Version July 2025
INTRODUCTION —
For patients with a broad range of serious life-threatening illnesses, loss of function and independence is common and a significant contributor to diminished quality of life (QOL) [1-3]. Rehabilitation of palliative care patients requires a multidimensional approach to meet the physical, emotional, social, and spiritual needs of patients and their families. Rehabilitation, even in the advanced phases of illness, can help to maintain or restore function, permit patients to retain mobility and independence, and improve symptoms.
This topic will cover the indications for and benefits of rehabilitation in the palliative care setting. We will also discuss tools to evaluate patients and specific issues related to the delivery of rehabilitation services in palliative care.
An overview of issues related to rehabilitation for older adults, cardiac rehabilitation programs, pulmonary rehabilitation for patients with chronic obstructive pulmonary disease (COPD), and physical rehabilitation for patients with cancer are presented elsewhere. (See "Geriatric rehabilitation interventions" 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" and "Physical rehabilitation for cancer survivors".)
OVERVIEW
Rationale — Functional loss is common among palliative care patients, has a detrimental effect on quality of life (QOL), and is potentially modifiable. 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, neurologic injury, and musculoskeletal problems. Patients with cancer can additionally experience sarcopenia from direct tumor effects and fatigue from cancer treatment [1,2,4-7].
Differences from traditional rehabilitation — The concept of rehabilitation is highly appropriate for patients with complex, progressive illness, depending on the patient's goals. While palliative care and rehabilitation share a commitment to improve overall QOL and multidisciplinary treatment, there are clear differences between rehabilitation in palliative care and the traditional rehabilitation approach within general medical care [8]:
●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 "Geriatric rehabilitation interventions".)
●In patients with serious illness, deterioration is not only likely, but inevitable. The scope of rehabilitation in this context emphasizes a coordinated multidisciplinary approach to the management of all symptoms, whether physical, spiritual, or emotional. The goals are to reach the fullest potential consistent with the patients' physiologic or anatomical impairment in the context of environmental limitations, preferences, and goals of care, and to maintain the highest possible QOL [2,7].
Multidisciplinary approach — The main rehabilitation modalities are physical therapy, occupational therapy, and speech and language pathology therapy, but can include input from psychologists, dieticians, nurses, chaplains, and case managers/social workers as well.
Types of rehabilitation — The type of rehabilitation depends on the patient's disease stage, function, and goals.
Defined categories or "classifications" of rehabilitation that were initially defined for patients with cancer [9,10] 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. This is also referred to as prehabilitation [11].
●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 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) [10]. 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, which must also consider the patient's environment, existing functionality, and available resources. (See "Discussing goals of care".)
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 [12]. 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.
In patients with serious life-threatening illnesses, patient condition and goals of care can shift over time. 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.
Underutilization — In general, rehabilitation is underutilized in palliative care patients [13-17]. 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 within 12 months of a noted deficit [13]. A 2020 cross-sectional study in Denmark showed that 64 percent of patients with chronic advanced diseases reported extensive unmet needs concerning physical activities, work and daily activities, fatigue, pain, concentration, and worries that could potentially be alleviated with an integrated palliative rehabilitation program [18].
It is often thought that physical therapy and rehabilitation are not cost effective, particularly for patients approaching the end stage of their illness. However, limited evidence from randomized trials suggests that rehabilitation is cost effective, at least for patients with advanced cancer [19-21]. The effect of pulmonary rehabilitation on health care utilization in patients with chronic obstructive pulmonary disease (COPD) is discussed separately. (See "Pulmonary rehabilitation", section on 'Health care utilization'.)
INDICATIONS AND BENEFITS
When to refer — 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 [7,22-24]. Benefits can include decrease in musculoskeletal pain and improvements in function and performance of activities of daily living (ADLs), mobility, endurance, mood, fatigue, and lymphedema [24]. There is no consensus as to when to consider a referral to physical medicine and rehabilitation in palliative care patients. Some general suggestions are provided below [25]:
●Frequent falls at home
●Neurocognitive changes affecting daily life
●Multifactorial pain that limits activity and function
●Interest in pursuing a long-term guided exercise program
●Caregivers or family members reporting an increased burden of care
●Fatigue that limits activity and quality of life (QOL), with a desire to be more active
●Recent illness exacerbation requiring hospitalization and accompanied by a decline in functional status
Patients with cancer — Some of the most common indications for rehabilitation in patients with 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. In addition, patients with cancer are sometimes referred to rehabilitation services in order to improve their performance status in order to be eligible for additional treatment. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Rehabilitative interventions' and "Cancer-related fatigue: Treatment", section on 'Exercise' and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management" and "Assessment and management of dyspnea in palliative care".)
