P E R S P E C T I V E P A P E R

The Role of Rehabilitation in

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Patients Receiving Hospice and

Palliative Care
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Marcos Montagnini, MD, FACP1 ; Noelle Marie Javier, MD2 ; Allison Mitchinson, MPH, BCTMB3
1
Division of Geriatrics and Palliative Medicine, University of Michigan, Ann Arbor, MI; 2 Brookdale Department of
Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; and 3 VA Ann Arbor
Healthcare System, Ann Arbor, MI

Patients receiving palliative and hospice care experience high levels of functional loss, dependency on activities
of daily living, and impairment in mobility. Physical disability affects important aspects of life, oftentimes
leading to depression, poor quality of life, increased caregiver needs, increased health resource utilization,
and institutionalization. Physical strength, the number of hours spent in bed, and the ability to do what
one wants are important indicators of quality of life for patients with cancer and their families. Progressive
debility with a sense of being a burden has been cited in the literature as a reason for desiring death among
these patients. This perception of increased dependence on others serves as a strong predictor for a patient’s
interest in the physician aid in dying (PAD). This highlights the desire and willingness of most palliative and
hospice care patients to remain physically independent during the course of their disease. Several studies have
shown that maintaining the most optimal level of functional ability, especially mobility, for as long as possible
is one of the main benefits of rehabilitation in the palliative and hospice care settings. Studies demonstrate
that rehabilitation in patients receiving hospice and palliative care can reduce the burden of care for families
and caregivers and improve patient’s quality of life, sense of well-being, as well as control of pain and non-
pain symptoms. (Rehab Oncol 2020;38:9–21) Key words: activities of daily living, cancer, disability, functional
disability, functional dependence, hospice, impairment in mobility, palliative care, rehabilitation, quality of
life

Patients with life-limiting illnesses and who may be
receiving hospice or palliative care services experience
progressive debility as evidenced by high levels of func-
tional loss, increased dependency with activities of daily
living (ADL), and mobility dysfunction.1,2 Disability re-
sults from multiple factors such as deconditioning, muscle
fatigue, sarcopenia from direct tumor effects, malnutrition,
depression, complications from therapies, bowel and blad-
der dysfunction, uncontrolled pain, thromboembolic dis-
ease, neurologic dysfunction, musculoskeletal deficits, and
active concurrent illnesses, among others.3,4 Therefore,
Rehabilitation Oncology
Copyright C 2020 Academy of Oncologic Physical Therapy, APTA.
The authors declare no conflicts of interest.
Correspondence: Marcos Montagnini, MD, FACP, Division of Geriatrics
and Palliative Medicine, University of Michigan, 2215 Fuller Rd (11-G),
Ann Arbor, MI 48104 (mmontag@umich.edu).
DOI: 10.1097/01.REO.0000000000000196
physical disability affects many aspects of life, resulting in
depressed mood, increased caregiver needs, overall poor
quality of life, and greater need for institutionalization.3-5
Physical strength, hours spent in bed, and the ability to
do what one wants are invaluable indicators of quality of
life for many patients with cancer and their families.4-7
Maintaining the highest level of functional abilities, es-
pecially mobility, through rehabilitation therapies is one
of the most fulfilling goals for this population. However,
these services are underutilized despite the growing body
of literature supporting its benefits. The concept of reha-
bilitation in patients receiving hospice or palliative care
would seem paradoxical. However, in reality, rehabilita-
tion is highly appropriate for these patients if functional
improvement is within their goals. Rehabilitation strategies
can reduce the burden of care for families and caregivers.
They also improve patients’ quality of life and satisfaction
of care and reduce distressing symptoms such as pain and
anxiety.1,2,8-10 The main goal is therefore to help the pa-
tient live a good life regardless of physical disabilities and
impairments. Rehabilitation in both hospice and palliative

