Physiotherapy in

Palliative Care
Presented by: Danae Hiebert
Physiotherapist, Riverview Health Centre

Outline
1. Focus and Role of Physio

Editorial

Studies
2. Receiving a Referral
3. Initial Assessment
4. Treatment:

Ambulation

Bed exercises

Passive Range of Motion / Stretching

Transfers

Respiratory Physio

Modalities – TENS

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Outline
5. Other Interventions
6. Discharge Planning
7. Occupational Therapy Role
8. Challenges
9. Conclusion
10. References

Focus

Physiotherapy in
palliative care is focused
on providing maximum
comfort for the patient
while maintaining the
highest level of physical
function in the face of
disease progression

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Editorial – Do Physiotherapists
Have a Role in Palliative Care?
(2001)

“World Health Organization principles of palliative
care (WHO, 1990):

Affirm life and regard dying as a normal process

Neither hasten nor postpone death

Provide relief from pain and other distressing symptoms

Integrate the psychological and spiritual aspects of patient
care

Offer a support system to help patients live as actively as
possible until death

Offer a support system to help family members cope during
the patient’s illness and their bereavement”1 p.5

Study – OT and PT in Hospice –

The Facilitation of Meaning, QOL
and Well-being (2004)

“Although people lie dying, they are still living –
living with the hope for improvements of life
despite acceptance that death is inevitable” 2p.129

Key Points:

“Blending of geriatrics and palliative care approach is
ideal” 2 p.121 – ie: focus not only on dying process, but
also on other physical problems associated with age
(joint pain, hearing / vision loss, fatigue)

“Rehab in palliative care is a paradox” 2 p.122 – need to
keep in mind when developing goals

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Study – OT and PT in Hospice –
The Facilitation of Meaning, QOL
and Well-being (2004)

Key Points (continued):

“smaller number of home exercises improves
compliance and performance” 2 p.122

“therapist recognition and affirmation of extreme
effort put forth by patient….great impact on their
sense of worth” 2 p.125

“recognize and discuss changes” 2 p.125 related to
decline in function

Holistic care by therapist is important

Study - The Utilization of Physical

Therapy in a Palliative Care Unit
(2003)

Key Points

Physiotherapy program benefited 56% of patients
assessed and who went through a physio
treatment program of 2 weeks

Patients with dementia diagnoses showed more
functional improvements

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Receiving a Referral

On Palliative Care physiotherapy works on a
referral basis, either from Doctor or Nursing.

Review chart and shift report

Liase with team (Nursing, MD, HCA)

Initial Assessment

Determine patient’s current physical strength
and functioning

Determine patient and/or caregiver’s goals
with physiotherapy treatment

May go in with OT for initial visit if we both
have received a referral

Chart documentation on initial assessment

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Physiotherapy
Treatments

Ambulation

Walking is the most functional exercise

Will assess need for mobility aid (2 or 4 wheeled
walker or cane)

Many benefits:

Reduces stiffness / relaxes tight muscles

Upright / weight-bearing posture

Aides digestion and constipation

“change of scenery”

Patient has feeling of purpose, and feel they can do

something for themselves

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Bed Exercises

Used if patient can not ambulate, or used for
additional exercises if they can ambulate

Includes Passive ROM, Active ROM and bed
exercises.

General bed exercises (see sample) or
specific bed exercises

Handout provided to patient

Exercises also shown to family / caregiver so
they can help

Bed Exercises

“Goals of PROM / AROM:

Minimize muscle wasting

Minimize contractures

Maintain joint and connective tissue mobility

Decrease restlessness

Assist circulation and vascular dynamics

Help maintain patient awareness of movement

Can give caregivers feeling of purpose if they can help with
the exercises

Develop coordination and motor skills for functional
activities (AROM)” 5 p.34-38

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Passive ROM / Stretching

This may be included in bed exercises

If patient has contractures / risk of developing
contractures or muscle tension

May also be done to relieve discomfort caused by lack of
movement

PROM is generally done to every major joint in the upper
and lower extremity

Stretching will be done to more specific tight musculature

Involve family / caregiver

WILL NOT: prevent muscle atrophy, increase strength
or endurance, or assist in circulation to the extent that
active and voluntary muscle contraction does.

Progression from Bed

Exercises

Practicing lie to sit transfer is the next step up
from doing bed exercises

Patient rolls onto side, lets legs go off edge of
bed, then pushes up to sitting

Once in sitting can “dangle” for as long as
tolerated

Trunk stabilization, leg and arm exercises
may be preformed in this position

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Transfers

Transfer assessments are done often on the
palliative care unit

Will work with patient to improve transfer as
best as we can

Nursing does initial assessment and will
contact physio if there are complications or
difficulty with the transfer

Transfers

Transfers range from:
Manual

Independent (I)

Stand-by Assist (SBA)

1 person assist (1PA)

2 person assist (2PA)

Mechanical

Sit-to-stand mechanical lift (SARAlift)

Total Mechanical lift (Hoyer / Opera)

Bedrest

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SARA lift 3000

2 caregivers need to be
present to operate the lift

Patient must be able to
put weight through both
legs, hold on with one
arm, and able to follow
simple directions.