Rehabilitative and physical modalities used to manage cancer pain can generally be grouped into four categories: nociceptive modulators, stabilization or unloading strategies on painful structures, modalities with physiologic effects that indirectly influence nociception, and rehabilitation approaches to manage musculoskeletal pain. Examples include electrical stimulation, heat and cold, counterstimulation and desensitization techniques, orthotics, therapeutic exercises, positioning, light and laser therapies, manual lymphatic drainage, deep heat modalities, RICE (rest, ice, compression, and elevation), myofascial release techniques and trigger points, and massage [26]. This subject is discussed in detail elsewhere. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Other modalities'.)
Benefits — Data support that general rehabilitation can improve function and QOL and reduce symptom burden in patients with cancer. 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 [27-34]. As examples:
●In a systematic review including 13 trials, general rehabilitation was associated with improvement in well-being, QOL, fatigue, and mood among patients with advanced cancer [35].
●Several trials indicate that physiotherapy can reduce cancer-related fatigue [36-39]. In a 2017 trial that included 60 patients with advanced cancer, those who received the intervention of 30-minute physiotherapy sessions three times a week over a two-week period had a reduction in the severity of fatigue as well as other symptoms (pain, drowsiness, anorexia, and depression), and an improvement in well-being compared with the control group [36]. The sessions included active therapeutic exercises of the upper and lower limbs, selected techniques of myofascial release, and selected techniques of proprioceptive neuromuscular facilitation (PNF). The use of exercise to treat cancer-related fatigue is discussed separately. (See "Cancer-related fatigue: Treatment", section on 'Exercise'.)
●A 2023 observational study integrating therapeutic exercise, passive mobilization, analgesic therapy with transcutaneous electrical nerve stimulation (TENS), respiratory physiotherapy, and relaxation techniques to patients in a palliative care unit showed improvements in functionality, independence, and skills for ADLs [40].
Chronic respiratory disease — Palliative care and pulmonary rehabilitation for patients with chronic respiratory diseases such as COPD and interstitial lung disease can substantially improve dyspnea and exercise tolerance, reduce anxiety, and reduce health care utilization [41-43]. (See "Palliative care for adults with nonmalignant chronic lung disease".)
The American Thoracic Society and the European Respiratory Society define pulmonary rehabilitation as a "comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors" [44,45].
The benefits of pulmonary rehabilitation in typical palliative care populations of patients with severe chronic respiratory disease can be found in inpatient, skilled nursing facilities, and outpatient settings [46-52]. Most of the evidence comes from patients with COPD, although there is some benefit for patients with interstitial lung disease as well.
A general overview of pulmonary rehabilitation, including a discussion of the benefits, components, and duration, is presented elsewhere. (See "Pulmonary rehabilitation".)
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 2). (See "Bronchiectasis in adults: Maintaining lung health", section on 'Airway clearance therapy'.)
Heart failure — Cardiac rehabilitation can be an appropriate option for patients with stable class II to III heart failure (table 3) who do not have advanced arrhythmias and who do not have other limitations to exercise. There are insufficient data that recommend cardiac rehabilitation for patients with class IV heart failure. Cardiac rehabilitation, including indications, is discussed separately. (See "Cardiac rehabilitation in patients with heart failure", section on 'Indications' and "Cardiac rehabilitation programs", section on 'Risk stratification for exercise' and "Cardiac rehabilitation in older adults".)
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 [53]. (See "Cardiac rehabilitation in patients with heart failure", section on 'Components of cardiac rehabilitation'.)
Neurodegenerative disorders — A variety of neurodegenerative conditions, including amyotrophic lateral sclerosis (ALS), dementia, Parkinson disease, and other movement disorders, are characterized by progressive and inexorable loss of neurologic function, which usually culminates in loss of mobility and independence. Patients with progressive neurologic disease could benefit from a multidisciplinary palliative care team approach that includes physiotherapists and other rehabilitation specialists to mitigate symptom burden while improving functional capacity and self-sufficiency [54].
