Original Article

The Benefits of Rehabilitation for Palliative Care Patients

American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(1) 34-43 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113514474 ajhpm.sagepub.com

Edward Barawid, DO1, Natalia Covarrubias, MD1, Bianca Tribuzio, DO1, and Solomon Liao, MD2

Abstract Palliative care requires an interdisciplinary team approach to provide the best care for patients with life-threatening illnesses. Like palliative medicine, rehabilitation also uses an interdisciplinary approach to treating patients with chronic illnesses. This review article focuses on rehabilitation interventions that can be beneficial in patients with late stage illnesses. Rehabilitation may be useful in improving the quality of life by palliating function, mobility, activities of daily living, pain relief, endurance, and the psyche of a patient while helping to maintain as much independence as possible, leading to a decrease in burden on caregivers and family. Rehabilitative services are underutilized in the palliative care setting, and more research is needed to address how patients may benefit as they approach the end of their lives. Keywords rehabilitation, interdisciplinary, quality of life, therapies, modalities, functional

Introduction Rehabilitation is similar to palliative care, in that the goal is not to cure or eliminate disease but to enhance quality of life (QOL).1 Patients diagnosed with common major diseases, such as cancer, chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and neurologic conditions such as amyotrophic lateral sclerosis (ALS) and dementia, benefit from rehabilitation as well as palliative care. Patients and families frequently transition from curative care to rehabilitative care to palliative care. At other times, they may move back and forth between the types of care or seek overlapping simultaneous care. Regardless of the type of care they receive, the ability to maintain as much independence and function as possible is a common struggle for these patients and is a significant part of their QOL. Rehabilitation even in the advanced phases of illness can help to restore or maintain function or slow down the functional decline through such means as strengthening, ambulation, range of motion (ROM), improving activities of daily living (ADLs), and pain relief. Rehabilitation medicine and palliative care have emerged as 2 important components of comprehensive medical care for patients with advanced disease; both disciplines have an interdisciplinary model of care, which aims to improve patients’ levels of function and comfort.2 Rehabilitation interventions can impact function and symptom management in terminally ill patients. Clinical experience and research from the literature suggest that the application of the fundamental principles of rehabilitation medicine is likely to improve their care.2 For example, in the setting of cancer,

Okamura sites several studies regarding the needs of patients with cancer in relation to rehabilitation.3 One such study showed that even during the terminal stage, 85% of the patients want to be able to walk or to move about in a wheelchair, and interventions with regard to these aspects were said to be effective and satisfactory.4 Maintaining motivation and the desire to be mobile may contribute to a prolonged and improved QOL, whereas physical inactivity contributes to premature deaths each year. Pate et al and Bryan et al reported poor exercise and nutrition were related to approximately 30% of total cancer deaths.5,6 Rehabilitation may serve to bridge this need and be an essential compliment to palliative care to provide a higher QOL. They are therefore 2 sides of the same coin (see Figure 1). Both emphasize patient- and family-centered care and focus on achieving the patient’s goals using a multidisciplinary approach. This team approach allows for the involvement of the physician, therapist, nursing, social work, and so forth working toward the same goal. In palliative care, therapists are

1

Department of Physical Medicine and Rehabilitation, University of California Irvine Medical Center, Orange, CA, USA 2 Department of Palliative Care, University of California Irvine Medical Center, Orange, CA, USA Corresponding Author: Natalia Covarrubias, MD, Department of Physical Medicine and Rehabilitation, University of California Irvine Medical Center, 101 The City Drive South, Bldg 53, Room 311A, Orange, CA 92868, USA. Email: [email protected]

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Palliative Care

Curative Care

Rehabilitative Care

Figure 1. Overlapping domains of the models of care.

involved in the following 4 levels: prevention, acute and postacute care, institutional and community-based rehabilitation, and symptom control.7 Along with the care of a rehabilitation medicine specialist, occupational and physical therapists work with critically ill patients to create realistic and meaningful goals for improving comfort, mobility, socialization skills, and ability to care for oneself regardless of disease state and medical status.8 Patients frequently and appropriately move between the 3 overlapping models of care: curative care, palliative care, and rehabilitative care. They often receive 2 or more types of care simultaneously. This article describes the role of rehabilitation modalities in palliative care and reviews the evidence for the benefit of rehabilitative care in the common, major diagnoses. The following sections will focus on major diagnoses; cancer, COPD, CHF, and neurodegenerative disorders; in the setting of palliative care, in need of rehabilitation, and the current interventions available.