Rehabilitation Oncology Rehabilitation in Hospice and Palliative Care 9

Copyright © 2020 Academy of Oncologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
 care settings can potentially help patients regain control
over many aspects of their lives and to remain as function-
ally independent and productive as possible.11-13
OBJECTIVES
1. To define the role of rehabilitation in the hospice
and palliative care settings;
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2. To discuss key points in the assessment and plan-
ning of palliative rehabilitation; and
3. To provide an overview of the roles of physi-
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cal therapy, occupational therapy, speech-language
pathology, and massage therapy in facilitating re-
habilitation in the hospice and palliative care
settings.
OVERVIEW OF REHABILITATION AND PALLIATIVE
MEDICINE
The specialties of rehabilitation medicine and pallia-
tive medicine play critical roles in the care of patients with
cancer along the continuum. Both specialties recognize
the health-related quality-of-life effects of physical and
psychological impairments.14,15 Furthermore, they both
use interprofessional teams to regularly evaluate patients’
medical, physical, cognitive, and functional status. They
also ensure that patients’ goals remain relevant while con-
curring disease or symptom-directed therapies exist. Both
fields of medicine help develop applicable measures that as-
sess constructs valued by patients and their caregivers such
as symptom control and function. Rehabilitation and pal-
liative medicine share a common goal of using multimodal
approaches to managing pain and other symptoms that
could be debilitating for patients and their caregivers.14,15
There is a clear distinction between conventional or
traditional rehabilitation and palliative rehabilitation.15 Pa-
tients without serious life-limiting illnesses can benefit
from conventional rehabilitation with the hope or expec-
tation that they will be able to recover and go back to their
previous level of functional state (if possible) despite their
impairments or disabilities.
DEFINITION OF PALLIATIVE REHABILITATION
Rehabilitation in the palliative and hospice care set-
tings has gained increased recognition in the literature. It
is defined as a process of helping a person to reach the
fullest physical, psychological, social, vocational, and edu-
cational potential consistent with his or her physiological
or anatomical impairment, environmental limitations, de-
sires, and life plans.2,16 Impairment is defined as the loss or
abnormality of psychological, physiological, or anatomical
structure or function resulting from pathology, whereas
disability refers to any restriction or lack of ability to per-
form an activity in the manner or within the range consid-
ered normal for a human being.16 Cheville et al17 in 2017
proposed a definition that in the advanced cancer pop-
ulation, palliative rehabilitation is function-directed care
10 Montagnini et al
Copyright © 2020 Academy of Oncologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
delivered in partnership with other clinical disciplines and
aligned with the values of the patients who have serious
and often incurable diseases in the context punctuated
by intense and dynamic symptoms, psychological distress,
and medical morbidity to realize potentially time-limited
trials.17 Moreover, the concept of palliative rehabilitation
was historically derived from Dietz’s concept of cancer
rehabilitation according to disease staging.18,19 Preventive
rehabilitation attempts to preclude or mitigate functional
morbidity caused by cancer or its treatment. Restorative
rehabilitation refers to the effort to return patients to their
premorbid functional status when little or no long-term im-
pairment is anticipated. Supportive rehabilitation attempts
to maximize function after permanent impairments caused
by cancer and/or its treatment. Palliative rehabilitation’s
primary goal is the reduction of dependence in mobility
and self-care activities in association with the provision of
comfort and emotional support.
EVIDENCE-BASED APPROACH TO PALLIATIVE
REHABILITATION
Data supporting the role of rehabilitation in hospice
and palliative care have grown steadily since the sentinel
study of Yoshioka10 in 1994. There is now official recog-
nition of the benefits of rehabilitation in this population
(Table 1).
Yoshioka’s10 study documented that hospice patients
who received rehabilitation had improved quality of life
and mobility and reduced symptoms such as pain, dysp-
nea, constipation, and leg edema. About 63% of patients
considered rehabilitation modalities to be effective.10 Sub-
sequent studies by Porock et al20 and Oldervoll et al21 re-
vealed that structured physical exercise programs reduced
fatigue and anxiety and improved quality of life in patients
receiving hospice and palliative care services.
Two separate but related studies by Sabers et al22 and
Marciniak et al23 used a comprehensive inpatient reha-
bilitation approach for patients with cancer. The former
showed significant reduction in pain and improvement in
mood, mobility, quality of life in the last 3 days, and com-
fort with going home and directing care. The Marciniak
et al23 study highlighted that the presence of metastatic dis-
ease did not influence functional outcomes. Patients with
cancer who received radiation therapy most notably made
larger functional improvements.23 Montagnini et al24 sup-
ported findings that inpatient physical therapy benefited
more than half of patients receiving palliative care. Their
ADL scores improved within 2 weeks and after comple-
tion of the program. Furthermore, patients with higher
albumin levels were correlated with greater functional
improvement.24
Scialla and colleagues25 retrospectively studied older
patients with cancer asthenia who underwent compre-
hensive multidisciplinary inpatient rehabilitation. The
rehabilitation goal for all patients was to maximize their
functional status to a level allowed by their impairments.
Using the Functional Independence Measure (FIM) for
Rehabilitation Oncology

Author(s) Methodology
Yoshioka10 Retrospective case series in a
hospice facility in Japan
Rehabilitation Oncology
Porock et al20 Experimental pre- and
posttest design in a home
hospice program in
Australia
Oldervoll et al21 Phase II interventional
(exercise) study in a
palliative care unit and an
oncological outpatient
clinic in Norway
Sabers et al22 Prospective study at the
Mayo Clinic in Rochester,
Minnesota
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Rehabilitation in Hospice and Palliative Care 11
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Summary of Selected Evidence-Based Literature on Palliative Rehabilitation
Sample Size
301 patients with terminal
cancer
9 patients enrolled in hospice
(mean age 59 y)
63 patients receiving hospice
and palliative care
299 patients hospitalized with
cancer
TABLE 1
Intervention and Outcome Measures Results
Rehabilitation within 6 mo of death 63% patients considered rehabilitation
Therapeutic exercises for range of motion, balance, procedures to be effective
muscle strength 27% average improvement in ADL scores
- ADL training Improvement in the BI score from 12.4
- Bed exercises prerehabilitation to 19.9 postrehabilitation
- Endurance training Almost all patients experienced some relief
- Chest PT from pain, dyspnea, leg edema, and
- Swallowing exercises constipation
- Thermotherapy Families expressed satisfaction with the
- Intermittent pneumatic compression program
- Acupuncture
- Use of brace, sling, and splint
- Comfortable or relaxed positioning with pillows
Measurement:
BI scores before and after rehabilitation
28-d exercise intervention Overall minimal fluctuation in the mean MFI
Measurements: subscale scores between days 0 and 28
MFI The general fatigue score remained the same
Symptom Distress Scale HADS trended toward decreased anxiety levels
HADS Patients enjoyed the exercise, and fatigue was
Graham and Longman’s QOL Scale not worse
Improvement in overall QOL scores
6 wk of structured exercise program supervised by a 34 patients completed the study
physical therapist Significant increase in walking length by 29 m
Exercise consisted of 10 min of warm-up session, from pre- to posttest (P = .007)
30 min of circuit training in 6 stations, and 10 min Significant decrease in timed sit to stand from
of relaxation/stretching session 5.1 to 4.1 s (P = .001)
Measurements for physical performance and balance: Measuring balance by functional reach
Six-Minute Walk Test improved from 30.4 to 32.8 cm (P = .07)
Timed repeated sit to stand The fatigue score improved (P = .06)
Functional reach Dyspnea reduced (P = .006)
Measurement for fatigue: Global QOL remained stable
Fatigue Questionnaire Role and social functioning improved from 50
Measurement for QOL: to 63 points (P = .02) and from 55 to 65
EORTC-QOL questionnaire points (P = .008), respectively
Inpatient rehabilitation 189 completed the study
Measurements: Significant improvement in KPS and BI scores
Barthel Mobility Index (BI) at completion of the program
KPS Improvement in multiple QOL parameters
QOL questionnaire at enrollment and completion of Nearly half of the patients (49%) believed they
the program benefited from rehabilitation
(continues)