●ALS – ALS is a progressive and degenerative neurologic disease affecting motor neurons and disrupting muscle control, and is 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). (See "Clinical features of amyotrophic lateral sclerosis and other forms of motor neuron disease".)
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 that includes rehabilitation at every phase of the illness [55], 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 QOL, and avoid complications, although the evidence base to support benefit from multidisciplinary rehabilitation and physiotherapy is limited [56-59]. (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. 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 "Symptom-based management of amyotrophic lateral sclerosis", section on 'Management of other associated symptoms' and 'Speech and language pathology therapist' below and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)
A 2021 scoping review of studies utilizing occupational therapy interventions among adults with multiple sclerosis and ALS showed improvement in perceived fatigue, manual dexterity, falls prevention, cognition, communication, depression, and QOL. A few examples of these interventions included use of aquatic bikes and cycle-ergometers, virtual reality rehabilitation with strength and proprioception exercises, muscle-tendon stretching, a cognitive strategies program, a six-week fatigue energy conservation program, sleep, and relaxation exercises among others [60].
In a systematic review of therapeutic physical exercise among patients with ALS, therapeutic exercise slowed the deterioration of the musculature, facilitating performance in ADLs and functional capacity [61].
●Dementia – Among patients with Alzheimer disease, physiotherapy interventions may improve QOL and physical functioning [62-66]. This is discussed in detail separately. (See "Management of the patient with dementia", section on 'Rehabilitation'.)
●Parkinson disease – Among the benefits of multidisciplinary rehabilitation in patients with Parkinson disease are improved sleep quality and physical performance, including gait and balance [67-73]. (See "Nonpharmacologic management of Parkinson disease", section on 'Exercise and physical therapy' and "Palliative approach to Parkinson disease and parkinsonian disorders".)
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. The benefits of exercise and physical therapy are discussed separately. (See "Nonpharmacologic management of Parkinson disease", section on 'Exercise and physical therapy'.)
RISKS OF REHABILITATION —
Potential risks or concerns include the possibility that rehabilitation worsens fatigue, although there is little evidence of this, even in patients with advanced cancer [74,75]. Other potential risks include aggravation of pain from manipulation or exercise, straining bones with metastatic disease that have impending fractures, cardiovascular risk, and falls. 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 any 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 nonpain 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 [7].
Using a systematic 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 in palliative care (table 4). 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 nonpalliative 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 "Geriatric rehabilitation settings and reimbursement", section on 'Optimal level of postacute rehabilitation'.)
Acute inpatient rehabilitation — Inpatient rehabilitation facilities are dedicated, freestanding 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. Considerations include:
●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 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 within 30 days after discharge from the hospital.
Additional criteria for a skilled nursing level of care may also apply, including that the patient requires skilled services daily, such as 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; clinician offices; outpatient hospital departments, including critical access hospitals; rehabilitation agencies (also called "other rehabilitation facilities"); comprehensive outpatient rehabilitation facilities; and skilled nursing facilities 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" [76]. 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 daily, and the services provided are contingent upon the skilled needs of the patient and the goals to be attained. A physician must certify that skilled nursing or rehabilitation is needed for eligible patients to recover from illness, injury, or an acute condition. Medicare Part A, Medicaid, and most private insurances cover this service [77,78].
The Medicare Hospice Benefit allows for physical therapy, occupational therapy, and speech and language pathology to be provided for symptom control or to enable the individual to maintain activities of daily living (ADLs) and basic functioning [79]. 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 and Standards of Ethical Conduct for the physical therapy assistants state that physical therapists and their assistants shall act in the best interests of their clients/patients in all practice settings, including hospice [80].
Roles of 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 [81]. The primary roles and functions of the members of the multidisciplinary rehabilitation team are outlined in the table (table 5). Some cancer outpatient rehabilitation programs have additional members including enterostomal therapists, vocational counselors, sex therapists, dentists, psychiatrists, dental hygienists, or maxillofacial prosthetists.
Physical therapists — Physical therapists play a prominent role in palliative care rehabilitation [82-84]. Physical therapists treat common functional disabilities such as deconditioning, pain, imbalance, and localized weakness. Functional tasks that can be addressed by physical therapists include [7]:
●Bed mobility – Rolling, positioning for comfort and/or pressure relief, bridging (lifting pelvis off the bed), and moving supine to sit and sit to supine
●Transfers – Setup (ie, positioning of wheelchair in relation to bed), sit to stand, pivot (or slide), and stand to sit
●Ambulation or gait – Gait assessment, assistive device placement, and foot placement
Specific interventions — Specific interventions utilized by physical therapists 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 [85].