on returning the patients back to their functional preoperative baseline by promoting early postoperative ambulation and improving physical functions. This goal is common in rehabilitation for all cancers. Ambulation is encouraged during chemotherapy to prevent disuse syndrome and maintain strength with mild exercise therapy and sedentary occupational therapy. The rehabilitation team evaluates those activities that the patient holds to be important in his or her life. This assessment allows the patient to recognize their own symptoms and his or her desired ADLs, with the rehabilitation staff offering activities that will help the patient do what he or she wants to do. Giving the patient a sense of control over his or her own activities is an important link to preserving his or her selfconfidence.3 With recurrence and advanced stages, the feelings of patients and their families may change markedly due to the transition to this period and may take time to mature. Fluctuating and mixed emotions are natural. The rehabilitation staff can help realign their goals to the new reality, accept the limits of rehabilitation, and to identify new goals of care, including rehabilitation goals.3 Even in the terminal stage, the staff can teach family members how to assist the patient, making adjustments to the environment around the bed and bathroom, and by making walking aids available, even when there is no prospect for improvement in the patients’ functions. The communication of rehabilitation staffs with patients and their families also becomes important during this phase. Another important role of rehabilitation is providing support to achieve understanding among patients, their families, and the staff by introducing communication aids or assisting with conversation. Even when a patients’ general condition deteriorates, rehabilitation can be performed until the very end by going to the patients’ bedside and touching the patients’ body through palliative interventions, such as ROM exercises for the patients’ limbs, massage for swollen lower limbs, or breathing assistance.3

Role of Physical Therapy Cancer Lehmann et al in 1978 and Harvey et al in 1982 first published comprehensive research reports on the need for rehabilitation in the treatment of patients with cancer.9,10 Disability in patients with advanced cancer can result from bed rest, deconditioning, or neurologic and musculoskeletal complications of cancer or cancer treatment.2 Rehabilitation modalities are frequently beneficial in treating these disabilities.

Classification of Cancer Rehabilitation Cancer rehabilitation has been divided into 4 categories according to the physical and individual needs of patients with cancer. These categories are preventive, restorative, supportive, and palliative (see Table 1).12 Table 2 gives the potential contributions of rehabilitation during different stages of cancer.13 After cancer surgery, emphasis is initially placed

Physical therapy has an important role in palliative care. Therapists play a significant role in the holistic care of patients diagnosed with cancer.14 The interventions provided by physical therapists in hospice and palliative care may be directed to 3 facets: delivering direct patient care, educating the patient– family care unit and fellow health professionals, and functioning as a team member.15 The most common care setting for the physical therapist is in the acute care hospital. In a hospitalbased palliative care unit, physical therapists treat the common functional disabilities such as deconditioning, pain, imbalance, and focal weakness.7 Other therapeutic strategies employed by physical therapists in palliative oncology include ambulation, musculoskeletal therapy, neurological therapy, respiratory therapy, use of electrophysical agents, mechanical therapy, and decongestive physiotherapy.2 Treatments used by physical therapists for patients with cancer may consist of modalities such as massage, heating pads, and transcutaneous electrical nerve stimulator (TENS) units, all of which

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36 Table 1. Classification of Cancer Rehabilitation.a    

I. Preventive rehabilitation II. Restorative rehabilitation III. Supportive rehabilitation

Begins after cancer diagnosis, even if no impairments of function Done prior or immediately after surgery, radiotherapy, or chemotherapy The purpose of the rehabilitation measures at this point is to prevent of impairments The goal is for the maximal recovery of function in patients with remaining function and ability

