Review Article

Physical Therapy in Palliative Care: From Symptom

Control to Quality of Life: A Critical Review
Senthil P Kumar, Anand Jim1
Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore,
1
Department of Physiotherapy, Bethany Navjeevan College of Physiotherapy, Trivandrum, India

Address for correspondence: Mr. Senthil P Kumar; E-mail: [email protected]

ABSTRACT

Physiotherapy is concerned with identifying and maximizing movement potential, within the spheres of promotion,
prevention, treatment and rehabilitation. Physical therapists practice in a broad range of inpatient, outpatient,
and community-based settings such as hospice and palliative care centers where as part of a multidisciplinary
team of care, they address the physical and functional dimensions of the patients’ suffering. Physiotherapy
treatment methods like therapeutic exercise, electrical modalities, thermal modalities, actinotherapy, mechanical
modalities, manual physical therapy and assistive devices are useful for a range of life-threatening and life-limiting
conditions like cancer and cancer-associated conditions; HIV; neurodegenerative disorders like amyotrophic lateral
sclerosis, multiple sclerosis; respiratory disorders like idiopathic pulmonary fibrosis; and altered mental states.
The professional armamentarium is still expanding with inclusion of other miscellaneous techniques which were
also proven to be effective in improving quality of life in these patients. Considering the scope of physiotherapy
in India, and in palliative care, professionals in a multidisciplinary palliative care team need to understand and
mutually involve toward policy changes to successfully implement physical therapeutic palliative care delivery.

Key words: Palliative physiotherapy, Quality of life, Rehabilitation, Therapeutic modalities

INTRODUCTION and rehabilitation. Physiotherapy involves the interaction

between physiotherapist, patients or clients, families and
World Confederation for Physical Therapy (WCPT) care givers, in a process of assessing movement potential
defines Physical Therapy as; “… providing services to and in establishing agreed upon goals and objectives using
people and populations to develop, maintain and restore knowledge and skills unique to physiotherapists”. [1]
maximum movement and functional ability throughout
the life-span. Physiotherapy includes the provision of Physical therapists practice in a broad range of inpatient,
services in circumstances where movement and function outpatient, and community-based settings, including the
are threatened by the process of ageing or that of injury following: [2]
or disease. Full and functional movement are at the heart • Hospitals (eg, critical care, intensive care, acute care,
and subacute care settings)
of what it means to be healthy. Physiotherapy is concerned
• Outpatient clinics or offices
with identifying and maximizing movement potential, • Rehabilitation facilities
within the spheres of promotion, prevention, treatment • Skilled nursing, extended care, or subacute facilities
• Homes
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• Education or research centers
Quick Response Code:
Website: • Schools and playgrounds (preschool, primary, and
www.jpalliativecare.com secondary)
• Hospices or palliative care centers
DOI: • Corporate or industrial health centers
10.4103/0973-1075.73670 • Industrial, workplace, or other occupational
environments
138 Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3
 Kumar and Jim: Physical therapy and palliative care

• Athletic facilities (collegiate, amateur, and professional) as invaluable members in the team of care.
• Fitness centers and sports training facilities.
The objective of this paper is to update the palliative care
Physiotherapists play an inherent role in the clinicians, physical therapists and other team members on
multidisciplinary palliative care team emphasizing on the role of a physical therapist in a palliative care team by
improving function and quality of life in patients who are detailed view of physical therapy treatment methods and
deemed to require physical and functional dimensions of their evidence for application into conditions requiring
care.[3] Physical dimension was defined as one’s experience palliative care.
of the physical discomfort associated with progressive
illness for a perceived level of physical distress.[4] Physical
dimension in physical therapy includes symptom control, PHYSICAL THERAPY TECHNIQUES
management of physical findings such as mobility,
strength, flexibility, endurance, deformity, co-ordination, Therapeutic exercise
balance, gait, breathing, exercise tolerance and energy
It comprises passive movement, assisted active movement,
expenditure. [5] Symptom control by physical therapy is
active movement, assisted-resisted active movement, and
applicable in patients with commonest symptoms which
resisted movement techniques. The techniques can be
require palliative care such as pain, weakness, cough and
applied in anatomical planes or as functional movement
breathlessness.[6]
direction. The techniques can be performed on land
or in water. The latter is termed as “hydrotherapy”.
Functional dimension is defined as one’s perceived
Best examples of therapeutic exercise techniques are
ability to perform accustomed functions and activities
relaxation, massage, suspension therapy, muscle- re-
of daily living, experienced in relation to expectations
education, progressive resisted exercise, floor aerobics,
and adaptations to declining functionality.[3] Functional
active mobility exercises, mobilization and stabilization
limitations include sensorimotor performance in the
exercise, proprioceptive neuromuscular facilitation
execution of particular actions, tasks, and activities (eg,
(facilitation and inhibition techniques); breathing exercise;
rolling, getting out of bed, transferring, walking, climbing,
postural training; work simulation, work conditioning
bending, lifting, carrying). These sensorimotor functional
and work hardening; graded activity program and
abilities underlie the daily, fundamental organized
cognitive-behavioral training. [2] Exercises are useful for
patterns of behaviors that are classified as basic activities
reconditioning and physical fitness.
of daily living (ADL) (eg, feeding, dressing, bathing,
grooming, toileting). The more complex tasks associated Electrical modalities
with independent community living (eg, use of public
transportation, grocery shopping) are categorized as Low-frequency modalities like neuromuscular electrical
instrumental activities of daily living (IADL). Successful stimulation (both galvanic and faradic) and functional
performance of complex physical functional activities, electrical stimulation, iontophoresis, high-voltage
such as personal hygiene and housekeeping, typically pulsed galvanic current, transcutaneous electrical
requires integration of cognitive and affective abilities as nerve stimulation (TENS) and diadynamic currents;
well as physical ones.[7] medium frequency modalities like Russian currents and
Interferential therapy. High frequency modalities are
Physicians address the physical dimension to their extent usually grouped under deep-heating modalities under
and nurses in functional dimension. Addressing both the thermal modalities. Electrical modalities are very useful
aspects simultaneously can be more beneficial for the adjuncts in pain management.
patient. Considering the current healthcare scenario in India
as reported by Seamark et al.[8] Inspite of most of population Thermal modalities
being rural, the current status of medical personnel and facilities in
our country is scarce; with only 34% of physicians and 25% of Cryotherapy (ice massage, cold pack, cold bath, vapocoolant
all hospital beds are available in rural areas. Nursing is considered spray); superficial heating agents (fluidotherapy, hot pack,
as a low-status job and is not a much-sought-after profession for infrared radiation, paraffin wax; and contrast baths. Deep
young people. Hence the need for an efficient allied health heating agents (diathermy- shortwave and microwave,
professional to fill in the current needs of palliative care ultrasound and phonophoresis); hydrotherapy (whirlpool
team sees the emergence of physical therapists, with their and contrast bath). Thermal modalities are effective
thorough professional background and clinical expertise, adjuncts to exercise and/or electrical modalities.
Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3 139
 Koshy, et al.: low cost continuous femoral nerve block