12
Author(s) Methodology
Montagnini et al
Marciniak et al23 Retrospective case series in a
university-affiliated
rehabilitation hospital in
the United States
Montagnini Retrospective chart review in
et al24 a hospital-based palliative
care unit at a Veterans
Affairs Medical Center
Scialla et al25 Retrospective chart review
in a rehabilitation hospital
in Scranton, Pennsylvania
Huang et al26 Case-controlled,
retrospective study in a
tertiary care medical
center inpatient
rehabilitation unit
Cole et al27 Retrospective case series in a
rehabilitation hospital in
Scranton, Pennsylvania
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Rehabilitation Oncology
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Summary of Selected Evidence-Based Literature on Palliative Rehabilitation (Continued)
Sample Size
159 patients with functional
impairments related to cancer
or its treatment
100 consecutive patients
receiving palliative care and
who were discharged from a
palliative care unit
110 patients with cancer and
who were older than 60 y
63 patients with brain tumor
who were matched with 63
patients with acute stroke
according to age, sex, and
location of lesion
200 patients with cancer and
who were older than 18 y
TABLE 1
Intervention and Outcome Measures Results
Comprehensive inpatient rehabilitation Significant functional gains made between
Measurement: admission (mean FIM score = 4.29) and
FIM-MM discharge (mean FIM score = 56) (P < .001)
The presence of metastatic disease did not
influence functional outcome
Those receiving radiation therapy made larger
functional gains
Completion of inpatient PT program PT benefited 56% of patients, with notable
Measurements: improvement in ADL scores
ADL scores on admission, at 2 wk, and upon A higher albumin level was correlated with
completion of the PT program functional improvement
Comprehensive multidisciplinary inpatient Improvement in the median total FIM score
rehabilitation from admission (71) to discharge (88)
Measurements: Improvements in physical function, asthenia,
FIM-MM and cognition
FIM-CM
Acute inpatient rehabilitation No significant difference found in both
Measurements: populations in regard to total admission
FIM scores on admission and discharge and measured FIM, total discharge FIM, change in total
in 3 subsets, namely, ADL, mobility, and cognition FIM, or FIM efficiency
FIM change and FIM efficiency were also calculated The admission mobility-FIM was higher in the
brain tumor group (13.6 vs 11.1, P = .04)
The admission ADL-FIM was found to have a
greater change in the stroke group (P = .03)
The 2 groups had similar rates of discharge to
the community at 85%
The tumor group had a significantly shorter
rehabilitation length of stay than the stroke
group (25 vs 34 d, P < .01)
Comprehensive multidisciplinary inpatient All patients made significant gains in motor
rehabilitation function regardless of the diagnostic group,
Measurements: the rehabilitation impairment group, the
FIM-MM and FIM-CM rehabilitation goal group, and cytotoxic
treatment status
Significant gains in cognitive function were
made by all patients except those with
intracranial neoplasms and central nervous
system dysfunction
(continues)

Summary of Selected Evidence-Based Literature on Palliative Rehabilitation (Continued)
Author(s) Methodology
Pyszora et al28 RCT
Rehabilitation Oncology
Schuler et al29 RCT
Paramanandam Systematic review looking at the effect
and Dunn30 of exercises on cancer-related fatigue
in lung cancer (PICOS format),
period of 2001-2012
Databases: CENTRAL, PubMed,
EMBASE, CINAHL, SPORTDiscus,
AMED, Web of Science
Salakari et al31 Systematic review using Fink’s model of
RCTs within the period of 2009-2014
Databases: MEDLINE, PubMed,
Cochrane
AMSTAR method (A MeaSurement
Tool to Assess systematic Reviews)
Jensen et al32 Retrospective study in a specialized
palliative care unit of a university
hospital in Hamburg, Germany, from
2009 to 2012
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Rehabilitation in Hospice and Palliative Care 13
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TABLE 1
Sample Size
60 patients with advanced
cancer receiving palliative
care
77 patients with advanced
cancer
10 articles involving adults with
lung cancer with or at risk for
lung cancer fatigue
13 RCTs (1169 participants), 7
patients with advanced cancer
All consecutive patients with
terminal cancer treated in a
palliative care inpatient ward
during a 3.5-y period were
included (n = 572)
Intervention and Outcome Measures
Treatment group: 30-min PT sessions (active
exercises, myofascial release, and
proprioceptive neuromuscular facilitation
techniques
Control group: No exercise
Measurements:
Brief Fatigue Inventory
Edmonton Symptom Assessment Scale
satisfaction scores
Physical exercise program and its effect on
fatigue at 12 and 24 wk after baseline
Group A: Treatment as usual
Group B: Structured sports program
Group C: Additional ambulatory PT
Measurements:
General fatigue using the MFI
Walking distance
Physical exercise (aerobic, resistance, mixed,
flexibility)
Measurement:
Fatigue score using the EORTC-QOL
questionnaire
Physical exercise and massage among patients
with advanced cancer
Measurements:
QOL
Symptom control (pain, mood, fatigue)
Physical exercise, breathing techniques,
relaxation therapy, positioning,
lymphedema treatment
Results
Significant reduction in fatigue scores
Improvement in general well-being
Reduction in symptoms (pain, drowsiness, lack
of appetite, depression)
Positive satisfaction scores
Rate of severe general fatigue significantly
reduced with group C
All MFI dimensions increased in group A
Patients with self-directed exercise program
and additional PT supervision had more
appreciable benefit on fatigue reduction
Nearly all studies except one (9/10) did not
show decline in function for patients who
exercised
7/10 studies showed that exercise intervention
is safe and feasible
Limitation: Studies are small
Exercise was associated with significant
improvement in general well-being and QOL
Rehabilitation had positive effects on fatigue,
general condition, mood, and cancer coping
Home-based exercise programs improved
mobility and sleep quality and reduced
fatigue
93% of patients with terminal cancer were able
to perform physical exercise at least once
during their hospital stay
Physical exercise was feasible in 54% of the
patients with terminal cancer, even within
the last days of their lives
About 50% received massage in the cohort who
were offered relaxation therapy
Older patients were just as receptive as their
younger cohort to receive exercise
instructions
(continues)
 Motor Function (FIM-MM) and Cognition (FIM-CM),