 Augments self-care ability and mobility with effective methods (eg, guidance with regard to self-help devices, self-care, and more skillful ways of doing things) for patients whose cancer has been progressing and whose impairments of function and abilities are declining  Additionally includes preventing disuse, such as contractures, muscle atrophy, loss of muscle strength, and decubitus ulcers  While respecting patient wishes, allows terminal patients to live a high QOL physically, psychologically, and socially  Aims to relieve symptoms (eg, pain, dyspnea, and edema) and prevent contractures and decubitus ulcers using  heat  low-frequency therapy  positioning  breathing assistance  relaxation  assistive devices

IV. Palliative rehabilitation

Abbreviation: QOL, quality of life. a Adapted from Shigemoto et al.11

Table 2. Possible Contributions of Rehabilitation in the Various Phases of the Disease.a Treatment

Posttreatment

Recurrence End of life

          

Evaluating the treatment effects on function Incorporating exercise, edema management, and increased activity to preserve and restore function Managing pain with heat, cold, and TENS units Creating and supporting a program to assist the restorating of daily routines and promote a healthy lifestyle Educating the patient about self-monitoring issues Overseeing a maintenance program of exercise, edema management, and mobility Educating the patient about how recurrence effects function and monitoring new issues regarding new clinical status Overseeing the patient in a suitable program to restore function or prevent its decline Educating the patient and family regarding mobility training, appropriate body mechanics, and assistive devices Pain management (nonpharmacologic treatment) and symptom control Maintaining independence and quality of life

Abbreviation: TENS, transcutaneous electrical nerve stimulator. a Adapted from Shigemoto et al.11

may help with pain management.16 The therapists provide education on activity modification, ROM, and strengthening exercises. Training in ambulation using assistive devices, environmental modification, energy conservation, and work simplification techniques may also be given.2 Multiple studies report that such therapy techniques may be beneficial in cancer-related fatigue.17–25







Role of Occupational Therapy



For patients with cancer (as for other advanced diseases), occupational therapists contribute to the patients’ care as their disease progresses by addressing the following areas:  Conducting baseline assessments and preoperative counseling sessions on how to prevent or reduce functional deficits prior to the start of medical treatment and thus improving long-term outcomes.



Providing instruction on self-care management including skin care, infection prevention, and adapted clothing. Evaluating the individual’s physical, emotional, and cognitive abilities in order to make appropriate recommendations for safe integration into community outreach and support programs. Teaching coping strategies to resume safe and comfortable sexual activity as well as providing interventions to improve healthy body image. Tailoring an individualized lifestyle approach to allow participation in important roles such as parenting, managing the home, and working. Strategies include, but are not limited to, conserving energy and managing fatigue; engaging in leisure activities; and developing coping skills. Training on therapeutic range-of-motion exercises and muscle reeducation techniques, including the neck, trunk, and arm, which progresses into meaningful activities such as grooming or bathing.

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 Addressing lymphedema by providing education on modifying or eliminating habits such as wearing tight clothes, routines such as sun bathing, and activities such as heavy yard work, as well as adding restorative treatment techniques such as manual lymph drainage.  Identifying specific cognitive deficits affecting occupational roles, and providing compensatory training to successfully complete activities such as cooking for one’s family or driving safely with minimal distractions.  Ongoing screening and monitoring of performance deficits and improvements throughout survivorship to modify the ongoing multidisciplinary intervention plan to meet changing needs.26 Lee et al conducted a study evaluating the effectiveness of occupational therapy in promoting feeding independence in patients with end-stage cancer in palliative care. Their data suggested a significant improvement in feeding independence from baseline to week 1.27 Through multilevel models they showed that improved feeding independence was sustainable through weeks 2 and 3. They found no significant differences in the level of feeding independence between weeks 1 and 2 and between weeks 1 and 3 among the patients after controlling for age and sex. They therefore concluded that the improvement in feeding independence in patients with end-stage cancer receiving palliative care may increase QOL, improve ADLs, and minimize excessive disability.27

