Abstract
Background:
Physical therapy encompasses the skilled treatment and care for patients across the life span through a multitude of different practice settings. This includes caring for individuals within end-of-life or palliative care settings. The goal of treatment in this stage of care is to relieve physical, social, psychological, and spiritual suffering in order to improve overall quality of life in patients with terminal illnesses. There has been limited research conducted to investigate the utilization of physical therapy interventions in palliative care settings.
Purpose:
The purpose of this study was to contribute to the current research involving physical therapy and end-of-life care in terms of its efficacy, value, and how this value is perceived by patients and their caregivers.
Methods:
This was completed by independently screening and reviewing the studies that were published between the years 1994 and 2014 and related to this topic. The databases and journals searched included CINAHL, PUBMED, MEDLINE, Cochrane, PEDro, the Journal of Palliative Care, the American Journal of Hospice and Palliative Medicine, and Google Scholar.
Results:
Thirteen qualitative articles were selected which met all inclusion criteria and discussed the role of physical therapy intervention in the palliative care setting. Methodological quality of articles were assessed using the QASP, scale and their findings were summarized and presented in table format.
Conclusion:
These articles support the utilization of physical therapy in palliative care settings and emphasizes the impact of physical therapy on improving patients’ physical, social, and emotional well-being.
Introduction
The number of patients receiving palliative and end-of-life care is constantly increasing. In 2013, an estimated 1.5 to 1.6 million patients received services in the United States. 1 With the remarkable amount of patients requiring care in this setting, it is essential for physical therapists to question and analyze how they are providing care for this population and in what ways this care is truly benefiting their patients.
As described in the vision statement of the American Physical Therapy Association, the goal of physical therapy as a profession is to work toward “transforming society by optimizing movement to improve the human experience.” 2 This vision statement applies directly to how physical therapists should approach patient care in end-of-life settings through utilizing their skills and knowledge to best serve this population. Rehabilitation utilized in the palliative care setting has the potential to improve quality of life, decrease pain, and help maintain or improve function in patients with a terminal illness. Rehabilitation professionals fill this role through “maximizing functional ability and comfort to enhance quality of life, assuring patient and care giver safety, helping people redesign their lives and life goals, and providing support around physical, emotional and spiritual issues at the end of life (p. 1).” 3 By promoting safety and independence, physical therapy improves the overall well-being of patients receiving end-of-life care. Patients often report a higher quality of life after physical therapy services due to the achieved improvements in function and independence. This increased perceived quality of life decreases the amount of nursing and social worker visits, in addition to decreasing physical and mental strain on the patient’s other caregivers. 3
With end-of-life services being increasingly utilized in health care, it is imperative that the health and well-being of these patients is well taken care of and held to a high consistent standard of care. Given that many of the diagnoses seen with individuals requiring end-of-life care are progressively worsening in nature, there is a need to shift medical treatment to a “caring, rather than curing” approach. 1 This shifted approach toward patient care lends itself directly to physical therapy in that physical therapists are uniquely trained to modify their treatments and care based upon the needs of the individual in the specific stage of his or her disease. Mackey and Sparling suggest that to further maximize meaning for patients who are dying, while maximizing endurance and conserving energy, physical therapists may foster continuity of those physical activities that have held particular meaning in the patients’ lives. 4 Through utilizing this kind of approach in caring for critically or terminally ill patients, physical therapists can help achieve more than just physical benefits. This allows physical therapists the opportunity to play a crucial and unique role in this area of care, as this field of care continues to grow within the profession.
Purpose
The purpose of this study was to systematically review the current research involving physical therapy and end-of-life care in terms of its scope, efficacy, value, and how this value is perceived by patients and their caregivers. This was completed through gathering, understanding, and appraising the presently available qualitative and quasi-experimental literature that addresses these previously mentioned goals.