Opera Lift

Comparable to Hoyer Lift

Must have 2 people
present to operate lift

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Respiratory Physiotherapy

If breathing or lung issues, respiratory
techniques may be used

Breathing Education:

Relaxation techniques

Pursed Lip Breathing

Postural Education

Stretches / Breathing Exercises

Pacing Techniques

Effective coughing techniques / Huffing

Respiratory Physiotherapy

Postural Drainage and Pummeling

Both are done with extreme caution and only if
specifically requested by MD

May help patients who are having trouble
coughing up secretions

Caution especially with cancer patients who may
have possible rib metastases

Encourage fluid intake and huffing throughout

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Respiratory Physiotherapy

Physiotherapists are trained in using pulse
oximetry

Will monitor oxygen saturations throughout
any breathing techniques or mobilization

Will also monitor breathing patterns and
levels of distress

RPE (rating of perceived exertion) 1-10 scale

MODALITIES

Transcutaneous Electrical Stimulation
(TENS)

Heat (Hot pack, Parrafin Wax bath)

Cold packs

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TENS

Transcutaneous Electrical Nerve Stimulation

Applications: muscle strengthening, pain
relief, wound healing

Pain control is the most common application
of TENS especially in palliative care

Depolarizes nerves: Action Potential

TENS for Pain Control

Gait Control Theory
TENS (non-nociceptive

TENS interferes with pain stimulus)
signals at the spinal cord level
A-beta nerves

PAIN (noxious stimulus)
When stimulated can inhibit

A-delta Nerves transmission of noxious

Unmyelinated C Nerves
stimuli

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Methods of TENS

Conventional TENS (high rate)

Acupuncture-like TENS

Burst mode

Conventional TENS

A-beta nerves can be stimulated by
Conventional TENS

100-150 pps

Only effect is while machine is on, so can be
used 24 hours a day, or when pain is most
severe

May have lasting effects by interrupting the
“pain-spasm cycle”

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Conventional TENS

Modulation – to prevent adaptation

May need intensity turned up throughout

treatment

Acupuncture-like TENS

Electrical stimulation may stimulate the
production and release of endorphins /
enkephalins

Studies have shown that endorphin /
enkephalin levels are raised after application
of TENS

Most effective at frequencies <10 pps

Acupuncture method of TENS can cause this
release

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Acupuncture-like TENS

Method may feel more sharp / uncomfortable
initially

Can produce a forceful muscle contraction

Effects can last 4-5 hours after a 20-30
minute session

Half-life of endogenous opiates released is
approx. 4.5 hours

Treatment >30 minutes may produce DOMS

Burst TENS

Stimulation is delivered in “bursts” or
“packages”

Similar to low rate TENS (Acupuncture-like)

Better tolerated than Acupuncture-like TENS

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Contraindications to TENS

Cardiac pacemakers or arrythmias

Placement over carotid sinus

Over areas of venous or arterial thrombosis
or thrombophlebitis

During pregnancy – over or around the
abdomen or low back

Precautions with TENS

Cardiac disease

Impaired mentation

Impaired or decreased sensation

Malignant tumors

On area of skin irritation or open wounds

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OTHER Interventions

Slings / braces

Acute Ortho, eg: Hip replacements

Measure and order TEDS

Positioning issues

Exercise equipment:

Restorator

Weights

Reciprocal pulleys

Discharge Planning

Assess need for mobility aid (walker / cane)
and provide purchase / rental information

Discuss lay-out of home

Stairs? Rail? Will practice before they go
home

OT is more involved in discharge planning
(home equipment)

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Occupational Therapy Role

Wheelchairs (custom / speciality / adaptations)

Splinting / Bracing

Positioning

Adaptive Tools (cutlery / comb, etc.)

Cognitive Assessments (Cognistat)

Home assessments / adaptations

Discharge planning and equipment recommendations
(ie: tub bench, raised toilet seat)

Assessments in ILU (independent living unit)

Challenges in Palliative Care

Caregiver / Family expectations

? Giving false hope

0.5 position for PT, 0.3 position for OT

Fluctuation in status

Medication side-effects

Visitors

MD and other professions visiting

No rehab attendant

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Conclusion

May not see physical gains like you would in
any other area of physio

Providing motivation / comfort to patient’s can
be just as, or more, rewarding

Questions??

References
1. Hoskins Michel, T. (2001), Editorial – Do Physiotherapists have
a role in palliative care? Physiotherapy Research International,
6(1) iii-iv.
2. Pizzi, M.B., Briggs, R. (2004). Occupational and Physical
Therapy in Hospice. Topics in Geriatric Rehabilitation, 20 (2)
120-130.
3. Montagnini, M., Lodhi, M., Born, W. (2003). The Utilization of
Physical Therapy in a Palliative Care Unit. Journal of Palliative
Medicine, 6(1).
4. Oldervoll, L.M., Loge, J.H., Paltiel, H., Asp, M.B., Vidvei, U.,
Wiken, A.N., Hjermstad, M.J., Kaasa, S. (2006). The Effect of a
Physical Exercise Program in Palliative Care: A Phase II Study.
Journal of Pain and Symptom Management 31(5) 421-430.
5. Kisner, C., Allen Colby, L. (2002) Therapeutic Exercise –
Foundations and Techniques 4th Edition. F.A. Davis Company,
Philedelphia, PA

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References
6. Pauls, J.A., Reed, K.L. (2004), Quick Reference to Physical
Therapy 2nd Edition, Pro-Ed, Austin, Texas
7. Cameron, M.H. (2003), Physical Agents in Rehabilitation – From
Research to Practice, Saunders, St.Louis, Missouri
8. Knezic, N., Blouw, L. (2000) ‘Physiotherapy Role in Palliative
Care’, Physio Connection, 10, No 2, pp.1 and 9
9. Knezic, N. (1999) Physiotherapy in Palliative Care Presentation
(Written for Presentation to Medical Rehabilitation Students).

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