Psychological Benefit Rehabilitation approaches for patients with cancer should consider both psychosocial and physical aspects by adequately understanding the strong connections between the patients’ physical, psychological and social aspects.28 The aim to improve or maintain the overall QOL holds precedent over mere functional improvements. As the survival duration for patients with cancer increases, the emphasis should be placed on maintaining the QOL of patients with cancer and prolonging it for as long as possible.29 A cross-sectional African survey concluded that ‘‘feeling at peace and having a sense of meaning in life were more important to patients than being active or physical comfort, and spiritual well-being correlated most highly with overall QOL.’’30 (p281) A study of 23 inpatients of a cancer hospital suggested that psychological suffering was alleviated by rehabilitation. Shigemoto provided rehabilitation for 2 weeks followed by a survey of the patients and their families to determine what changed before and after the rehabilitation. He discovered that the interventions changed several emotional aspects in the patients and their families on top of the patient’s physical improvements. Patients mentioned a feeling of relief, and their families had increased contentment that self-confidence and fun were restored in the patients’ life.11 Other studies in patients with cancer (including advanced stage cancer) have also shown a decrease in anxiety, stress, and depression and improvements in pain, fatigue, shortness of breath, constipation, and insomnia

due to exercise.31 Lo´pez-Sendı´n et al found that a combination of massage and exercise reduced pain and improved mood in patients with terminal cancer. They observed a sustained effect on pain and psychological distress; however, physical distress and the lowest pain score were no greater in the intervention group than in the controls.32

Neurologic Diseases Amyotrophic Lateral Sclerosis Amyotrophic lateral sclerosis is a progressive, degenerative neurological disease affecting motor neurons disrupting muscle control and ultimately leading to death. On top of their motor impairment, patients have high symptom burdens such as pain, fatigue, dyspnea, and sialorrhea.33 Muscle atrophy and weakness result in postural imbalance and cause pain in muscles and joints due to compensation. Loss of muscle mass around the bones and joints can lead to increased pressure and pain. Muscle cramping and spasticity commonly leads to pain. Muscle relaxants can provide significant pain relief, and occasionally intrathecal Baclofen pumps are needed to treat intractable spasms. The prevalence of increased pain in the final month of life is high, and yet currently no studies exist on the efficacy of pain treatment in patients with ALS.33,34

Interdisciplinary Supportive Care in ALS Briggs suggests a ‘‘rehabilitation in reverse’’ approach in patients with ALS in which certain interventions are presented in reverse order than they are traditionally given.35 At the beginning physical therapists may intervene for gait and balance training with a cane, using ankle–foot orthotics, fitting, and gait training with a walker on a variety of terrain. They may instruct and train caregivers to assist in safe ambulation. As ambulation declines, a manual or power wheelchair will be needed and should be properly fitted. Transfers will become more difficult, initially requiring only standby assistance, but over time progressing to moderate or maximal assistance, or even completely dependent with the use of a mechanical lift. New goals regarding safety, independence, and equipment use will have to be adjusted as the level of function declines with disease progression. The number and type of visits and the treatment frequency for ‘‘Rehabilitation in Reverse’’ will also change accordingly. Case management is an essential aspect of care for patients with ALS, because their comorbid and secondary conditions require complex care by multiple caregivers. As licensed, skilled professionals, therapists contribute to the case management evaluation even when direct patient treatment is not the focus of intervention.35 Therapists provide ongoing reevaluation of the caregiving situation leading to education of the caregivers, modification of the care plan, and updates of the home exercise and activity program. This interdisciplinary model provides for (1) optimal prevention of complications that might require hospitalization, (2) knowledge and safety for

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38 the caregivers, and ultimately (3) QOL for the patient.35 Case management visits are also opportunities to identify needs for short-term direct intervention in order to solve new care issues and can be scheduled once per 30 or 60 days.35 These visits are recognized and covered under the Medicare Home Health Benefit. Skilled maintenance is another recognized benefit under the Medicare. According to the Medicare Web site, physicians may refer patients in the event they require skilled care from personnel including registered nurses, physical therapists, occupational therapists, and speech-language pathologists. A need must be documented for these treatments on a daily basis (5-6 days a week), and the care must be provided in a skilled nursing facility or on an inpatient basis.36 ‘‘Supportive care’’ consists of manual care such as massage, ROM, joint mobilization, and instruction of caregivers about the performance and follow through of these activities.35 Psychosocial and spiritual support are also important components.