Abbreviations: ADL, activities of daily living; BI, Barthel Index; EORTC-QOL, European Organization for Research and Treatment of Cancer Quality of Life; FIM, Functional Independence Measure; FIM-CM,
Functional Independence Measure for Cognitive Function; FIM-MF, Functional Independence Measure for Motor Function; HADS, Hospital Anxiety and Depression Scale; KPS, Karnofsky Performance Scale;
a striking improvement in the median total FIM score

Positive effect of PT on the patient’s physical,

Support the utilization of PT in the palliative
from admission to discharge was observed.25 In contrast,

Improvement in mobility and ADL tasks

the Huang and colleagues26 case-controlled retrospective
study concluded that patients with brain tumors can

emotional, and social well-being

achieve positive outcomes and rates of discharge com-

Reduced musculoskeletal pain

Positive caregiver satisfaction

parable with patients with stroke. Furthermore, in the
Results

Cole et al27 study of 200 patients with cancer who under-

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went a comprehensive inpatient rehabilitation program,

most reported significant gains in motor and cognitive
care setting

functions.
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More recent data on the beneficial effects of physical

therapy on cancer fatigue were highlighted in the 2017
study by Pyszora et al28 in which 60 patients with cancer
receiving palliative care were randomized to the treatment
group (physical therapy program) versus control. Using
fall prevention, transfer training, etc) in the
PT interventions (strengthening, therapeutic
exercise, caregiver education, balance and

the Brief Fatigue Inventory, the treatment group had lower

Intervention and Outcome Measures
Summary of Selected Evidence-Based Literature on Palliative Rehabilitation (Continued)

scores of fatigue and its effect on daily functioning. More-

over, there were notable gains in general well-being and
reduced intensity of distressing symptoms such as pain.28
Critical Appraisal Skills Program

Another study by Schuler et al29 looked into the effect of

a structured individual sports program on fatigue among
palliative care setting

patients with advanced cancer. This was a randomized con-

Caregiver satisfaction

trolled trial (RCT) that enrolled 77 patients, the majority of

Symptom control

whom were receiving palliative intent to treat, who partic-

MFI, Multidimensional Fatigue Inventory; PT, physical therapy; QOL, quality of life; RCT, randomized controlled trial.
Measurement:

Patient QOL

ipated in the exercise program, and whose fatigue scores

were monitored at 12 and 24 weeks after baseline. The
program contained 5 standardized exercises for strength
TABLE 1

training and endurance such as walking, running, and bi-

cycling. The exercises that were conducted mostly at home
occurred 5 times per week for 12 weeks. The trial demon-
strated the positive effects of physical exercise on cancer
and treatment-related symptoms such as severe fatigue.29
Sample Size

13 qualitative articles

Furthermore, the study underscored the benefit of exercise

among patients with cancer receiving curative and/or pal-
liative care. Paramanandam and Dunn30 showed a trend
that physical exercise might be helpful for patients with
lung cancer fatigue including those receiving palliative
care.
A 2015 systematic review of 13 RCTs on the effects
of physical exercise among patients with advanced can-
Journal of Palliative Care, Google

cer underscored that it led to significant improvement in

scholar, and American Journal of
1994-2015) using the following

Hospice and Palliative Medicine

MEDLINE, Cochrane, PEDro,
databases (CINAHL PubMed,

general well-being and quality of life.31 Overall, rehabilita-

Systematic review (period of

tion showed positive effects on fatigue, general condition,

Methodology

mood, and coping with cancer.31

Jensen et al32 systematically studied the feasibility of
physical therapy in 528 patients with terminal illness. Re-
sults showed that physical therapy is practical and attain-
able in more than 90% of patients who are terminally ill
and dying.32 Putt et al33 published a systematic review of
13 qualitative and quasi-experimental articles supporting
the utilization of physical therapy interventions such as ex-
ercise, balance and fall prevention training, and massage,
among others, in the care of patients receiving palliative
al33

and hospice care. Moreover, there are psychological bene-

Author(s)