Mechanical modalities EVIDENCE FOR PHYSICAL THERAPY IN

PALLIATIVE CARE
Traction therapy, compression therapy, therapeutic taping
and continuous passive motion. Compression therapy can Need for physical therapy in palliative care
be very useful in managing lymphedema.
Pate et al,[9] and Bryan et al,[10] reported an earlier estimate
Additional physical agents- Actinotherapy that approximately 30% of total cancer deaths are related
to poor exercise and nutrition, and when taking into
Ultraviolet, LASER, Extracorporeal Shock Wave therapy consideration both cardiovascular disease and cancer,
are useful in selected situations. that physical inactivity contributes to as many as 250,000
premature deaths per year. Understanding the beneficial
Miscellaneous modalities effects of exercise and physical activity, the expanding
role of physical therapy in palliative care indicated a rapid
Biofeedback is useful in patients with limited cognitive growth of evidence. The physical therapist, like other
abilities and neuromuscular dyscontrol. members of the team, provides palliative care. Modalities
range from using heat, cold, and TENS for alleviation of
Manual physical therapy (manual therapy) pain; teaching activities of daily living that accommodate
to the strength and body mechanical capabilities of the
Myofascial patient; and designing exercises and positioning that will
Massage, deep transverse frictions, myofascial release, maintain functional ranges of motion.[11]
trigger point therapy, muscle energy techniques, motor
control retraining. Toot[11] in addition, explained the interventions provided
by physical therapists in hospice and palliative care that
Articular may be directed to three facets: (1) delivering direct patient
Joint mobilization using passive physiological and passive care, (2) educating the patient-family care unit and fellow
accessory (joint play) movements, combined movements, health professionals, and (3) functioning as a team member.
mobilization with movements, manipulation (high-velocity
Laakso[12] emphasized that in palliative care, physical
low amplitude thrust techniques). therapists are involved in the following four levels-
Prevention; Acute and post-acute care; Institutional and
Neural
community-based rehabilitation; and Symptom control.
Neurodynamic techniques of neural tissue loading and The most common currently occurring role of the physical
nerve massage. therapist is in the hospital-based care. Montagnini et al,[13]
said, in a hospital-based palliative care unit, physical
Manual physical therapy techniques are used in a variety therapists treat most common functional disabilities like
of settings ranging from hospital-based to home-based. deconditioning, pain, imbalance and focal weakness.
The effects of the techniques depend upon the skills of
the handling therapist. The importance of physical therapy is widely stated in the
most-read textbook- Oxford Textbook of Palliative Medicine,
Assistive devices as follows;
Orthosis- splints/ braces: supportive devices for the body
parts. Physiotherapy aims to “optimise the patient’s level of physical function
and takes into consideration the interplay between the physical,
Prosthesis: artificial limbs. psychological, social and vocational domains of function…… The
physiotherapist understands the patients underlying pathological
Mobility aids: locomotor training devices like wheelchair, condition, but this is not the focus of treatment. The focus of
prone crawlers. physiotherapy intervention is, instead, the physical and functional
sequelae of the disease and/or its treatment, on the patient.”[14]
Walking aids: canes, crutches and walkers.
Physiotherapy aims to: maintain optimum respiratory
Assistive devices are useful for training functional activities function; maintain optimum circulatory function; prevent
for patients with limited function. muscle atrophy; prevent muscle shortening; prevent joint
140 Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3
 Kumar and Jim: Physical therapy and palliative care