Exercise Exercise is important to prevent atrophy of muscles from disuse and is key for remaining mobile for as long as possible. Doing so comfortably and safely requires proper education and training.37 The myth that exercise may accelerate the progression of weakness due to overuse prevented the prescription of exercise in neuromuscular patients. In a single study, Sinaki and Mulder showed potential negative effects of exercise in rapidly progressive cases.38 However, no controlled studies have documented that ‘‘overuse weakness’’ actually occurs, and many other studies have shown benefits of exercise in patients with neuromuscular disease. These studies of slow progressive cases have reported gains in strength due to physical activity.39–44 Four types of exercise training have been shown to be important for overall neuromuscular patients: flexibility, strength, balance, and aerobic exercise. Flexibility exercises prevent the development of contractures in patients with neuromuscular diseases.37 These contractures may become painful and directly interfere with daily activities. Flexibility training may also be beneficial in reducing spasticity, thus decreasing the risk of falls.37 Exercises are beneficial in the initial phase preventing fatigue, muscular weakness, and disuse weakness.45 Gradual resisted isometric exercises have demonstrated an increased muscular force.46 Since nearly all deaths in patients with ALS are eventually a result of respiratory complications, respiratory issues pose a challenge to maintaining function, and QOL.47 Correction of hypoxia with noninvasive positive pressure ventilation (NIPPV) in the setting of physical exercise, prior to exertion, promotes positive effects by increasing muscle force with less oxygen consumption and less fatigue for the same exercise intensity.37 Therefore, NIPPV is frequently used in the management of respiratory deficits in patients with ALS. In addition to improving QOL and functional status, NIPPV may improve long-term survival in rapidly progressive ALS without resorting to tracheostomy.37 NIPPV functions analogous to

a respiratory orthosis that support the diminished muscles. By not taking over the function of their respiratory muscles, NIPPV still allows specific exercise of these muscles that would otherwise suffer from further disuse atrophy and deconditioning.37 Factors such as age, cardiopulmonary health, ongoing medication, baseline degree of physical activity, and rate of disease progression must be taken into account prior to the initiation of exercise.37 This consideration is important, because rapidly progressive disorders such as ALS may respond differently than others, especially regarding rate of progression. Optimal exercise requires supervision to prevent severe injuries, falls, sprains, or other complications. On the horizon is a study called the FACTS-2-ALS study, which is the first theory-based randomized controlled trial to evaluate the effects of aerobic exercise therapy and cognitive behavioral therapy on functioning and QOL in patients with ALS. The expectation is for this study to provide new evidence for the effect of multidisciplinary care of persons with ALS. Results of the study will hopefully lead to adaptations of ALS treatment protocols to improve or preserve QOL and functioning in patients with ALS.48

Advanced Dementia Dementias are irreversible, degenerative disorders of the brain. Alzheimer disease (AD) is the most common of all dementias, accounting for approximately 60% to 70% of dementia cases.49 The Centers for Disease Control and Prevention lists AD as the sixth leading cause of death in 2009, ahead of diabetes.50 Advanced dementia not only involves distressing neuropsychological symptoms but encompasses various medical complications that lead to patients’ death.51 They may develop pressure sores, recurrent urinary tract infections, urosepsis, poor oral intake affecting weight and nutrition, constipation, and delirium.51 Individuals lose the ability to ambulate and then experience complete loss of muscle control needed to maintain even in their sitting posture.52 As dementia progresses to end stage, basic brain functioning deteriorates, and patients become bed bound, unable to verbally communicate, and eventually unable to swallow. Most patients with end-stage dementia die from an aspiration pneumonia. Despite the aforementioned facts, the American public does not generally consider AD a terminal disease and therefore usually do not think about hospice care. These patients and their families should be offered extensive palliative and rehabilitation services from which they would benefit. Rehabilitation therapies offer support to patients with advanced dementia and for their families. Physical and occupational therapy can provide patients with aerobic conditioning, strengthening, transfer training as well as assistance with ADLs training. Family training may also be performed. Passive ROM, even while in bed, helps to prevent contractures and reduce the development of pressure ulcers in these patients. One study showed that physical activity in patients with AD may prevent multiple devastating and frequent complications of the disease such as falls, behavior disturbances, mobility, disability,