Putt et

fits experienced by patients who are dying. These include

positive mood and improved function and overall quality
of life.33

14 Montagnini et al Rehabilitation Oncology

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 Although the studies listed in Table 1 show numer-
ous benefits of rehabilitation strategies in the hospice and
palliative care settings, it is important to emphasize that
physical and cognitive functions change dramatically on
a daily basis. It is therefore prudent to review physical
therapy goals and to customize interventions on a regu-
lar basis. Rehabilitation therapists will have to be flexible
with the treatment plan while respecting patient choices
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and acknowledging frequent interruptions in day-to-day
therapies.
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PLANNING FOR PALLIATIVE REHABILITATION
In general, the rehabilitation plan is designed in
collaboration with members from multiple disciplines
including physical therapy, occupational therapy, speech-
language pathology, psychology, nursing, nutrition,
respiratory therapy, recreational therapy, case manage-
ment, pharmacy, social work, chaplaincy, and patient
care associates, to name a few. This collaboration is
coordinated by a physiatrist experienced in hospice and
palliative medicine.34 The plan should be individualized
and tailored on the basis of the patient’s stage of serious
illness, overall prognosis, potential to regain function, and
desire and motivation to participate in the program.
Rehabilitation can be provided in a number of settings
including inpatient, outpatient, and home-based venues.35
Inpatient acute rehabilitation is designed for patients who
are able to tolerate at least 3 hours of daily therapy 5
times per week. Subacute inpatient rehabilitation offers
coordinated interprofessional services to patients who can
tolerate at least 1 hour of therapy each day 5 times per
week. Outpatient rehabilitation offers comprehensive in-
terprofessional or single rehabilitation services for patients
residing in the community. Most home care agencies can
provide physical therapy, occupational therapy, speech-
language pathology, social work, and skilled nursing care
to patients who are homebound. Hospice programs may
occasionally provide rehabilitation services in the inpa-
tient setting as well as the home environment if aligned
with goals of care and part of the comprehensive hospice
plan of care.36 Financial coverage for these rehabilitation
services is obtained through Medicare, Medicaid, and most
private insurance companies or third-party payers accord-
ing to their specific reimbursement criteria. Patients en-
rolled in the Medicare hospice benefit are eligible to re-
ceive them without additional cost.36,37 Medicare-certified
hospice agencies are reimbursed on a daily rate for services
provided at home or in a facility. When the goal of further
home-based rehabilitation supersedes that being offered by
hospice, there is no direct reimbursement for additional
sessions. Patients and families will have to explore out-of-
pocket expense to continue more rehabilitation services
at home or outpatient. Under the Medicare hospice bene-
fit, rehabilitation resources covered include safety training,
symptom control, and assistance with ADL. The financial
reimbursement for patients receiving palliative care is not
as well defined by medical insurances. To mitigate access
Rehabilitation Oncology
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issues, clinicians and rehabilitation specialists might con-
sider a 1-time evaluation during a patient’s inpatient stay
so that both the patient and caregivers are educated on
helpful rehabilitation techniques to be continued at home
or in an outpatient setting. For patients receiving home-
based palliative care, rehabilitation therapies may be of-
fered through Medicare Part A home care program as a
skilled need rather than a separate or specific coverage for
palliative rehabilitation. Furthermore, depending on the
severity of the serious illness and the level of functionality,
patients might benefit from conventional rehabilitation in
subacute, home, and outpatient settings before formally
enrolling in hospice services at home or in a facility. Medi-
care Part A and most private insurances will reimburse for
conventional rehabilitation.37
Discharge planning is a vital part of the rehabilita-
tion plan. This is achieved through a dynamic team-based
approach that takes into account the patient’s progress to-
ward meeting the preestablished rehabilitation goals, the
degree of caregiver support postrehabilitation, and the ap-
propriate setting for further care.37 Frequently, the pa-
tient is followed by the entire team including therapies
until death or transition to and from palliative care or
hospice care. Patients with serious illness who are dis-
charged from the hospital and later enrolled in hospice
and have the desire to continue some degree of function-
ality could benefit from palliative rehabilitation regardless
of the hospice venue (eg, home, acute inpatient, long-term
care, assisted living). Rehabilitation therapists who work
with hospice can provide a limited number of visits to pa-
tients. This is carried out typically as a 1-time to a few
times visit(s) depending on patient mood, degree of im-
pairment, and capacity to participate in meaningful therapy
sessions on a daily basis. The provision of palliative reha-
bilitation services must be included in the comprehensive
hospice plan of care. Patients on hospice may choose to
disenroll from hospice should they feel the need to benefit
more from intensive rehabilitation such as consideration
of further skilled home care, outpatient therapy, and sub-
acute rehabilitation.38 In the same token, patients with
serious illness undergoing subacute rehabilitation may be
discharged from this level of care if they no longer meet
criteria as a result of progression of disease, more disabil-
ity, and lack of motivation to do so. Following discharge,
they may be enrolled in hospice if aligned with their goals.
The bottom line is that hospice care will work with patients
and families to match their goals of care and will be flexible
with the provision and/or revocation of hospice services.
PATIENT ASSESSMENT
Performing a comprehensive patient assessment is
an essential component of rehabilitation planning. This
will help determine the patient’s previous level of func-
tioning, potential for functional recovery, and capacity
to participate in a rehabilitation program. Information
on disease staging, previous and current treatments, life