Methods
Procedure
Qualitative studies including retrospective cohort studies, interviews, surveys, case studies, and quasi-experimental studies that were published between January 1, 1994, and December 31, 2015, were screened for inclusion in the current study. The databases and journals searched included CINAHL, PUBMED, MEDLINE, Cochrane, PEDro, the Journal of Palliative Care, the American Journal of Hospice and Palliative Medicine, and Google Scholar. In order to be considered for inclusion in this review, an article must discuss using physical therapy as an intervention in caring for patients in palliative and hospice care settings, and an outcome measure must have been utilized when assessing patient outcomes. The following exclusion criteria were set for rejecting articles from being included: articles in a non-English language, review articles, articles discussing the caregiver’s or physical therapist’s perspective on caring for patients in palliative care, and articles discussing the care of pediatric patients in palliative care.
A preliminary search and screening for relevant article titles and abstracts was completed by 5 independent researchers utilizing the following key words sets: physical therapy and hospice, physical therapy and hospice and quality of life, physical therapy and palliative, physical therapy and palliative and quality of life, physical therapy and end of life, and physical therapy and end of life and quality of life. This initial database search resulted in the gathering of a total of 102 article titles and abstracts once duplicates had been removed. From this point, these titles and abstracts were independently screened for accordance with the set inclusion and exclusion criteria; 79 articles in total were excluded, leaving 23 articles included for full-text review. After independently analyzing the 23 full-text articles, the researchers identified 13 articles to have met the inclusion criteria and be appropriate for use in this review.
The visual representation of this article selection process is shown in the PRISMA Flow Diagram (Figure 1). Quality assessment of each article was then completed using the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist 31.05.13 (Middle Way, Oxford) via 2 independent blinded raters who were doctoral degree students who have been well trained in evaluation and critique of evidence. If discrepancies in rated scores arose, this was resolved through raters’ consensus or by a senior research advisor. Following this, pertinent information from each article was then entered into a table (Table 1) for a condensed summary of study results.
Process of article identification and selection for the review process.
Summary Table for Articles Included in the Systematic Review.
Abbreviation: CASP, Critical Appraisal Skills Programme; PT, physical therapist.
Discussion
The purpose of this study was to contribute to the current research involving physical therapy and end-of-life care in terms of its efficacy, its value, and how this value is perceived by patients and their caregivers. This was completed by analyzing the currently available literature on this topic. Through this process, 13 qualitative and quasi-experimental articles were selected which met all of the previously described criteria and discussed the role of physical therapy intervention in the palliative care setting. These articles support the utilization of physical therapy in palliative and hospice care settings and describe the impact of physical therapy and patient satisfaction with treatment in these settings. Using the constructed summary table, a comparison of these 13 studies was performed to find the common trends between those articles. Authors identified 5 common components (themes) as being discussed by each article: the age of participants, the types of physical therapy treatments/interventions used, the assessment tools used to measure patient outcomes, and the efficacy of physical therapy treatment with this patient population. In addition to this, trends regarding the discussion of patient satisfaction and perceived quality of life were also noted in several articles.
Age of Participants
Although the average participant age was not consistent between every article, all of the participants included in these studies did share a common element in that they were receiving palliative care and physical therapy services due to a diagnosis of a critical or terminal illness. The mean age and/or age range of participants was discussed within 11 of the 13 selected articles; the remaining two studies did not explicitly discuss the age of their participants. From these eleven studies the youngest participant discussed was 17 years old 8 and the oldest individual mentioned was 95 years old. 13 However, the majority of the studies only included participants who were in at least the fifth to seventh decade of life. 7,9,10,13 –16 It is typically thought that this may be when a majority of terminal illnesses begin to manifest in patients. However, 4 of our articles included patients who were between the ages of 18 and 50. 8,6,11,17 This emphasizes the idea that not all terminal illnesses occur only in older adults. Some aggressive congenital diseases and cancers can affect much younger populations, and as professionals, rehabilitation team members must be prepared to address end-of-life care for patients of all ages.
Physical Therapy Interventions
A trend was identified between multiple studies in which several physical therapy interventions were commonly implemented. The most frequently discussed interventions included the following: strengthening/therapeutic exercises, 8,13,10,14,17,5 patient and family/caregiver education, 10,7,16,5 balance and fall prevention training, 8,14,7,16,17,5 and transfer training. 8,10,15,16,17 In addition to these most frequently used interventions, other therapy techniques such as respiratory exercises, range of motion exercises, endurance training, manual massage techniques, and bed mobility training were all mentioned in more than one study in this review. This comparison of the interventions being used most often in this setting allows for a better understanding of current practice trends and could assist in someday creating a more universal standard of care for physical therapists to best treat this patient population.
