobility.
Pain
Due to the extensive literature on use of medications for end-
of-life pain, the focus in this review is on nonpharmacologic
strategies. Pain is a complex phenomenon that comprises not
only somatic sensations but also processing of emotions and
thoughts and has a significant impact on physical function, self-
efficacy, and interpersonal and social relationships. These are
outlined in Zaza and Baine’s review.41 Pujol and Monti’s
review of nonpharmacologic and complementary treatments
for cancer pain acknowledged the paucity of high-quality
studies to guide treatment.42 They did review several potential
interventions to reduce pain and improve QOL.
Modalities such as heat, ice, electrical stimulation, and mas-
sage can reduce pain. With each of these, a physiatrist can
make recommendations regarding safety and efficacy of spe-
cific therapies. For example, there is concern that massage
directly over a tumor may lead to regional spread. However,
in patients with cancer, massage is often valuable to help with
relaxation, muscle stiffness and pain, and alleviation of mus-
culoskeletal complaints, when licensed and specialized thera-
pists are used.43 Patients with advanced cancer in the treatment
group receiving therapy (active exercise, myofascial release,
and proprioceptive neuromuscular facilitation) 3 times per
week showed improved Edmonton Symptom Assessment Scale
and satisfaction scores in pain compared to controls.44
Psychological and mind–body approaches should be at the
center of discussions with persons with cancer. The existential
threat, and subsequent challenge of acknowledging one’s
death, is for many the most profound tasks of their terminal
illness. Patients and families may benefit from individual coun-
selors, support groups, and peer-to-peer interactions to explore
these problems. Mindfulness, relaxation techniques, and bio-
feedback are several tools that patients can utilize for pain
management. Complementary strategies such as acupuncture,
mindfulness-based stress reduction, and hypnosis have all
shown some benefit for both malignant and nonmalignant
pain.45-47 In general, these have been found to be safe and may
reduce the dose burden of narcotic medications.
Summary/Recommendations
Whatever the etiology may be, the experience of pain may be
magnified by psychological or existential distress and at least
partially alleviated by nonpharmacologic interventions. Treat-
ment strategies must balance potentially harmful side effects
against the benefits of pain relief. For example, excessive slee-
piness or cognitive cloudiness may be unacceptable to a person
at the end of life who wishes to meaningfully interact with
loved ones.
Conclusion
Patients with serious and life-limiting illnesses often experi-
ence a common subset of symptoms, including fatigue, mood
disorders, breathlessness, pain, and functional decline. All of
these symptoms contribute to decreased QOL. Many patients
want to retain as much functional independence as possible and
reduce burden on their caregivers. Frequent reassessment of
patient goals and rehabilitation interventions, which may help
to meet agreed-upon goals, is critical in ensuring feasibility and
success. As we experience a trend in medicine of moving the
involvement of palliative care teams upstream in patient care,
we encourage greater consideration being given to involving
the rehabilitation medicine team as well. We advocate for
increased collaboration among palliative care and rehabilita-
tion medicine consultants in the care of these complex patient
Wittry et al
populations, as both can work together to optimize physical,
psychological, and patient satisfaction outcomes. As patient’s
disease progresses toward end-of-life care, goals and priorities
often shift, but there are still rehabilitation interventions that
can be helpful to support caregivers’ ability to care for their
loved ones at home and maintain a sense of well-being and
dignity for patients. Unreasonable expectations regarding func-
tional improvements must be adjusted for advancing disease as
this could worsen patients’ morale. Additionally, PM&R clin-
icians can be very helpful in preventing complications of bed
rest and deconditioning in patients near the end of life, who
have poor endurance and are unable to do any out-of-bed activ-
ity. Preventing contractures and pressure injuries while assist-
ing with equipment setup and caregiver training are key
components during this stage of disease.
We believe physiatrists add value to comprehensive care
plans of many patients also receiving palliative care, regardless
of their stage of disease, and even near the end of life. Physia-
tric evaluation may reveal new or worsening impairments
impacting function. Rehabilitation interventions, including
individualized exercise programs, therapies, equipment and
assistive device prescriptions, and other modalities, can be
helpful adjuncts in patient care. Rehabilitation and palliative
care team members share many approaches and goals in patient
care, and we believe they are both instrumental and uniquely
valuable in providing care focused on QOL and improving
function.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
ORCID iD
Sarah A. Wittry http://orcid.org/0000-0002-5467-1120.
Ny-Ying Lam http://orcid.org/0000-0001-7212-3091.
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