contractures; influence pain control; optimize independence improved overall quality of life[33] and sense of well-being[34]
and function; and, education and participation of the carer. in persons with normal ageing. Specialist palliative care has
an established role in the management of patients with
The following section describes the role of physical therapy advanced progressive neurological disease. A proactive
in common conditions that require palliative care. palliative care approach in patients with amyotrophic lateral
sclerosis (ALS) can significantly improve their quality of
Palliative physical therapy in patients with cancer life. Physiotherapy, counseling, addressing nutritional issues
and regular respite can be supportive in ALS/ MND.[14]
Physical therapists have a very important role to play in
holistic care of patients diagnosed with cancer as stated Multiple sclerosis
by Flomenhoft[15] and Rashleigh.[16]. Rashleigh[17] listed the
Multiple sclerosis (MS)[34] is the most prevalent chronic
therapeutic strategies employed by physical therapists in
disabling neurological disease among adults. Physical
palliative oncology as ambulation and musculoskeletal
activity is indirectly associated with improved QoL through
therapy; neurological therapy; respiratory therapy;
pathways that include fatigue, pain, social support, and
electrophysical agents; mechanical therapy; decongestive
self-efficacy in individuals with MS. Motl et al,[35] also found
physiotherapy; and, education. Santiago-Palma and
improvements in social support, self-efficacy and reduced
Payne[17] listed treatments used by physical therapists on
functional limitations following physical activity program in
cancer patients are therapeutic massage, therapeutic heat,
MS patients. Besides drugs, physiotherapy is the mainstay
therapeutic Cold, patient education- advice on activity
in the management of spasticity in MS.[14]
modification, range of motion and strengthening exercise,
training ambulation using assistive devices, environmental Alzheimer’s disease
modification, energy conservation and work simplification
Weih et al,[36] performed a meta-analysis of cohort studies
techniques. Twycross[18] mentioned that physical treatment
and they concluded that regular physical activity showed
methods like massage, heat pads and TENS are useful for
better benefits not only on the overall patients’ quality of
pain management in cancer patients.
life but also reduced the risk of development of the disease
Physical therapy treatment techniques have also been during ageing.
reported in cancer-related fatigue by Watson and Mock,[19]
Spinal cord injury and brain injury
breast cancer,[20,21] prostate cancer[22] and breast cancer-
related lymphedema,[23,24] older women with cancer,[25] Ginis et al,[37] reported that spinal cord injury patients
cancer therapy-related hyperthermia,[26] and colorectal reported less pain, depression and stress, and increased
cancer.[27] quality of life and better physical self-concept after a
program of aerobic and resistance exercise training. Also
Narayanan and Koshy[28] emphasized the importance of they had enhanced self-motivation as found by Latimer
group exercise therapy, energy conservation techniques and et al.[38] Katz et al,[39] earlier found psychological effects of
regular physical activity to be effective for cancer-related exercise training in paraplegia patients, which was again
fatigue. Lyles et al,[29] said that aversiveness associated confirmed by Nayak et al, [40] in their study on music therapy
with cancer chemotherapy could be treated by relaxation which showed significant positive effect on mood and social
training with guided imagery. Jacobsen et al,[30] performed interaction in traumatic brain injury and stroke patients. In
a meta-analysis of 30 randomized controlled trials and stroke rehabilitation, the most recent therapeutic advance is
they concluded treatment effect sizes to be in favor the use of motor imagery and mental practice techniques.
of non-pharmacological interventions. Of them both Holmes[41] mentioned- The use of motor imagery (MI)—presumed
psychological and physical activity-based interventions were to be a visual and kinesthetic neural representation of the overt
proven to be better in improving quality of life in patients behavior—has relied on two major assumptions. The first assumption
with cancer-related fatigue. is that the internally generated movement patterns involve the same
neuronal correlates as the overt behaviors (i.e., the two conditions are
Palliative physical therapy in patients with functionally equivalent). Second, it assumes that using MI will lead
neurodegenerative disorders to cortical and subcortical neuronal modification that is of benefit
to a person who has experienced a stroke. Mental practice as an
The Chartered Society of Physiotherapy (CSP)’s evidence effective technique for locomotor training and rehabilitation
summary emphasizes the effectiveness of physical therapy was also employed in most neurological conditions as found
in the palliative care of older people.[32] Physical activity in their comprehensive review by Malouin and Richards.[42]
Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3 141
 Kumar and Jim: Physical therapy and palliative care