A study by Javier and Montagnini 18 further supports the use of these physical therapy interventions for managing symptoms and improving the functional levels of patients. This study investigated the role of physical therapy, occupational therapy, and speech therapy in caring for patients in palliative care through analyzing previous studies on this topic. In regard to physical therapy, Javier and Montagnini discovered that all of the above-mentioned interventions were frequently used in treating this patient population, in addition to prescribing and instructing use of assistive devices and introducing environmental modifications to assist patients in performing functional activities. In addition to this, Javier and Montagnini suggested that the use of physical therapy treatment in the palliative care setting is highly feasible. 18 Jensen et al systematically studied the feasibility of physical therapy in 528 terminally ill patients. The most common interventions provided were physical activity (50%), relaxation techniques (22%), breathing training (10%), and lymphedema treatment (6%). The authors of the study found that physical therapy treatment is practical and attainable in greater than 90% of patients. 19 These findings further enhance the understanding for the need of these therapeutic treatments in caring for this patient population. 18,19
Assessment Tools and Outcome Measures
The most commonly discussed assessment tools between studies were those which rated patients’ pain levels, with a simple numeric pain rating scale being used most often. 9,7,15,5 A variety of other assessment tools were also identified throughout the studies that measured areas such as functional level, mobility, balance, and quality of life. These specific assessment tools included the Edmonton Functional Assessment Tool, Edmonton Symptom Assessment Scale, De Morton Mobility Index, Brief Pain Inventory, Memorial Pain Assessment Card, Memorial Symptom Assessment Scale, Patient Specific Functional Scale, Tinetti, Fall Efficacy Scale-International, Bipolar Confidence Scale, McGill Quality of Life Questionnaire, and the Barthel Mobility Index. 13,11,14,16,6 However, it was not found that any of these assessment tools or outcomes measures were utilized by more than 1 study. This suggests the need for the development of a comprehensive standardized measurement approach to best capture and assess patients’ function and improvements in the palliative care setting.
Efficacy of Physical Therapy Treatment
Throughout all of the 13 reviewed articles, it was reported that physical therapy resulted in improvements in a variety of aspects of patients’ function and symptoms. The most frequently described benefit after receiving physical therapy care was a substantial decrease in patient-rated musculoskeletal pain levels. 13,9,7,14,15,6,5 In addition to this, chief improvements in function/performance in activities of daily living and mobility were also noted. 8,13,10,14,15,5 Several other benefits were noted by individual studies including improvements in endurance, mood, fatigue, and lymphedema. These described physical benefits signify the valuable role that physical therapy plays in caring for patients in palliative care and the impact it can have on patients’ function and symptom management.
In congruence with the current study, Kumar and Jim 20 found that physical therapists can play a vital role in the multidisciplinary palliative care team. Through a critical review of several studies, the authors identified common intervention themes of therapeutic exercise, electric modalities, thermal modalities and manual therapy. Some of the most common symptoms reported by patients in palliative care were pain, weakness, cough, and breathlessness. Through utilizing interventions for symptom control, physical therapy was able to have a positive influence on the quality of life and perceived well-being in these patients, which further supports the findings of this review. 20
Patient Satisfaction and Perceived Quality of Life
The final common theme found among these studies was the discussion about enhancements of patient and caregiver satisfaction as well as improvements in the rating of patients’ perceived quality of life. Of the 13 studies, 5 directly discussed results in which patients and/or caregivers expressed higher satisfaction and quality-of-life ratings following a program of physical therapy intervention and education. 8,13,16,17,5 This review revealed that patients who received physical therapy services while in palliative care reported increased quality of life. 13,17,5 These patients also reported improved mood, confidence, and well-being following treatment. 11,6 Furthermore, patient caregivers expressed increased knowledge, safety, and quality of life after physical therapy interventions were implemented. 8,16
The basis for 2 of the reviewed studies revolved around conducting private interviews using open-ended questions to investigate patient perceptions of the physical therapy care they had previously received. 11,12 These types of studies provide a first-hand account of the benefits of physical therapy from the patients’ perspective. In these 2 studies, patients described similar attitudes toward therapy such as psychological support and reduced fatigue as well as describing physical therapists as motivators who provided meaningful psychological support. Overall, both the patients who received physical therapy and the patients’ caregivers reported higher satisfaction with the services they received. 8,16,1