Some general recommendations and special considerations for specific palliative care populations are outlined below [25]:
●Cancer – In general, patients with nonhematologic malignancies may be prescribed exercise before, during, and after treatment, while rehabilitation is more commonly started after treatment in patients with hematologic malignancies due to concerns of fatigue. Considerations in patients with cancer include thrombocytopenia, neutropenia, risk of pathologic fractures, neuropathy (risk for skin breakdown), and restrictions in range of motion (eg, after treatment for breast cancer) [86].
●Chronic obstructive pulmonary disease (COPD) – Exercise training is an important component of pulmonary rehabilitation [87]. (See "Pulmonary rehabilitation".)
Other pertinent issues include smoking cessation counseling, nutritional counseling and weight management for cachexia, and hypoxemia, which may necessitate supplemental oxygen.
●Advanced heart failure – Exercise training is an important component of cardiac rehabilitation, but clearance from the patient's cardiologist should be obtained before initiating the program. (See "Cardiac rehabilitation in patients with heart failure".)
Limiting factors to rehabilitation include ongoing angina and hypotension.
●Neuromuscular diseases – The trajectory of functional decline may be rapid, so the goals of treatment should be frequently revised. (See "Palliative approach to Parkinson disease and parkinsonian disorders" and "Symptom-based management of amyotrophic lateral sclerosis".)
Exercise needs change as function and strength decline. Therapists focus on fitting equipment, caregiver training, respiratory needs, nutrition and swallowing safety, bed and wheelchair mobility, positioning, communication, and other patient-specific goals. (See "Swallowing disorders and aspiration in palliative care: Definition, pathophysiology, etiology, and consequences" and "Swallowing disorders and aspiration in palliative care: Assessment and strategies for management".)
Therapists coordinate with neurologists and palliative care providers when discussions about noninvasive positive pressure ventilation and feeding tubes are indicated. (See "Noninvasive ventilation in adults with chronic respiratory failure from neuromuscular and chest wall diseases: Patient selection and alternative modes of ventilatory support".)
There is no "one size fits all" approach to physical rehabilitation. In general, specific modalities should be discussed with the rehabilitation therapist, with shared decision making about what approaches are most likely to be effective and least likely to cause harm. Possible roles for physical therapists include:
●Pain management – Examples of physical modalities used by physical therapists to manage 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 devices [88]. (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Other modalities' and "Screening for and prevention of breast cancer-related lymphedema" and "Management of peripheral lymphedema", section on 'Physiotherapy' and "Management of peripheral lymphedema", section on 'Complete decongestive therapy'.)
In addition to massage, other pain-relieving techniques for manual physical therapy include myofascial release, trigger point therapy, traction therapy, and compression therapy. (See "Management of peripheral lymphedema" and "Screening for and prevention of breast cancer-related lymphedema" and "Pathophysiology, classification, and causes of lymphedema".)
Management of peripheral edema – Modifications to lymphatic massage therapy that may be necessary for palliative care patients are discussed in detail separately. (See "Management of peripheral lymphedema", section on 'Palliative care modifications'.)
●Assistive and adaptive equipment – Physical therapists can make recommendations for the type of equipment that patients may benefit from based on 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 weightbearing on an affected extremity (eg, crutches, canes, walkers, wheelchairs, scooters, lifts, ramps, and transfer boards). Adaptive equipment pertains to devices used to improve performance in 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 "Geriatric rehabilitation interventions", section on 'Assistive technology, adaptive equipment, and adaptive methods'.)
●Orthotic devices – 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.
●Home environments – 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 [89]. 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 "Geriatric rehabilitation interventions", section on 'Environmental modification' and "Geriatric rehabilitation interventions", section on 'Prosthetics and orthotics'.)
●Education – Physical therapists can provide education such as energy conservation strategies (table 6 and table 7) and good body mechanics to promote balance and safety and to prevent falls. (See "Cancer-related fatigue: Treatment", section on 'Nonpharmacologic interventions'.)