expectancy, comorbidities, pain and nonpain symptoms,
Rehabilitation in Hospice and Palliative Care 15
 medications, cognition, mood, nutrition, and physical
function is necessary.39 The assessment of home and com-
munity support systems and financial resources is also
taken into consideration.40 A complete physical examina-
tion with careful attention to the musculoskeletal and neu-
rologic systems is essential in determining motor strength,
joint flexibility, gait, coordination, and fall risk.37,39,40
Several functional assessment tools can be used to
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quantify and qualify function, mobility, endurance, and
fall risk in patients receiving hospice and palliative care
services (Table 2). These include the following:
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1. The Karnofsky Performance Scale (KPS), origi-
nally developed for patients with cancer, provides
a global evaluation of the patient’s functional sta-
tus. It is also a reliable tool for prognostication in
hospice and palliative care. The KPS consists of a
100-point scale of general function corresponding
to the patient’s ability to live independently and/or
the need for institutionalization.41
2. The Eastern Cooperative Oncologic Group Scale is
a 5-point scale that quantifies a patient’s ability to
walk, care for self, and the need for dependence on
others. It was developed for patients with cancer
and is commonly used for prognostication in the
hospice and palliative care settings.42
3. The Edmonton Functional Assessment Tool was
originally designed and validated for the palliative
care population. It consists of 2 parts, namely: part
1, which assesses communication, mental status,
Functional Assessment Instruments
Category Assessment Instrument
Physical Function Karnofsky Performance Scale (KPS)41
Eastern Cooperative Oncology Group
(ECOG) Functional Index42
Edmonton Functional Assessment
Tool43,44
Palliative Performance Scale (PPS)45
Katz Activities of Daily Living (ADL)46
Lawton Instrumental Activities of Daily
Living (IADL)47
Barthel Index48,49
Functional Independence Measure (FIM)50
Balance/Fall Risk Berg Balance Scale51
Tinetti Assessment of Gait and Falls52
Timed Up and Go (TUG)53
Endurance 6-Minute Walk Test (6MWT)54
16 Montagnini et al
Copyright © 2020 Academy of Oncologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
pain, respiratory function, sitting or standing bal-
ance, mobility, walking or wheelchair locomotion,
ADL, fatigue, and motivation; and part 2, which
pertains to a single overall rating of the patient’s
functional status.43,44
4. The Palliative Performance Scale (PPS) quantifies
ambulation, activity level, self-care, oral intake,
and level of consciousness. It is a reliable tool for
determining survival in patients receiving hospice
and palliative care services and can provide infor-
mation on the patient’s care needs.45 PPS scores are
determined by reading horizontally at each level to
find a “best fit” for the patient, which is then as-
signed as the %PPS score. The lower the score, the
more disability there is.
5. The Katz Activities of Daily Living was originally
developed for the frail geriatric population and is
commonly used to evaluate physical function in
patients receiving hospice and palliative care. It
looks at 6 domains of function necessary for in-
dependent living including bathing, dressing, toi-
leting, transferring, continence, and feeding, which
are rated as dependent or independent.46 A score of
6 indicates full function, 4 indicates moderate im-
pairment, and 2 or less indicates severe functional
impairment.46
6. The Lawton Instrumental Activities of Daily Living
evaluates 8 domains of function including medi-
cation management, telephone use, housekeeping,
TABLE 2
Characteristics
Provides a general measure of function; useful for prognostication
100-point scale (100 = normal function; 0 = death)
Provides a general measure of function; useful for prognostication
5-point scale (0 = perfect health; 5 = death)
Designed and validated for the palliative care population
4-point scale (0 = functionally independent; 4 = total loss of function)
Provides a general measure of function; reliable tool for prognostication
Originally developed for older adults but frequently used for functional
assessment in the hospice and palliative care settings; measures 6 domains of
function; each domain is rated as 0 (dependent) to 1 (independent)
Total scores: 6 = full function; 4 = moderate impairment; 2 = severe
impairment.
Commonly used in geriatric populations; measures 8 domains of function; each
domain is scored either 0 (impairment) or 1 (normal function)
Assesses 10 functional tasks; can be used for a measure of function and to track
improvement over time
Yields a total score, a motor score, and a cognitive score
Higher scores indicate independence
Performance-based scale for balance with 14 items
Each task is measured on a 5-point scale (0 = lowest level of function; 4 =
highest level of function) (maximum total score = 56)
Performance-based instrument, with 9 items for balance and 7 items for gait.
Each task is scored on a 3-point scale (0 = complete impairment; 2 =
independence).
Risk for falls if total score 19-24; high risk for falls if total score <19
High risk for falls if time to complete the task ≥20 s
Total distance (meters) walked in 6 min
Rehabilitation Oncology
 food preparation, laundry, financial management,
transportation, and shopping.47 A summary score
ranges from 0 (low function, dependent) to 8 (high
function, independent).47
7. The Barthel Index quantifies a patient’s capacity to
independently perform 10 tasks including feeding,
dressing, personal hygiene, bowel control, blad-
der control, wheelchair transfer to and from bed,
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toilet transfer, bathtub transfer, walking on level
or being propelled by wheelchair, and ascending
and descending stairs.48 Total possible scores range
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from 0 to 20, with lower scores indicating increased
disability.48,49
8. The Functional Independence Measure is a com-
prehensive observer-rated scale that contains 18
items rated on a 7-level ordinal scale, with a
score of 1 requiring total assistance and 7 with
full independence.50 The items include self-care,
sphincter control, mobility, locomotion, commu-
nication, and social cognition. It is a reliable and
valid tool measuring functional outcomes in reha-
bilitation settings.50
For the assessment of fall risk, the Berg Balance Test51
and the Tinetti Assessment of Balance and Gait52 are com-
monly used.