A review conducted by Mackey and Sparling in 2000 supports this theme of increasing patient satisfaction through physical therapy services. The aim of their study was to acquire knowledge to be used by physical therapists in assessing and treating older individuals with cancer. Three older women receiving palliative care were interviewed about their experience receiving treatment while in palliative care. This study found 4 reoccurring themes discussed by the 3 women: spirituality, social relationships, response to personal mortality, and meaningful physical activity. The authors concluded that physical activity was an important part of patient experiences and that it provided an important link to their previously carried out life roles. The findings of this study further support the role of physical therapists in providing meaningful activity to maximize patients’ experiences in palliative care settings. 4
Limitations and Recommendations
The authors acknowledge several limitations of this present study and have developed multiple recommendations for future research regarding this area of interest. First, the majority of current literature discussing the use of physical therapy intervention in palliative and hospice care settings is qualitative due to the nature of the topic. A few studies provided quantitative data in terms of patient outcomes and results; however, these studies were not identified as being true experimental in designs. It would be beneficial if future studies were able to gather more quantitative data of patient outcomes and satisfaction to further justify the efficacy and importance of physical therapy care in this setting.
Second, while many of the included studies discussed the types of physical therapy treatments provided, these descriptions were not always as in depth as one might hope. Explanations of the treatments often lacked specific details such as the exact exercises performed, length of treatment time, and the type of patient education provided. Therefore, future studies would be more advantageous for readers if they included the specific parameters and details of each treatment and intervention utilized.
Third, throughout several of the studies, multidisciplinary care was discussed in which physical therapy was not the only intervention patients were receiving. While this is a realistic description of patient care in this setting, it does make it difficult to distinguish whether physical therapy was the direct cause for patient improvement. Thus, designing a study in which physical therapy care could be studied separately would be useful in identifying the benefits patients in end-of-life settings can receive through physical therapy services alone.
The fourth limitation of this study resides in the realization that the included articles did not discuss the financial costs associated with providing physical therapy care for patients in these settings. Given the current changes in the country’s medical system, it becomes more important than ever to thoroughly analyze and evaluate the required costs versus the received benefits of the care we are providing for patients. Therefore, future studies should investigate the relationship between these 2 factors so that a better understanding of the costs related to physical therapy in this setting can be reached.
The fifth limitation found in this study is the high number of dropouts and/or loss of participants mentioned throughout many of the included articles. Common causes of losing participants included patients being discharged from physical therapy care, patients’ conditions deteriorating to the point where they were too ill to participate in physical therapy, and unfortunately patients passing away while in palliative care. This high number of patient losses resulted in smaller sample sizes for many of the studies. Thus, results from these studies may not be widely generalizable to the larger population of patients receiving physical therapy care in these settings.
The final limitation of this study is that of all described outcome measures or assessment tools, none were utilized by more than one of the reviewed studies. Although functional improvements and increases in perceived quality of life were identified within most of the articles, these results cannot be compared across studies due to the lack of consistent rating tools. For that reason, it is recommended that future studies establish a consistent selection of validated assessment tools to best capture patient outcomes in a more standardized manner.
Conclusion
Overall, the review of these articles provided a better understanding of the most frequently used physical therapy techniques and interventions for treating patients in palliative care settings. Furthermore, this review examined physical and psychological benefits that these patients can achieve as a result of receiving physical therapy during this final stage of life. It is apparent that there is benefit in utilizing physical therapy in end-of-life and palliative care settings. Although patients’ conditions may be deteriorating, interventions may be used and outcomes can be achieved to improve the function, independence, and quality of life of all patients. Improving the comfort, mood, and function in patients can be very beneficial and may encourage them to become more involved with their care and caregivers.
Through the analysis of the current evidence and literature, this review concludes that physical therapy is underutilized in palliative and end-of-life care settings, despite the reported benefit. 5 This review confirms that physical therapists serve a vital role in the palliative and end-of-life care settings and should be active members of the multidisciplinary team providing care for this critical patient population.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.