Introduction: With various serious illnesses, patients experience high levels of functional loss, deconditioning and dependency for activities of daily living (ADLs). This can lead to social isolation, depression, caregiver breakdown, and institutionalization (1,2).  This Fast Fact will review the benefits and challenges of palliative rehabilitation.

What is Palliative Rehabilitation?  Palliative rehabilitation is defined as the process of helping a person with a progressive, often terminal illness reach their physical, psychological, and social potential consistent with physiological and environmental limitations and life preferences (3,4). While the aim of conventional rehabilitation is to restore function closer to or better than baseline, palliative rehabilitation primarily aims to promote independence in self-care activities, improvement in symptom control, stabilization of functional decline, and/or provision of emotional support. Subset definitions of palliative rehabilitation have been described based on the patient’s anticipated recovery (5-6):

• Preventative Rehabilitation: attempts to preclude or mitigate anticipated functional morbidity from the underlying illness or its treatment for patients who often have no functional impairments yet.
• Restorative Rehabilitation: refers to the effort to return patients to their premorbid functional status when little long-term impairment is anticipated (e.g. short-term functional impairments anticipated from a neutropenic fever, but there is a high chance of return to previous baseline functional level).  
• Supportive Rehabilitation: attempts to maximize function after permanent impairments caused by an underlying illness and/or its treatment for which morbidity is anticipated to progress over time.
• Subacute Rehabilitation (SAR): pertains to the more conventional rehabilitation.  SAR requires at least an hour per day of physical therapy and is delivered five days a week or more in a subacute care facility. In most circumstances SAR cannot be co-administered while on the Medicare Hospice Benefit (MHB).  Therefore, the decision to pursue a trial of palliative rehabilitation versus SAR should be individualized on prognosis, potential to regain function, and overall goals of care.

Benefits of Palliative Rehabilitation: Research suggests that cancer and non-cancer patients with progressive illness and pain, dysphagia, skin breakdown, muscle weakness, diminished endurance, and/or orthostatic hypotension can all benefit from palliative rehabilitation (2,3):

• In a study of over 300 hospice patients with cancer, those who received near daily palliative rehabilitation until their death, reported improved quality of life along with a reduction in pain, leg edema, dyspnea, and immobility. Modalities included range-of-motion exercises, chest physiotherapy, swallowing exercises, acupuncture, and bed repositioning using pillows (7). 
• A retrospective study of patients admitted to a VA palliative care unit suggested that 56% of patients had improved ADL scores within 2 weeks of completion of the rehabilitation program (4). 
• Other studies have supported that a comprehensive inpatient or outpatient rehabilitation program for cancer patients led to improvement of pain, mood, mobility, cognition, and quality of life (8-12). 
• For COPD, CHF, and neurologic illnesses, customized rehabilitation strategies have been associated with improvements in quality of life, exercise capacity, fatigue, dyspnea, and mood (13-17).

Who performs palliative rehabilitation?  Physical Therapists (PT), Occupational Therapists (OT), and Speech and Language Pathologists (SLP) are board-certified and licensed clinicians who can focus on different aspects of palliative rehabilitation (18). To prevent miscommunication, clinicians should clearly inform rehabilitation specialists when the goals of rehabilitative care are not for complete restoration of function, but rather symptom management, safety, or prevention of immobility or skin breakdown.

• PT: manages common functional issues such as muscle weakness, deconditioning, motor deficits, and pain. Specific interventions offered include stretching, muscle strengthening, provision of adaptive equipment, environmental modification, education on energy conservation, and therapeutic exercise. They can play an active role in caregiver education and on the use of equipment, body mechanics, and fall prevention (18-21).
• OT: assesses and provides treatment programs to improve or maintain performance with ADLs, work tasks, recreation, use of adaptive equipment, and discharge planning. OTs focus more on fine motor deficits than PTs. Specific OT interventions include home assessments, prescription of adaptive equipment, coaching in domestic tasks, stress management, and caregiver support (19,22,23).
• SLP: addresses oral-pharyngeal-laryngeal function and the cognitive components in communication. They assist with feeding and communication via evidence-based modalities including vocal training, visual comprehension, tongue coordination techniques, and food management strategies (19,24). 

Insurance Coverage and Reimbursement Challenges:  Often insurances will only cover the cost of rehabilitation in an inpatient setting (acute or subacute) if the patient is demonstrating objective progress in restoring function. The MHB allows for rehabilitation resources (albeit often limited in duration) for safety training, symptom management, and ADL assistance (18). Many palliative care programs lack rehabilitation partners with specialized education and training in end-of-life care. Hence, many patients who would benefit from palliative rehabilitation struggle to gain access to it. To mitigate access issues, clinicians and rehabilitation specialists might consider one-time evaluations during inpatient stays, whereby the patient gets evaluated and both the patient and the caregiver are educated on helpful rehabilitation strategies to be continued at home or in an outpatient setting.