Palliative physical therapy in patients with anatomically by scarring of the lungs and symptomatically
respiratory diseases and critical illnesses by exertional dyspnea. Fan and Kozinetz[47] reported that
the maximum life expectancy for a patient with IPF is 3-5
The role of physical therapy in palliative care of patients years. Pediatric ILD still has a shorter life span of about
with respiratory disorders ranges from home-based 47 months. In the absence of anti-inflammatory therapies
care such as training symptom control for cough and failing to improve outcomes in these patients,[48] physical
breathlessness to providing interventions such as airway therapy treatment methods would definitely address the
clearance techniques in the intensive and critical care units problems of cough and dyspnea by enhancing quality of
in hospital-based rehabilitation. The renowned professional life in those cases.
body for respiratory and cardiac conditions, the American
Thoracic Society[43] emphasised this role in its definition Cough
for pulmonary rehabilitation; Keenleyside and Vora [49] recommended that chest
physiotherapy together with steam inhalation can be given
Pulmonary rehabilitation is a multidisciplinary program of care for sputum clearance in patients who complained of cough.
for patients with chronic respiratory impairment that is individually Cough therapy as described by Fulton and Else[14] included
tailored and designed to optimize physical and social performance forced exhalation, airways vibration, assisted coughing
and autonomy. ATS has listed four essential components of techniques, postural drainage.
pulmonary rehabilitation as; (1) exercise training (upper
extremity endurance training, low extremity endurance Breathlessness
training, strength training and respiratory muscle training),
LeGrand [50] stated that breathing retraining such as
(2) education (breathing strategies, energy conservation and
diaphragmatic breathing or pursed lip breathing are useful
work simplification, end-of-life education), (3) psychosocial
in palliative management of dyspnea. In addition to the
and behavioral intervention (coping strategies, stress
central role of opioids, the palliative approach to dyspnea
management), and (4) outcome assessment. This was also
is multidisciplinary, with the need for an individualized
mentioned by Lanken et al,[44] that pulmonary rehabilitation
program including education, emotional support, physical
includes exercise training, psychosocial support, nutritional
therapy, and respiratory therapy. Syrett and Taylor[51] while
therapy, and self-management education, including breathing
emphasizing on a collaborative nurse-physiotherapist
strategies, use of supplemental oxygen, pharmacologic
model in palliative care setup, referred to techniques of
therapy (to relieve airways obstruction), and panic control.
positioning, relaxation, breathing awareness exercises,
The authors gave following suggestions in order to treat
walking and stair-climbing activities, coping and pacing,
psychosocial factors: For anxiety, use relaxation techniques,
distraction, activity modifications, behavior modifications, activity modification being useful in physiotherapy
and breathing strategies. For depression, use cognitive management of breathlessness. Vora[52] explained that
therapy, antidepressants, or a combination of both. non-drug measures such as lifestyle modification, stress
management, breathing control and posture, and relaxation
The therapeutic efficacy of pulmonary rehabilitation was techniques are useful for control over breathlessness. Lox
demonstrated convincingly in many systematic reviews and and Freehill[53] found pulmonary rehabilitation to improve
randomized controlled trials and hence physical therapy in both physiological and psychological measures of self
the form of exercise training in globally accepted and widely efficacy for 6-min walking distance, dyspnea, fatigue,
practised position statements and treatment guidelines. emotional function and overall quality of life in patients
diagnosed with COPD.
Nici et al,[45] mentioned that American Thoracic Society
and European Respiratory Society has endorsed exercise Sachs and Weinberg[54] explained the use of both active
training in their position statement as a comprehensive and passive strategies in pulmonary rehabilitation. Active
component of pulmonary rehabilitation to gain effective strategies like lower intensity exercise protocols, including
symptom control for dyspnea. interval training and single-leg ergometry similar to aerobic
exercise, are effective in improving dyspnea and functional
Of the respiratory disorders requiring palliative care, capacity. Passive strategies such as neuromuscular electrical
the most life-limiting condition is idiopathic pulmonary stimulation have been demonstrated to improve muscle
fibrosis. Raghu et al,[46] stated that idiopathic pulmonary strength and mass and reduce exertional dyspnea. The
fibrosis (IPF), a type of interstitial lung disease (ILD), is authors also added that home-based, self-monitored
a progressive life-threatening disease that is characterized programs compare favorably with outpatient hospital-based
142 Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3
 Kumar and Jim: Physical therapy and palliative care

programs. There was increasing evidence that pulmonary was found to be effective by Hillier et al,[65] in another
rehabilitation was well tolerated and effective for patients systematic review, Crepaz et al,[66] found cognitive-behavioral
with severe COPD, and that other diseases associated with interventions to have positive effect on mental functioning
disabling dyspnea would improve symptomatically with and also immune function in patients living with HIV.
pulmonary rehabilitation.
Palliative physical therapy for people with psychiatric
Emery et al, found exercise, education and stress
[55] disorders and altered mental states
management (EXESM) intervention produced better
effects both on physiological functioning (pulmonary Exercises as a treatment for altered psychological states
function, exercise endurance), psychological well-being have been through over the years grounded on the
(depression, anxiety, quality of life), and cognitive principle, “sound mind and a sound body” and authors like
functioning (attention, motor speed, mental efficiency, Wilfey and Kunce[67] and Tuckman and Hinkle[68] found
verbal processing). earlier that exercise has not only physical effects but also
psychological, which was found both in adults and in
Ciesla[56] elaborated the role of chest physical therapy in children respectively. Later other authors like King et al,[69]
intensive care units with use of. techniques like postural also found similar findings.
drainage, percussion, vibration, breathing exercises, cough
stimulation techniques, limb mobilization, positioning Cognitive effects of exercise
and airway suctioning that were routinely performed in
Though exercise had been a part of behavioral medicine
the treatment of critically or terminally ill patients in the
for treating altered physiological states like obesity, diabetes,
intensive care units.
cardiovascular risk modification and smoking according
The reported benefits of formalized exercise training to to Martin and Dubbert,[70] through its cognitive effects,
an informal recreational physical activity in chest physical according to Tomporowski and Ellis,[71] exercise also had
therapy also extended to include systemic conditions like the potential to address disorders like dementia, depression
chronic renal failure to have positive effects on quality of and altered mood states. Exercise also positively influences
life by Eng and Ginis.[57] Also self- determined motivation memory-search performance or reaction time,[72] cognitive
of patients attending a cardiac rehabilitation was improved abilities like reasoning,[73] working memory.[73]
followed by a regular physical activity program as found
Emotional effects of exercise
by Russell and Bray.[58]
Exercise therapy programs such as aerobic exercise
Palliative physical therapy for people living with training was shown by McCann and Holmes[74] to positively
human immuno deficiency virus (HIV) or acquired influence depression, followed by Brown and Siegel,[75] who
immuno deficiency syndrome (AIDS) studied adolescent population and later McNeil et al, [76]
confirmed this with added effects of exercise on anxiety.
Palliative care improved outcomes in patients living with Exercise as an adjunct to enhanced imagery was studied
HIV or AIDS. Home palliative care and in-patient hospice by Schwartz and Kaloupek[77] for anxiety reduction. It was
care improved a number of patient outcomes, particularly Bruning and Frew[78] who found exercise to be beneficial
in terms of pain and symptom control, anxiety, insight for stress management and Puetz et al,[79] found chronic
and spiritual well-being. Harding et al,[59] also stated that exercise to influence feeling of energy and fatigue, and
palliation should be offered as a flexible, integrated recently Chafin et al,[80] found exercise as an effective
approach when needed, across the range of institutional strategy for anger control. More recently, Jerstad et al,[81]
and home care settings, alongside new therapeutics. found adolescent female population to benefit from
Dysfunction of the aerobic system as a major cause of physical activity in reducing their levels of depression
physical disability in HIV patients was found by Cade et al,[60] since physical activity and depression was shown to have
and hence the other authors Nixon et al,[61] 2005, O’Brien a reciprocal inverse relationship.
et al,[62] found aerobic exercise interventions to be effective
in their systematic reviews of randomized controlled trials. Intensity of exercise training and psychological effects
Steptoe and Cox[82] found that high-intensity exercise led to
Earlier proponents like O’Brien et al,[63] and O’Brien et al,[64] increases in tension/anxiety and fatigue, whereas positive
advocated positive effects for progressive resisted exercise mood changes (vigor and exhilaration) were seen following
in their systematic reviews. While therapeutic massage low-intensity exercise only.
Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3 143
 Kumar and Jim: Physical therapy and palliative care