●Development of home exercise programs – 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 (PNF) using facilitation and inhibition techniques, graded activity program, and cognitive behavioral training [90]. 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.
Occupational therapist — The occupational therapist screens for and monitors performance deficits, and 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 the occupational therapist include [7]:
●Self-care – Bathing, dressing, grooming, toileting, and 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; and carrying objects.
●Home management – Food preparation; managing faucets, lights, doors, and drawers; use of remote controls, the phone, and home appliances; food management (grocery list compilation, shopping); social management (transportation, calendar, communications); and money management.
Speech and language pathology therapist — For patients with serious life-threatening illness, speech-language pathologists aim to optimize the patient's ability to communicate effectively, and to optimize function and patient satisfaction in a way that emphasizes the safest way to eat [91,92].
The functional tasks that are addressed by speech and language therapy include [7]:
●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), and 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, and presence of regurgitation.
The functional activities supervised by speech and language therapists overlap with occupational therapists insofar as eating or feeding is an ADL; however, occupational therapists address the ability to get the food into the mouth, while speech and language therapists address swallowing.
Assessment and management of swallowing disorders in palliative care patients are addressed separately. (See "Swallowing disorders and aspiration in palliative care: Definition, pathophysiology, etiology, and consequences" 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 rehabilitation goals, the patient's goals of care, the degree of caregiver support needed, and the setting in which the patient will receive care.
In general, rehabilitation facilities have protocols in place for deciding whether and when patients will be discharged from their services. Some common reasons for discontinuation of services in both the inpatient and outpatient rehabilitation venues are as follows:
●Patients have reached their maximum rehabilitative potential based upon existing goals
●Treatment services are refused by the patient and/or their family
●Needed treatment services are not offered by physical or occupational therapy
●Referral to a different agency or department better meets the patient's needs
●Changes in the patient's condition preclude further rehabilitation services
●Patient is discharged from the hospital or inpatient facility
●Patient's goals of care have changed and preclude further continuation of rehabilitation therapy services (ie continued treatment no longer promotes quality of life [QOL] 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 [93], the American Occupational Therapy Association [94], and the American Speech-Language-Hearing Association [92]. However, none of these guidelines specifically addresses indications for discontinuing services in palliative care patients.
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Palliative care" and "Society guideline links: Neuropathic pain".)
SUMMARY AND RECOMMENDATIONS
●Rationale – For patients with serious life-threatening illnesses, loss of function and independence contributes to diminished quality of life (QOL). Rehabilitation, even in the advanced phases of an illness, can help patients retain mobility and independence, and improve QOL. (See 'Rationale' above.)
●Multidisciplinary approach and goal setting – Rehabilitation teams can include physical therapists, occupational therapists, and speech-language pathologists, as well as psychologists, dieticians, nurses, chaplains, and case managers/social workers. For palliative care patients, goals of rehabilitation should take into account the patient's rehabilitation potential, preferences, and values as well as their physical needs and the availability of social support. (See 'Multidisciplinary approach' above and 'Goals' above.)
●Risks and benefits – Evidence supports benefit in many patient populations, including those with cancer, chronic respiratory disease, heart failure, and neurodegenerative disorders. Potential risks include aggravation of pain and fatigue. (See 'Indications and benefits' above and 'Risks of rehabilitation' above.)
●Patient assessment – Patient assessment involves gathering information on disease severity, previous and current therapies, estimated life expectancy, comorbidities, pain and nonpain 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 4). (See 'Patient assessment for rehabilitation planning' above.)
●Settings – 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 home. The intensity and scope of services differ across care settings, and the choice of the setting depends on a number of factors. (See 'Setting' above.)
●Therapist roles
•Physical therapists – 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 therapists' above.)
•Occupational therapists – The occupational therapist 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.)
•Speech and language pathology therapists – The role of the speech-language pathologist is to provide consultation in the areas of communication, cognition, and swallowing function, to optimize the patient's ability to communicate effectively, and to assist in optimizing function and patient satisfaction in a way that emphasizes the safest way to eat. (See 'Speech and language pathology therapist' above.)
●Discontinuation of services – Discharge planning is an integral component of any rehabilitation program and is driven by the patient's progress toward meeting the preestablished rehabilitation goals, the patient's evolving goals of care, the degree of caregiver support needed after discharge, and where the patient will receive subsequent care. (See 'Discontinuation of services' above.)