References

1. Cheville AL. Rehabilitation of patients with advanced cancer. Cancer Suppl. 2001;92:1039-1048.
2. Curtis EB, Krech R, Walsh TD. Common symptoms in patients with advanced cancer. J Palliat Care. 1991;7:25-29.
3. Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer Suppl. 2001;92:1049-1052.
4. Montagnini M, Lodhi M, Born W. The utilization of physical therapy in a palliative care unit. J Palliat Med. 2003;6:11-17.
5. Cheville Al. Cancer rehabilitation. Semin Oncol. 2005;32:219-224.
6. Javier NS, Montagnini ML. Rehabilitation of the hospice and palliative care patient. J Palliat Med. 2011;14(5):638-648.
7. Yoshioka H. Rehabilitation for the terminal cancer patient. Am J Phys Rehabil. 1994;73:199-206.
8. Sabers SR, Kokal JE, Girardi JC, Philpott CL et al. Evaluation of consultation-based rehabilitation for hospitalized cancer patients with functional impairment. Mayo Clin Proc. 1999;74:855-861.
9. Marciniak CM, Silwa JA, Spill G, Heinemann AW, Semik PE. Functional outcome following rehabilitation of cancer patients. Arch Phys Med Rehabil. 1996;77:54-57.
10. Pyszora A, Budzynski J, Wojcik A, Prokop A, Krajnik M. Physiotherapy programme reduces fatigue in patients with advanced cancer receiving palliative care: randomized controlled trial. Support Care Cancer. 2017;25:2899-2908.
11. Van den Dungen IA, Verhagen CA, Van den Graaf WT, et al. Feasibility and impact of a physical exercise program in patients with advanced cancer: a pilot study. J Palliat Med. 2014;17(10):1091-1098.
12. Cheville AL, Kollasch J, Vandenberg J, et al. A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung cancer and colorectal cancer: a randomized controlled trial. J Pain Symptom Manage. 2013;45(5):811-821.
13. Guell R, Resqueti V, Sangenis M, Morante F, Martorell B et al. Impact of pulmonary rehabilitation on psychosocial morbidity in patients with severe COPD. Chest. 2006;129:899-904.
14. Resqueti VR, Gorostizza A, Gladis J, Lopez E et al. Benefits of a home-based pulmonary rehabilitation program for patients with severe chronic obstructive pulmonary disease. Arch Bronconeumol. 2007;43:599-604.
15. Freimark D, Schechter M, Schwadmenthal E, Tanne D et al. Improved exercise tolerance and cardiac function in severe chronic heart failure patients undergoing a supervised exercise program. Int J Cardiol. 2007;116:309-314.
16. Cheng HWB, Chen WTT, Chu CKA, Lee S, Lee JS et al. The development of neurology palliative care service for motor neuron disease (MND) patients: Hong Kong experience. Ann Palliat Med. 2017;doi: 10.21037/apm.2017.08.17
17. Van Dam van Isselt EF, Groenewegen-Sipkema KH, Spruit-van Eijk M, Chavannes NH, Achterberg WP. Geriatric rehabilitation for patients with advanced COPD: programme characteristics and case studies. Int J Palliat Nurs. 2013;19(3):141-6
18. National Hospice and Palliative Care Organization. Medicare hospice conditions of participation allied therapists. http://www.nhpco.org/sites/default/files/public/regulatory/Allied_therapist_tip_sheet.pdf (Accessed on August 3, 2018).
19. Frost M. The role of physical, occupational, and speech therapy in hospice: Patient empowerment. Am J Hosp Palliat Care. 2001;18:397-402.
20. Ebel S, Langer K. The role of physical therapist in hospice care. Am J Hosp Palliat Care. 1993;10:32-35.
21. American Physical Therapy Association. Who are physical therapists, and what do they do? A guide to physical therapist practice. Phys Ther. 2001; 81:39.
22. Cooper J, Littlechild B. A study of occupational therapy interventions in oncology and palliative care. Int J Ther Rehabil. 2004;11:329-333.
23. Pearson E, Todd JG, Futcher JM. How can occupational therapists measure outcomes in palliative care? Palliat Med. 2007;21:477-485.
24. Pollens R. Role of speech-language pathologist in palliative hospice care. J Palliat Med. 2004;7:694-702. 

Conflicts of Interest: None

Author Affiliations:  Icahn School of Medicine at Mount Sinai, New York, NY; University of Michigan, Ann Arbor, MIVersion History: Originally edited by Sean Marks MD, first electronically published in October 2018