Effects of exercise on psychiatric disorders HIV, neurological disorders, cardiopulmonary conditions

Tkachuk and Martin[83] in their review, concluded that and mental illnesses.
exercise therapy was a viable, cost-effective treatment
The scope of physiotherapy practice is influenced by the
strategy for depression in psychiatric disorders and in
ratio of qualified physiotherapists to the population. The
chronic pain states. Less strenuous forms of regular
exercise such as a physical activity like walking was shown number of physiotherapists per head of population in India
to have larger health benefits compared to neuropsychiatric is 1:212,000.[101] This often is an underestimated scope for
drugs. The exercise therapy was found useful for clinical a profession in a country with ever-growing demands for
depression, developmental disabilities, schizophrenia, palliative care. This fact should give enough impetus to
somatoform disorders and substance-abuse disorders. It was budding physical therapists to enter into the healing world
Dubbert[84,85] who continuously reported and emphasized of palliative care. The continuously growing numbers of
the potential of using exercise and physical activity in a in patients requiring palliative care in India necessitates
scientific manner to promote mental health and also inspired professional involvement on the part of the physical
toward continued efforts to understand the underlying therapists and mutual understanding from palliative care
biological, psychosocial, and cognitive mechanisms. team members to bring about a policy change and to
streamline implementation at ground-level.
Other related therapeutic techniques used by
physical therapists in palliative care Meier et al,[102] suggested three barriers for palliative
medicine, which in turn can be applicable toward
Though theoretically not part of physical therapy, physical integration of physical therapy into palliative care such as:
therapists are trained in the following techniques and they professional knowledge and skills in palliative care among
do perform these in their regular practice. therapists and other team members; professional and public
attitudes about the goals of physical therapy; and financial
Relaxation and structural attributes of the health care industry.
Tarler-Benlolo[86] emphasized the therapeutic role of
Future studies are warranted on the following aspects;
relaxation and Halonen and Passman[87] found it an useful
1. Assessment of knowledge, attitudes, beliefs and
technique for reducing post-partum distress and Carey and
experiences toward palliative care among physical
Burish[88] found the same for cancer chemotherapy patients.
therapists
2. Evolution of a palliative care training program for
Other techniques
physical therapists.
EMG Biofeedback,[89] exercise-related imagery,[90] music 3. Qualitative research on experiences of palliative care
therapy,[91,92] play therapy,[93] virtual reality- Plante et al,[94] and team members with physical therapists
exercise environment[95] was shown to influence perceived 4. Influence of physical therapy on patient and caregiver
well-being where outdoor exercises energizes while indoor perceptions and quality of life in other palliative care
exercises relaxes,[96] and, Qigong exercises had positive conditions.
effects on mood and anxiety.[97]
The authors wish to recommend three approaches to
Other complementary therapies which are often included improve physical therapy in palliative care.
in physical therapist’s treatment armamentarium are 1. Improving professional knowledge and skills
acupuncture, aromatherapy, reflexology, relaxation and 2. Changing professional attitudes toward care at end-of-life
massage.[98] 3. Recognizing the palliative care healthcare system in
India.
Massage therapy as a complementary therapy technique
for feet[99] and hands[100] is also effectively used by physical “Coming together is the beginning, keeping together is progress,
therapists in their routine plan of care. working together is success”
- Henry Ford.
CONCLUSION
ACKNOWLEDGMENTS
Physical therapy was shown to have positive influence on
quality of life and perceived well-being in a wide range of Father Philip Neri, Founder-director, Bethany Navjeevan
patient populations requiring palliative care such as cancer, Educational Trust and Group of Instiutions, Trivandrum, Kerala

