PHYSIOTHERAPY
IN
PALLIATIVE CARE
Pauline Cerdor - Physiotherapist
Palliative Care Unit
Peninsula Health
Frankston
DEFINITION
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"care which provides coordinated medical,
nursing and allied services for people who are
terminally ill, delivered where possible in the
environment of the person's choice, and which
provides physical, psychological, emotional and
spiritual support for patients, and support for
patients' families and friends.
---- includes grief and bereavement support for
the family and other carers during the life of the
patient and continuing after death.“
(http://www.palliativecare.org.au)
Palliative Care
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“… the active, total care of patients whose
disease no longer responds to curative
treatment and for whom the goal must be the
best quality of life for them and their families”.
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What do you let the patient tell you? by Barbara Martlew quoting from Lamerton, 1980 and Doyle, 1987.
WHERE
Palliative physiotherapy is found in: Specific palliative care wards
 Nursing homes
 General wards
 Oncology wards
 Community rehabilitation (homes)
OBJECTIVES of TREATMENT
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to be as free as possible from unnecessary
suffering (physical, emotional or spiritual);
to maintain patient’s dignity and independence
throughout the experience;
to be cared for in the environment of choice;
to have patient’s grief needs recognised and
responded to;
to be assured that families needs are also being
met.
(http://www.palliativecare.org.au)
PHYSIOTHERAPY
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Physiotherapy in palliative care is orientated to
achieve the optimum quality of life as perceived
by the patient.
Wholistic & problem solving approach to therapy
Achieve maximum physical, psychological, social,
vocational function
Adapt traditional therapy to the patient’s
changing function
More beneficial if begins with diagnosis of cancer
and continues as required through the various
stages -preventative, restorative, supportive, palliative
(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
Preventative
Aims at restricting or inhibiting the development
of disability in the course of the disease or
treatment before disability occurs
 Education for patient and families commencing
immediately after diagnosis
 Mobility and exercise programs.
 Availability of therapist as a resource for patients
and families
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(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
Restorative
Rehabilitation is the objective when no or little
residual disability is anticipated for some time
and patients are expected to return to normal
living styles
 Encouragement, education and treatment in
achieving physical, work and lifestyle goals
 Specific treatments as required
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(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
Supportive
Enhance independent functioning when residual
cancer is present and progressive disability is
probable
 Encouragement, education and treatment in
achieving physical, work and lifestyle goals
 Availability of therapist as a resource
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(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
Palliative
Primarily directed at promoting maximum
comfort
 Maintaining the highest level of function possible
in the face of disease progression and
impending death
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(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
In Brief
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The Chartered Society of Physiotherapy www.csp.org.uk Page 8/43 Ref: EB 04
• Prevent muscle shortening
 • Prevent joint contractures
 • Influence pain control
 • Optimise independence and function
 • Education and participation of the carer
(Fulton and Else, 1997).
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Goal of Physiotherapy
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Determine the patient’s functional loss
Estimate functional potential
Implement a plan to progress from measured
loss to full potential
To improve quality of life
To listen ‘actively and positively’ with an
awareness of priorities as determined by the
patient
Achieve the best possible quality of life for
patients and their families
Availability as a resource for patient and families
Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. 2001
(Martlew, B. What do you let the patient tell you. 1996)
(wHO 1990)
AIM of Physiotherapy 1
Assess and optimise the patient’s level of
physical function
 Take into consideration the interplay between
the physical, psychological, social and vocational
aspects of function
 Understand the patients underlying emotional,
pathological and psychological condition,
 Focus is the physical and functional
consequences of the disease and/or its
treatment, on the patient.
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Fulton and Else, 1997; p817 Chartered Society of Physiotherapy
AIM of Physiotherapy 2
Restore the patient’s sense of self
 Facilitate and optimise the patient's ability to
function with safety and independence in the
face of diminishing resources.
 Maintain optimum respiratory & circulatory
function
 Listen to patient
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Set realistic goals with the patient
AIM OF PHYSIOTHERAPY 3
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Prevent muscle shortening & joint contractures
Influence pain control
Educate in all aspects of physical function
Education and participation of the carer
Treat the patient with dignity – allowing them
to “live until they die”
Build a relationship of confidence and trust
(Fulton and Else, 1997 Chartered Society of Physiotherapy).
(Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972)
DIFFERENCES IN PALLIATIVE
PHYSIOTHERAPY TREATMENT
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Traditional physiotherapy treatments need to be
modified to accommodate the irregular changing
needs of the patient
Treatments are brief often less than 10 minutes
and are repeated several times per day if
possible
Frequent rests are required
Patient’s status can change suddenly and rapidly
Requirement to balance ‘effort’ and ‘fatigue’
Requirement to:- Monitor and respond appropriately to patient’s
verbal & non-verbal expressions of pain
- Monitor patient very closely during and
between treatments
 Timely communication to/with other team members
is particularly important
 Changes in patients status
 Information given or obtained from patient
 Contribute to staff confidence with patient transfers
by accurate assessment and reporting of patient’s
changing transfer abilities
 Coordinate & participate with nursing staff in
transfers of patient
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Major issues the patient and therapist face
Fatigue,
nausea,
pain,
weakness,
lack of confidence,
disparity between perceived & actual
physical ability,
drug reactions,
Cachexia (major weight loss),
progressive , irregular decline in ability,
muscle wasting,
disease progression,
ascities,
varying grief reactions.