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or weight loss.53 In addition, 20 other studies suggested a significant and independent preventive effect of physical activity on cognitive decline or dementia. For example, 1 study reported that low-level activity may be enough to reduce cognitive decline. In this study, elderly patients who did more than 1 hour of physical activity per week, had a 2-fold decreased risk of cognitive decline compared to those who did less than 1 hour per week.54 A recently conducted project assessed the effect of cognitive stimulation, physical activity, and socialization on patients with AD and their informal caregiver’s QOL and mood. Fourteen patients with AD were randomly divided into an active treatment group and a control group. The study reported a significant improvement in apathy, anxiety, depression, and QOL in the active treatment group. Caregivers in the active treatment group also exhibited a significant improvement in their mood and in their perception of patients’ QOL.55

Cardiovascular Disease Cardiovascular rehabilitation (CR) is a treatment option for the improvement of function and prevention of further morbidity in patients with cardiac disease. The American Association of Cardiovascular and Pulmonary Rehabilitation defines CR as ‘‘a medically supervised program designed to optimize a cardiac patients’ physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing death and disability.’’ CR provides exercise on top of education, modification of risk factors, and secondary prevention.56 Cardiovascular rehabilitation benefits patients’ quality and quantity of life. Cardiovascular rehabilitation reduces total mortality by 20% and cardiac mortality by 26% when compared with usual medical care.57 Additionally, CR improves left ventricular ejection fraction (LVEF), myocardial oxygen demand, autonomic tone, coagulation, inflammatory markers, endothelial function, and the development of coronary collateral vessels.58,59 These improvements may be attributed to the reduction of risk factors for cardiovascular disease (CVD), but nonetheless, they are important changes for secondary prevention. Improvement of LVEF is particularly significant because it correlates to symptoms and QOL and is an important predictor of mortality in patients with coronary artery disease. In a recent Cochrane review, 7 of the 10 trials that evaluated QOL with exercise-based CR showed a significantly higher level of QOL compared to the control group.59 The 4 phases of CR are acute inpatient care, home-based recuperation, outpatient program, and independent self-care.60 The first phase of CR can begin with education as soon as the patient is medically stable. Educational topics include nutrition, risk factor modification, potential medical complications, and the therapies to follow. Passive ROM exercises are important to prevent joint contractures and maintain muscle tone. Exercise intensity is gradually increased under telemetry monitoring.60 The acute inpatient rehabilitation setting requires an interdisciplinary team to achieve medical stability and

functional independence. This program usually consists of monitoring by a rehabilitation physician, ongoing education, 60 minutes a day of telemetry-monitored aerobic exercise, 60 minutes of physical therapy, and occupational therapy daily. Inpatient CR is less favorable due to its higher costs and studies showing no difference in outcomes between inpatient and outpatient rehabilitation.61,62 After discharge from the hospital, patients gradually incorporate their everyday activities into their lives but usually without aerobic exercises. Outpatient rehabilitation is therefore needed to progressively improve aerobic conditioning and alter modifiable risk factors. A safe exercise program is prescribed based on the patient’s medical, functional, and physiologic abilities. The patient typically attends 3 outpatient sessions per week for a total of 36 sessions and is slowly introduced to an independent exercise program. On discharge from the supervised CR program, patients are instructed that maintenance is lifelong. The patient is expected to exercise 2 to 5 times per week and to monitor their heart rate during exercise. Despite the large amount of evidence showing the success of CR, it is still an underutilized resource that should be offered for the benefit of our patients’ QOL, health, and cardiac function.

Chronic Heart Failure Chronic heart failure is a clinical syndrome resulting from insufficient cardiac output to meet the demands of the body63 and is the end stage in the CVD continuum.64 Chronic heart failure is an incurable and progressive condition, which is estimated to be present in 5 million US citizens.65 It causes dyspnea and fatigue, thereby affecting the patients’ ability to participate in physical activity.66 In its advanced stages, CHF frequently leads to a relentless cycle of recurrent hospitalizations causing further deconditioning. This deconditioning is usually not adequately addressed with medical management alone, therefore resulting in further inactivity to avoid symptoms.63 Chronic heart failure is associated with autonomic dysregulation (a decrease in vagal tone and an increase in sympathetic activity), which is believed to be the mechanism behind its high mortality.67 Aerobic exercise is a well-known tool to improve the clinical and prognostic outcome of patients with CHF.68 Multiple studies have shown CR’s ability to improve exercise tolerance, dyspnea, fatigue, QOL, ability to perform ADLs, and decrease anxiety and depression, without changing left ventricular function.69–71 Hospital readmission and cardiac mortality were both reduced, and autonomic dysregulation demonstrated improvement.67,69,72 The pathophysiology is thought to be related to the effects of exercise centrally and peripherally, such as increases in peak cardiac output, heart rate, stroke volume, reduction in afterload, as well as improved vasodilation in active muscles, decreased sympathetic nervous system activation, and an increase in vagal tone.67,69,73