144 Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3

 Kumar and Jim: Physical therapy and palliative care

for his inspiring support, moral guidance and encouragement 25. Mackey KM, Sparling JW. Experiences of older women with cancer receiving
to the authors. hospice care: Significance for physical therapy. Phys Ther 2000;80:459-68.
26. Luk KH, Drennan T, Anderson K. Potential role of physical therapists in
hyperthermia in cancer therapy- the need for further training. Phys Ther
1986;66:340-3.
REFERENCES 27. Courneya KS, Friednreich CM, Arthur K, Bobick TM. Understanding
exercise motivation in colorectal cancer patients: A prospective study using
1. World Confederation for Physical Therapy. Description of Physical Therapy- the theory of planned behavior. Rehabil Psychol 1999;44:68-84.
what is Physical Therapy? London, UK. Available from: http://www.wcpt. 28. Narayanan V, Koshy C. Fatigue in cancer: A review of literature. Indian J
org/node/29599 [last accessed on 2010 May 21]. Palliat Care 2009;15:19-25.
2. American Physical Therapy Association. Who are physical therapists, and 29. Lyles JN, Burish TG, Krozely MG, Oldham RK. Efficacy of relaxation
what do they do? A guide to physical therapist practice. Phys Ther 2001;81:39. training and guided imagery in reducing the aversiveness of cancer
3. Egan KA, Abbott P. Interdisciplinary team training- preparing new chemotherapy. J Consult Clin Psychol 1982;50:509-24.
employees for the specialty of hospice and palliative care. J Hosp Palliat 30. Jacobsen PB, Donovan KA, Vadaparampil ST, Small BJ. Systematic review
Nurs 2002;4:161-71. and meta-analysis of psychological and activity-based interventions for
4. Byock I, Merriman MP. Measuring quality of life for patients with terminal cancer-related fatigue. Health Psychol 2007;26:660-7.
illness: The Missoula-VITAS Quality of life index. Palliat Med 1998;12:231-44. 31. The Chartered Society of Physiotherapy. Effectiveness of physiotherapy
5. American Physical Therapy Association. What Is Physical Therapy? A guide in the palliative care of older people. London, UK; 2002. Available from:
to physical therapist practice. Phys Ther 2001;81:21. http://www.csp.org.uk/uploads/documents/evidencebrief_palliative_
6. Kumar RS, Rajagopal MR. Palliative care in Kerala- problems at presentation EB04.pdf [last accessed on 2010 May 21].
in 440 patients with advanced cancer in a south Indian state. Palliat Med 32. Netz Y, Wu M, Becker BJ, Tenenbaum G. Physical activity and psychological
1996;10:293-8. well-being in advanced age: A meta-analysis of intervention studies. Psychol
7. Jette AM. Physical disablement concepts for physical therapy research and Aging 2005;20:272-84.
practice. Phys Ther 2010;74:380-6. 33. McAuley E, Elavsky S, Jerome GJ, Konopack JF, Marquez DX. Physical
8. Seamark D, Ajithakumari K, Devi PS, Koshy R, Seamark C. Palliative care activity-related well-being in older adults: Social cognitive influences. Psychol
in India. J Royal Soc Med 2000;93:292-5. Aging 2005;20:295-302.
9. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. 34. Motl RW, McAuley E. Pathways between physical activity and quality of
Physical activity and public health: A recommendation from the centers for life in adults with multiple sclerosis. Health Psychol 2009;28:682-9.
disease control and prevention and the American college of sports medicine. 35. Motl RW, McAuley E, Snook EM. Physical activity and quality of life
J Am Med Assoc 1995;273:402-7. in multiple sclerosis: Possible roles of social support, self-efficacy and
10. Bryan A, Hutchinson KE, Seals DR, Allen DL. A transdisciplinary model functional limitations. Rehabil Psychol 2007;52:143-51.
integrating genetic, physiological and psychological correlates of voluntary 36. Weih M, Degirmenci U, Kreil S, Kornhuber J. Physical activity and
exercise. Health Psychol 2007;26:30-9. alzheimer’s disease- a meta-analysis of cohort studies. Gerontol Psychol
11. Toot J. Physical therapy and hospice- concept and practice. Phys Ther 2010;23:17-20.
1984;64:665-71. 37. Ginis KA, Latimer AE, McKechnie K, Ditor DS, McCartney N, Hicks AL,
12. Laakso L. The role of physiotherapy in palliative care. Aust Fam Physician et al. Using exercise to enhance subjective well-being among people with
2006;35:781. spinal cord injury: The mediating influences of stress and pain. Rehabil
13. Montagnini M, Lodhi M, Born W. The utilization of physical therapy in a Psychol 2003;48:157-64.
palliative care unit. J Palliat Med 2003;6:11-7. 38. Latimer AE, Ginis KA, Arbour KP. The efficacy of an implementation
14. Fulton CL, Else R. Rehabilitation in Palliative Care: Physiotherapy. In: intention intervention for promoting physical activity among individuals
Doyle D, Hanks GW, MacDonald N, editors. Oxford Textbook of Palliative with spinal cord injury. Rehabil Psychol 2006;51:273-80.
Medicine. Oxford: Oxford University Press; 1997 39. Katz JF, Adler JC, Mazzarella NJ, Ince LP. Psychological consequences of an
15. Flomenhoft D. Understanding and helping people who have cancer- A exercise training program for a paraplegic man. Rehabil Psychol 1985;30:53-8.
special communication. Phys Ther 1984;64:1232-4. 40. Nayak S, Wheeler BL, Shiflett SC, Agostinelli S. Effect of music therapy on
16. Rashleigh LS. Physiotherapy in palliative oncology. Aust J Physiother mood and social interaction among individuals with acute traumatic brain
1996;42:307-12. injury and stroke. Rehabil Psychol 2000;45:274-283.
17. Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer 41. Holmes PS. Theoretical and practical problems for imagery in stroke
2001;92:1049-52. rehabilitation: An observation solution. Rehabil Psychol 2007;52:1-10.
18. Twycross R. Factors associated with difficult-to-manage pain. Indian J Palliat 42. Malouin F, Richards CL. Mental practice for relearning locomotor skills.
Care 2004;10:67-78. Phys Ther 2010;90:240-51.
19. Watson T, Mock V. Exercise as an intervention for cancer-related fatigue. 43. American Thoracic Society. Pulmonary rehabilitation-1999. Am J Respir
Phys Ther 2004;84:736-43. Crit Care Med 1999;159:1666-82.
20. Molinaro J, Kleinfeld M, Lebed S. Physical therapy and dance in the surgical 44. Lanken PN, Terry PB, DeLisser HM, Fahy BF, Hansen-Flaschen J, Heffner
management of breast cancer- a clinical report. Phys Ther 1986;66:967-9. JE, et al. An official American Thoracic Society policy statement: Palliative
21. Keays KS, Harris SR, Lucyshyn JM, MacIntyre DL. Effects of pilates care for patients with respiratory diseases and critical illnesses. Am J Respir
exercises on shoulder range of motion, pain, mood, and upper extremity Crit Care Med 2008;177:912-27.
function in women living with breast cancer: A pilot study. Phys Ther 45. Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, et
2008;88:494-510. al. American Thoracic Society/ European respiratory society statement on
22. Clay CA, Perera S, Wagner JM, Miller ME, Nelson JB, Grrenspan SL. Physical pulmonary rehabilitation. Am J Respir Crit Care Med 2006;173:1390-413.
function in men with prostate cancer on androgen deprivation therapy. Phys 46. Raghu G, Weycker D, Edelsberg J, Bradford WZ, Oster G. Incidence and
Ther 2007;87:1325-33. prevalence of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med
23. Megens A, Harris SR. Physical therapist management of lymphedema 2006;174:810-6.
following treatment for breast cancer: A critical review of its effectiveness. 47. Fan LL, Kozinetz CA. Factors influencing survival in children with chronic
Phys Ther 1998;78:1302-11. interstitial lung disease. Am J Respir Crit Care Med 1997;156:939-42.
24. Bicego D, Brown K, Ruddick M, Storey D, Wong C, Harris SR. Exercise for 48. Selman M, King TE, Pardo A. Idiopathic pulmonary fibrosis: Prevailing and
women with or at risk for breast cancer–related lymphedema. Phys Ther evolving hypotheses about its pathogenesis and implications for therapy.
2006;86:1398-405. Ann Intern Med 2001;134:136-51.