9. The Berg Balance Scale is an observer-rated
performance-based instrument that reviews 14
tasks related to changes in position from sitting
to standing, transferring, reaching out with out-
stretched arm, turning, and standing on 1 foot.
Scores of more than 41 indicate high functional-
ity and independence.51
10. The Tinetti Assessment of Balance and Gait is
an observer-rated performance-based instrument
that contains 9 items for balance and 7 items for
gait. The items for balance include sitting bal-
ance, rising, attempts to rise, immediate standing
balance within 5 seconds, standing balance, be-
ing nudged, eyes closed, turning 360◦ , and sitting
down. The items for gait include initiation of gait,
step length and height, step symmetry, step conti-
nuity, path walked, trunk, and walking stance.52
11. The Timed Up and Go test is a performance-based
instrument originally developed for older adults.
The patient is asked to stand without using prox-
imal muscles if possible from a sitting position
and asked to walk 3 m forward and come back
to a sitting position. The average normal time to
complete the task is about 10 seconds. If the time
is more than 20 seconds, then the patient has a
higher risk of falling.53
12. The Six-Minute Walk Test is a self-paced measure
of endurance in which the patient is scored on his
or her ability to walk in 6 minutes. It is a useful
measure of functional capacity and is widely used
for measuring response in cardiac and pulmonary
rehabilitation.54
Rehabilitation Oncology
Copyright © 2020 Academy of Oncologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
ROLE OF PHYSICAL THERAPY
Physical therapists are integral members of the re-
habilitation and palliative care teams.55 More specific in-
terventions used by physical therapists include the use of
physical modalities for pain control, provision of assistive
equipment, environmental modification, education on en-
ergy conservation, and exercise.56 Examples of physical
modalities used to manage pain include massage, heat,
cold, ultrasound, transcutaneous electrical nerve stimu-
lation, diathermy, manual lymphatic drainage, and soft-
tissue mobilization.57 Physical therapists use assistive de-
vices that are prescribed for ambulation, mobility, balance,
pain, fatigue, weakness, joint instability, excessive skele-
tal loading, and elimination of weight-bearing on affected
extremities. Orthotics can be helpful in enhancing joint
stability and safety for patients with motor deficits. Pallia-
tive orthotic prescription is by and large often expensive,
poorly tolerated by patients, and inconsistently covered by
third-party payers. It is important therefore to determine
whether it will enhance comfort. Environmental modifica-
tion is a significant intervention by physical therapy. Some
examples include placing a recliner on a platform to assist
in transfer, having a high stool in the kitchen to reach a
cupboard, and adjusting the height and arms of the chair
to assist in transfer. Moreover, patient education is a key
component of care. Patients are taught and trained in en-
ergy management and conservation such as monitoring of
fatigue levels and guidance on rest periods. Physical ther-
apists can also play an active role in caregiver education
and support, including instructions on the use of equip-
ment, good body mechanics, and utilization of strategies
to prevent falls and maintain balance. Physical therapists
are known to use therapeutic exercises in the maintenance
of muscle strength, joint flexibility, range of motion, and
balance. The positive effects of exercise in patients with
advanced cancer include enhancements in the physio-
logical and psychological functional parameters such as
functional capacity, body composition, mood, self-esteem,
quality of life, and distressing symptoms such as fatigue,
nausea, pain, muscle spasm, and edema.58 Recondition-
ing programs for patients with advanced cancer include
graded aerobic and stretching exercises to increase car-
diopulmonary capacity and endurance.59 In addition, pul-
monary rehabilitation programs for advanced lung cancer
include interventions such as inspiratory muscle retrain-
ing, noninvasive mechanical ventilation, education on oxy-
gen consumption, breathing techniques, postural drainage,
management of secretions, and relaxation techniques.60
Physical therapists can use interventions normally applied
with conventional rehabilitation albeit with more flexibil-
ity and creativity in matching treatment interventions with
overall goals of care and day-to-day changes in physical and
cognitive functions.
ROLE OF OCCUPATIONAL THERAPY
The National Council for Hospice and Specialist
Palliative Care Services recognized the importance of
Rehabilitation in Hospice and Palliative Care 17
 occupational therapy in the rehabilitation of patients with
cancer and palliative care patients.61 Occupational thera-
pists conduct baseline assessments and provide treatment
programs in several functional areas such as ADL, work
tasks, self-esteem, employment, role-related tasks (eg,
parenting, recreation), use of adaptive equipment (eg,
reachers, rocker knives, one-handed cutting boards), cop-
ing skills, and discharge planning. More specific palliative
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interventions include home assessments for safety, equip-
ment prescription, coaching in personal and domestic
tasks, educational strategies for symptom control (eg,
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lymphedema and skin care), relaxation techniques, stress
management, facilitation of social and leisure activities,
and provision of support for caregivers.57,62 The study
by Lee et al63 looked at the effectiveness of occupational
therapy in promoting feeding independence through fine
motor therapies among patients with end-stage cancer.
Notable improvement in feeding independence was
observed from baseline to week 1. This was sustainable
up to 3 weeks. This improvement increased quality of life,
promoted ADL function, and reduced overall functional
debility.63 When receiving inpatient and home-based
palliative care, occupational therapists assess the patients’
physical and cognitive abilities to participate in therapy
sessions on a regular basis. For patients enrolled in
hospice, the emphasis of training will be on both patients’
abilities to carry out functional tasks related to their goals
and the training of caregivers who will continue further
rehabilitation of the patients at home once the formal
hospice rehabilitation visits are completed.
ROLE OF SPEECH-LANGUAGE PATHOLOGY
In general, there are 4 roles practiced by the speech-