TREATMENT
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Assessment of patient’s physical, & transfer
abilities
Respiratory management/education
Mobility towards maximum level independence –
treatment & education
Active &/or passive mobilization
Pain & symptom management
Exercise prescription
TREATMENT
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Assessment & education in functional ADL
Provision of walking aides
Pain management - education
- TENS
Lymph management
Massage
Relaxation
Hydrotherapy
TREATMENT
Home discharge planning with Occupational
Therapist
- home visit
- education, patient & family
- provision of aides
- liaison with other palliative staff
 Multidisciplinary meetings
 Family meetings
 Listening and supporting
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Case Study- Mr S
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Male 65 years old, with SCLC, cord compression
and neuropathic painS
SOB on minimal exertion
Chest – moist, productive cough
Strength – R – 4/6; L – 3/6
Joint mobility – full functional
Bed mobility – range from assist x 1 to assist x 2
Mobility –used 4ww due to pain, not walked 4+
days
Pain – back and legs/hips
Ascities
Fatigues easily
GOALS
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Improve chest status and management
Increase leg strength
Encourage bed mobility
Achieve best possible walking mobility
Liaise with wife
Educate as appropriate
TREATMENT
- breathing techniques
- SOB management
- fatigue management
 Exercise program
 Assist with bed/chair transfers
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Education
Progress to sit/stand exercises
 Walking in Physiotherapy gym
 Progress to walking with 4ww
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Education of patient in techniques to
manage at home
 Education and support of wife, prior to
discharge
 Liaison with Occupational Therapist
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OUTCOME
Discharge home after 6.5 weeks
 Walking with supervision & 4ww, 10-15m
 Supervision with ADL
 Light supervision with transfers
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Patient was re-admitted 6 weeks later, having
been active at home for that time, with
increased severity of symptoms and died 7days
after re-admission.
Case 2 - Bill
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83 years old, married with independent children
Wood and hand craft worker
Prostate Cancer, colostomy, bowel obstructions
Neuropathic pain – pelvis, right side abdominal
area
Non-mobile when first referred
TREATMENT
Exercise routine
 Use overhead tracking in department
 mobilisation on 4ww
 Education in pacing activities, energy
conservation
 Referred to rehabilitation GLR
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OUTCOME
Discharged home after 4 weeks via TCP
(Transition Care Program)
 At home 3-4 months
 Re-admitted to Palliative Care with
increased pain
 Died 1 week later
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Case 3 - Graeme
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Colorectal cancer and caecum cancer
Age 65, married with teenage son
Fit and independent prior to diagnosis
Presented
- 3 drain tubes
- large abdominal wounds
- unstable gait
Treatment - mobilisation with 4ww/wheel chair
- exercises,
- education
Currently patient for 3+ months
CRP REFERRALS RATIONALE
Often small window of opportunity for patient to
return home
 Monitor return home
mobility
exercises
 Act as education resource for patient and family
 Treat new issues as they arise
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What do palliative patients require
from a physiotherapist
Flexibility
 Understanding both emotionally and physically
 Information
– clarity
- agreeing with other sources
 Education
 Encouragement
 Respect for their choices
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STATISTICS
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25% of Palliative Care patients are discharged,
either home or to a care facility
Average length of stay --- 10 to 12 days
Physiotherapist currently works 16 hours/week
15 bed ward
Average 21 referrals per week
Average over 22 treatments per week
BENEFIT OF INCREASE IN HOURS
7.56% increase in daily referrals
 48% increase in number of daily treatments
 120% increase in the number of treatments per week
 60% increase in referrals per week
 increase presence on the ward
 increase staff assistance with transfers
 increase in frequency of treatments
 attendance at team meetings and some ward rounds
 improved palliative approach to treatment
 improved interactions and involvement on ward
 availability for in-service
 greater input into patient care
 Availability for GLR staff and other meetings
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Personal comments
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Why I like working in palliative care
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BIBLIOGRAPHY
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http://www.medicineau.net.au/clinical/palliativecare/PhysioLymph.html
http://www.pallcarevic.asn.au
http://www.palliativecare.org.au
http://www.csp.org.uk/uploads/documents/evidencebrief_palliative_EB04.pdf
Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical
Therapists. 1991
Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972
Martlew, B. What do you let the patient tell you. 1996
WHO 1990
Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient
Empowerment. 2001
Winningham, M.L. Walking Program fro People with Cancer. Getting Started. 1991
Brown, D.J. The Problem of Weakness in Patients with Cancer. 1999
Laakso, E. McAuliff, AJ. Cantlay, A. The Impact of Physiotherapy Interventions on Functional
Independence and Quality of Life in Palliative Patients. 2003
Shanks, R. Physiotherapy in Palliative Care. 1982