Cardiovascular Rehabilitation for CHF The 2 methods of aerobic training typically used in patients with CHF are continuous and interval training. No set guidelines for

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40 Table 3. Borg Rating of Perceived Exertion (RPE) Scale.a 6 7 9 11 13 15 17 19 20

No exertion Extremely light Very light Light Somewhat hard Hard Very hard Extremely hard Maximal exertion

a A measure of exercise capacity to prevent risk of excessive intensity during cardiovascular rehabilitation. Adapted from Borg.75

exercise training exist, rather each program must be individualized to the patient.68 This individualization is particularly important for patients with severe CHF having a left ventricular ejection fracture of less than 25%.71 Continuous aerobic training is usually prescribed at a moderate to high intensity for 45 to 60 minutes per session. Interval training requires high-intensity exercises repeated in short bouts, up to 2 minutes’ duration each, separated by periods of recovery.68 Two studies suggest that a continuous aerobic training program is more beneficial than interval or resistance training programs.67,74 A comprehensive CR program also includes physical activity counseling, psychosocial support, and risk factor education for weight control, lipids, blood pressure, and smoking cessation.70 Prior to starting rehabilitative therapies, an electrocardiogram (ECG) should be obtained as part of the cardiopulmonary testing. The American College of Sports Medicine recommends stopping exercise if diastolic blood pressure exceeds 110 mm Hg, if systolic blood pressure decreases more than 10 mm Hg, if ventricular or atrial dysrhythmias develops, if a second- or third-degree heart block occurs, if there are signs of exercise intolerance including angina and dyspnea, or if the ECG changes suggest ischemia.70 Contraindications to physical exercise include moderate to severe aortic stenosis, a myocardial infarction of less than 4 weeks ago, uncontrolled hypertension, unstable angina, and uncontrolled atrial or ventricular dysrhythmias.70 Peak Vo2 is used to measure exercise capacity. Alternatives to Vo2 are indirect methods such as Borg Rating of Perceived Exertion (RPE) scale (see Table 3) and heart rate. A 50% peak heart rate is a common starting point, or 11 in the Borg RPE scale to avoid risk of excessive intensity.68 Currently no insurance coverage is available for inpatient CR stays for CHF. Therefore, most rehabilitation programs are outpatient.62 Most of the CR studies were performed on an outpatient basis. Home-based rehabilitation is also an option and has shown to have the same cardiovascular benefits as outpatient therapies.76,77 Home rehabilitation can be and should be part of home palliative care program for patients with CHF.

Chronic Obstructive Pulmonary Disease COPD is the third leading cause of death and the 12th leading cause of morbidity in the United States. Patients with this

disorder generally have dyspnea, poor exercise tolerance, chronic cough, wheezing, and eventually respiratory failure. The natural history of this disorder is such that exacerbations are common, occurring at a frequency of 0.8 to 2.5 per patient per year.78 Severe, acute exacerbations require hospitalization causing high economic burden to the health system and to the society. Pulmonary rehabilitation (PR) is an accepted treatment method, which has been proved to decrease hospital readmissions.79