Indian Journal of Palliative Care / Sep-Dec 2010 / Vol-16 / Issue-3 145

 Kumar and Jim: Physical therapy and palliative care

49. Keenleyside G, Vora V. Cough. Indian J Palliat Care 2006;12:51-5. 76. McNeil JK, LeBlanc EM, Joyner M. The effect of exercise on depressive
50. LeGrand SB. Dyspnea: The continuing challenge of palliative management. symptoms in the moderately depressed elderly. Psychol Aging 1991;6:487-8.
Curr Opin Oncol 2002;14:394-8. 77. Schwartz SG, Kaloupek DG. Acute exercise combined with imaginal exposure
51. Syrett E, Taylor J. Non-pharmacological management of breathlessness: A as a technique for anxiety reduction. Can J Behav Sci 1987;19:151-66.
collaborative nurse-physiotherapist approach. Int J Palliat Nurs 2003;9:150-8. 78. Bruning NS, Frew DR. Effects of exercise, relaxation and management
52. Vora V. Breathlessness: A palliative care perspective. Indian J Palliat Care skills training on physiological stress indicators: A field experiment. J Appl
2004;10:12-8. Psychol 1987;72:515-21.
53. Lox CL, Freehill AJ. Impact of pulmonary rehabilitation on self-efficacy, 79. Puetz TW, O’Connor PJ, Dishman RK. Effects of chronic exercise on
quality of life and exercise tolerance. Rehabil Psychol 1999;44:208-21. feelings of energy and fatigue: A quantitative synthesis. Psychol Bull
2006;132:866-76.
54. Sachs S, Weinberg RL. Pulmonary rehabilitation for dyspnea in the palliative-
care setting. Curr Opin Support Palliat Care 2009;3:112-9. 80. Chafin S, Christenfeld N, Gerin W. Improving cardiovascular recovery from
stress with brief post-stress exercise. Health Psychol 2008;27:S64-72.
55. Emery CF, Schein RL, Hauck ER, MacIntyre NR. Psychological and
cognitive outcomes of a randomized trial of exercise among patients with 81. Jerstad SJ, Boutelle KN, Ness KK, Stice E. Prospective reciprocal relations
chronic obstructive pulmonary disease. Health Psychol 1998;17:232-40. between physical activity and depression in female adolescents. J Consult
Clin Psychol 2010;78:268-72.
56. Ciesla ND. Chest physical therapy for patients in the intensive care unit.
Phys Ther 1996;76:609-25. 82. Steptoe A, Cox S. Acute effects of aerobic exercise on mood. Health Psychol
1988;7:329-40.
57. Eng JJ, Ginis KA. Using the theory of planned behavior to predict leisure
83. Tkachuk GA, Martin GL. Exercise therapy for patients with psychiatric
time physical activity among people with chronic kidney disease. Rehabil
disorders: Research and clinical implications. Prof Psychol Res Pr
Psychol 2007;52:435-42.
1999;30:275-82.
58. Russell KL, Bray SR. Promoting self-determined motivation for exercise
84. Dubbert PM. Exercise in behavioral medicine. J Consult Clin Psychol
in cardiac rehabilitation: The role of autonomy support. Rehabil Psychol
1992;60:613-8.
2010;55:74-80.
85. Dubbert PM. Physical activity and exercise: Recent advances and current
59. Harding R, Karus D, Easterbrook P, Raveis VH, Higginson IJ, Marconi K.
challenges. J Consult Clin Psychol 2002;70:526-36.
Does palliative care improve outcomes for patients with HIV/AIDS: A
systematic review of the evidence. Sex Transm Infect 2005;81:5-14. 86. Tarler-Benlolo L. The role of relaxation in biofeedback training- a critical
review of the literature. Psychol Bull 1978;85:727-55.
60. Cade WT, Peralta L, Keyser RE. Aerobic exercise dysfunction in human
immunodeficiency virus: A potential link to physical disability. Phys Ther 87. Halonen JS, Passman RH. Relaxation training and expectation in the
treatment of postpartum distress. J Consult Clin Psychol 1985;53:839-45.
2004;84:655-64.
88. Carey MP, Burish TG. Providing relaxation training to cancer chemotherapy
61. Nixon S, O'Brien K, Glazier R, Tynan AM. Aerobic exercise interventions
patients: A comparison of three delivery techniques. J Consult Clin Psychol
for adults living with HIV/AIDS. Cochrane Database Syst Rev
1987;55:732-7.
2005;2:CD001796.
89. Qualls PJ, Sheehan PW. Electromyograph biofeedback as a relaxation
62. O'Brien K, Nixon S, Tynan AM, Glazier RH. Effectiveness of aerobic
technique: A critical appraisal and reassessment. Psychol Bull 1981;90:21-42.