language pathologists (SLPs) at the end of life.64 First, they
provide consultations to patients, families, and the hospice
team in the areas of communication, cognition, and swal-
lowing functions. Second, they develop strategies in the
areas of communication skills to support patients’ role in
decision making, maintenance of social closeness, and as-
sistance with patients approaching end of life in terms
of their fulfillment of functional goals.65,66 Third, they
assist in optimizing function related to dysphagia symp-
toms, thereby improving patient comfort and satisfaction
and promoting positive feeding interactions with family
members. Fourth, they communicate with the hospice and
palliative care teams in the provision and acknowledgment
of feedback related to overall patient care. Speech-language
therapy also addresses functional tasks involving the oral-
pharyngeal-laryngeal function and the cognitive compo-
nents in the communication process.67
In 2001, Frost67 highlighted that the activities super-
vised by SLPs overlap with those facilitated by occupa-
tional therapists insofar as eating or feeding being an ADL
task. The clear distinction is that occupational therapists
specifically addressed the ability to get the food into the
mouth whereas SLPs addressed what occurs between the
lips and the stomach. Examples of maneuvers used by SLPs
18 Montagnini et al
Copyright © 2020 Academy of Oncologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
include lip closure, tongue use, pocketing, effective mas-
tication, epiglottal use, esophageal tone, and contraction.
For patients experiencing dysphagia, simple remedies in-
clude modifying position, cuing, bolus modifications of
food consistencies and bite sizes, and swallowing maneu-
vers such as dipping chin, additional dry swallows, and
many more.
ROLE OF MASSAGE THERAPY
In patients with advanced cancer, moderate pressure
effleurage (a form of Swedish massage) is used often and
can be combined with myofascial release, neuromuscular
therapy, friction, and/or compression to treat specific prob-
lem areas such as shoulder pain.68 Techniques may need to
be modified, pressure-reduced, or avoided when patients
have metastases, low platelet counts, skin breakdown, deep
vein thrombosis, severe cachexia, and the presence of med-
ical devices.69 Massage performed by licensed and trained
massage therapists or physical therapists is safe and rarely
leads to adverse events.70,71 Two-thirds of patients with
advanced, metastatic, or terminal diseases have pain and
other associated symptoms such as fatigue, insomnia, and
shortness of breath.72,73 Studies support the role of mas-
sage therapy in decreasing anxiety and improving mood in
patients with advanced cancer and those receiving pallia-
tive care.74,75 In this instance, massage can induce a state of
relaxation and peacefulness that can improve overall well-
being and promote better sleep.69,71,75,76 Furthermore, soft
or gentle massage can help a patient find inner peace, dig-
nity, and a sense of hope, thereby supporting the emotional
and spiritual dimensions as well.77 Massage can also pro-
vide a temporary respite from suffering, especially if the
person is socially isolated or confined to the bed. Although
research studies on massage as an adjuvant for cancer pain
have been limited by small sample size and study design,
2 recent meta-analyses have concluded that massage has a
beneficial effect on the relief of cancer pain, including pain
experienced by patients with metastatic bone disease.78-80
It is important to underscore that studies examining the
effect of massage on pain control among patients with can-
cer have not distinguished the different types of pain or
specific sources of pain and have used protocols that do
not focus on specific pain areas. According to the 2016
data of the Centers for Disease Control and Prevention,
about 20% of Americans have chronic pain that increases
in prevalence with advancing age.81 As a result, patients
with cancer may experience other sources of pain besides
their primary cancer diagnosis such as concurrent arthritis
or rotator cuff injuries. Furthermore, myofascial pain is
underrecognized in these patients and may be overlooked
by providers, particularly when there are multiple sources
of pain.82,83 Kalichman et al84 estimate that the prevalence
of myofascial pain syndrome (MPS) varies between 11%
and 45% among these patients depending on cancer type.
It is important for practitioners and patients with cancer
to be informed that treating MPS can reduce pain levels
and improve quality of life and function.84 Massage for
Rehabilitation Oncology
 MPS reduces muscle tension, lengthens muscles, releases
myofascial trigger points, and increases range of motion.85
Overall, massage therapy is a safe, effective, and ac-
ceptable modality to treat pain and associated symptoms
of patients experiencing life-limiting illnesses. It can be a
valuable addition to a palliative rehabilitation plan as its
effect goes beyond the physical nature of the symptoms.
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SUMMARY
There is significant debility experienced by patients
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with advanced cancer and those receiving hospice and pal-
liative care. Disability results from multiple factors such
as deconditioning, muscle fatigue, sarcopenia from di-
rect tumor effects, malnutrition, depression, complications
from therapies, bowel and bladder dysfunction, poorly
controlled pain, thromboembolic disease, neurologic dys-
function, musculoskeletal deficits, and active coexisting
illnesses, among others. This leads to mood disorders,
caregiver burden, heightened health resource utilization,
increased rates of institutionalization, and overall poorer
quality of life. Maintaining the highest level of functional
abilities (eg, mobility) through rehabilitation therapies is
one of the most fulfilling goals for this patient popula-
tion. There is a growing body of literature supporting the
role of rehabilitation in this population. The interventions
are matched with patients’ overall functional goals and
dynamic physical and cognitive changes as a result of dis-
ease progression, treatment complications, and distressing
symptoms. Rehabilitation strategies can reduce the bur-
den of care for families and caregivers, improve patient’s
overall quality of life and satisfaction of care, and reduce
symptoms such as pain and anxiety. With the collaborative
nature of the rehabilitation specialists, a multidimensional
and holistic approach to care is thereby carried out.
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