Pulmonary Rehabilitation Pulmonary rehabilitation is an interdisciplinary approach that helps patients to adapt to their chronic illness, reduce symptoms, and optimize function by stabilizing or reversing manifestations of the disease.80 It does not directly affect the underlying pathology but improves primary and secondary impairments in function and symptoms.80 Pulmonary rehabilitation consists of physical therapy, occupational therapy, and education regarding lifestyle modifications, smoking cessation, weight loss, and so on. The goal of therapy is to optimize the patients’ physical performance, reduce their symptoms, maximize function, reduce caregiver dependence, and minimize hospital admissions.79,81 The American College of Physicians and 2 Cochrane reviews have all reported that PR improves dyspnea and QOL, reduces hospital readmissions and mortality, and is cost effective.78,81,82 Although the American Thoracic Society recommends 2 to 3 supervised sessions of high-intensity training per week over 8 to 12 weeks, not all patients are able to tolerate this therapy.83 Although this high-intensity schedule may yield significant short-term results, it may also lead to lower adherence rates in the long term.84 For example, therapies for as short as 4 weeks have been shown to significantly improve healthrelated QOL and functional exercise capacity.85 However, consistent physical activity of as little as 2 hours per week has been shown to have a 30% to 40% reduction in the risk of hospital admissions and respiratory mortality.79 To maintain longterm benefit, PR should ideally include endurance training, such as cycling or walking, in addition to strength training. For those who cannot tolerate high-intensity sessions, shorter interval training is more appropriate, accepting that the result will be substantially less symptom improvement. Early recognition and treatment of exacerbations, breathing strategies, and bronchial hygiene and addressing risk factors such as obesity are all part of the education of patients and families. The most studied PR approach is outpatient, office-based rehabilitation, because it is cost effective and occurs in a safe, monitored environment. While inpatient rehabilitation may be appropriate for the severely deconditioned or those lacking transportation, this approach is generally not practical due to its high cost and difficulty of obtaining insurance approval. Homebased therapy is another option, which is known to improve the efficacy of long-term PR84 but has not been shown to be very effective for the severely disabled.83 Maintenance programs were demonstrated in a review by the Ontario working group

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to have an impact on health-related QOL and hospitalizations but did not significantly improve exercise capacity.85 Even patients with COPD having seemingly normal exercise capacity can still benefit from PR, with improvements in exercise capacity, respiratory muscle strength, and exertional dyspnea scores.86

this gap in the literature. We hope that models of collaboration between palliative care and rehabilitation will increasingly be developed, demonstrated, and evaluated for the benefit of patients, their families, the health system, and ultimately our society as a whole. Declaration of Conflicting Interests

Limitations of Rehabilitation in Palliative Care As we have discussed, rehabilitation modalities in palliative care patients have been documented to be successful, but the lack of its utilization is the unfortunate fact of our medical system. Rehabilitation is often not offered in hospice services due to the thought that it is not cost effective. Contrary to this belief, if patients received therapies, which prolong life, hospice services can receive more income. Telerehabilitation is a newer utilization of technology, which allows therapy to reach patients all over the globe. Therapists can instruct patients and their caregivers on how to conduct therapies in their home. In order to monitor palliative patients’ outcomes during rehabilitation, specific outcome measures should be utilized. While the functional independence measure is frequently used in rehabilitation, palliative care outcome measures are better suited for this respective patient population. The most frequently used is the palliative performance scale that takes into account functional and psychosocial factor. In considering both function and psychosocial aspects, a more complete picture can be obtained when trying to measure improvements with therapies.

Conclusion Regardless of the diagnosis, the goal for all palliative care patients should be to maintain their QOL and maximize their function in accordance with the patient and family’s priorities. This narrative review article has provided evidence to support that rehabilitation should be part of the palliative care to achieve that goal. As more and more physiatrists enter into the specialty of palliative medicine, palliative care professionals will increasingly have the opportunity to partner with our physical medicine and rehabilitation colleagues to provide the appropriate care at all levels and across the continuum of the patient’s care. Clinicians should be aware of the rehabilitative options available to patients with advanced cancer, CHF, COPD, ALS, and dementia and offer them appropriate rehabilitative treatment. This article focused on the common and major palliative care conditions as examples of how rehabilitative therapies can benefit the patients’ QOL and comfort care. The article was limited in its scope to cover all the end-stage diseases and advance diagnoses for which rehabilitative therapies can contribute and was not intended to be an exhaustive coverage of the topic. Even for the common major conditions that most Americans will face, the research is currently insufficient about how rehabilitative services can best benefit them as they approach the end of their lives. More research is therefore needed to address

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.

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