exercise in adults living with HIV/AIDS: Systematic review. Med Sci Sports
Exerc 2004;36:1659-66. 90. Rodgers WM, Hall CR, Blanchard CM, Munroe KJ. Prediction of obligatory
exercise by exercise-related imagery. Psychol Addict Behav 2001;15:152-4.
63. O'Brien K, Nixon S, Glazier R, Tynan AM. Progressive resistive exercise
interventions for adults living with HIV/AIDS. Cochrane Database Syst 91. O’Kelly J. Music therapy in palliative care: Current perspectives. Int J Palliat
Nurs 2002;8:130-8.
Rev 2004;4:CD004248.
92. Pawuk LG, Schumacher JE. Introducing music therapy in hospice and
64. O'Brien K, Tynan AM, Nixon S, Glazier RH. Effects of progressive
palliative care- an overview of one hospice’s experience. Home Healthc
resistive exercise in adults living with HIV/AIDS: Systematic review and
Nurse 2010;28:37-44.
meta-analysis of randomized trials. AIDS Care 2008;20:631-53.
93. Oden KA, Johnson QS. An exercise in values exploration for play therapists.
65. Hillier SL, Louw Q, Morris L, Uwimana J, Statham S. Massage therapy for
International Journal of Play Therapy 2010;19:117-28.
people with HIV/AIDS. Cochrane Database Syst Rev 2010;1:CD007502.
94. Plante TG, Aldridge A, Su D, Bogdam R, Belo M, Kahn K. Does virtual
66. Crepaz N, Passin WF, Herbst JH, Rama SM, Malow RM, Purcell DW, et al.
reality enhance the management of stress when paired with exercise? An
Meta-analysis of cognitive-behavioral interventions on HIV-positive persons'
exploratory study. Int J Stress Manag 2003;10:203-16.
mental health and immune functioning. Health Psychol 2008;27:4-14.
95. Plante TG, Gores C, Brecht C, Carrow J, Imbs A, Willemsen E. Does
67. Wilfley D, Kunce J. Differential physical and psychological effects of
exercise environment enhance the psychological benefits of exercise for
exercise. Couns Psychol 1986;33:337-42. women? Int J Stress Manag 2007;14:88-98.
68. Tuckman BW, Hinkle JS. An experimental study of the physical and 96. Plante TG, Cage C, Clements S, Stover A. Psychological benefits of exercise
psychological effects of aerobic exercise on schoolchildren. Health Psychol paired with virtual reality: Outdoor exercise energizes whereas indoor virtual
1986;5:197-207. exercise relaxes. Int J Stress Manag 2006;13:108-17.
69. King AC, Taylor CB, Haskell WL, DeBusk RF. Influence of regular aerobic 97. Johansson M, Hassmen P, Jouper J. Acute effects of Qigong exercise on
exercise on psychological health: A randomized controlled trial of healthy mood and anxiety. Int J Stress Manag 2008;15:199-207.
middle-aged adults. Health Psychol 1989;8:305-24.
98. Ernst E. Complementary therapies in palliative cancer care. Cancer
70. Martin JE, Dubbert PM. Exercise applications and promotion in behavioral 2001;91:2181-5.
medicine: Current status and future directions. J Consult Clin Psychol
99. Puthusseril V. Special foot massage as a complimentary therapy in palliative
1982;50:1004-17. care. Indian J Palliat Care 2006;12:71-7.
71. Tomporowski PD, Ellis NR. Effects of exercise eon cognitive processes: 100. Osaka I, Kurihara Y, Tanaka K, Nishizaki H, Aoki S, Adachi I.
A review. Psychol Bull 1986;99:338-46. Endocrinological evaluations of brief hand massages in palliative care. J
72. Blumenthal JA, Madden DJ. Effects of aerobic exercise training, age and Altern Complement Med 2009;15:981-5.
physical fitness on memory-search performance. Psychol Aging 1988;3:280-5. 101. Higgs J, Refshauge K, Ellis E. Portrait of the physiotherapy profession. J
73. Clarkson-Smith L, Hartley AA. Relationships between physical exercise and Interprof Care 2001;15:79-89.
cognitive abilities in older adults. Psychol Aging 1989;4:183-9. 102. Meier DE, Morrison RS, Cassel CK Improving palliative care. Ann Intern
74. McCann IL, Holmes DS. Influence of aerobic exercise on depression. J Med 1997;127:225-30.
Pers Soc Psychol 1988;46:1142-1147.
75. Brown JD, Siegel JM. Exercise as a buffer of life stress: A prospective study Source of Support: Nil, Conflict of Interest: None declared.
of adolescent health. Health Psychol 1988;7:341-53.

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