Oncology and Palliative Care: Difference between revisions

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Defined as increased sensitivity of a higher order neuron within the central nervous system, that causes constant pain in the absence of a peripheral nociceptive stimulus.<ref name="Kumar 2011" /><br>  
Defined as increased sensitivity of a higher order neuron within the central nervous system, that causes constant pain in the absence of a peripheral nociceptive stimulus.<ref name="Kumar 2011" /><br>  


==== ''Interventions to Employ''  ====
==== ''Interventions to Employ<ref name="K&S2011" />''  ====


*Patient Education  
*Patient Education  

Revision as of 22:14, 26 March 2014

Definition[edit | edit source]

End-of-life care, also known as Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of the patients and their families who face the problems which are associated with life-threatening illnesses, through the prevention and relief of suffering by means of early identification, impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”[1] Palliative care is all about relieving suffering and achieving the best possible quality of life for the patients as well as their caregivers.[2] All of this can be explained by one goal of helping the patients to die with dignity.[3]

Role of Physical Therapist[edit | edit source]

As defined by the World Confederation for Physical Therapy; “Provide services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the life-span... Physical Therapists are concerned with identifying and maximising quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation.”[4] Therapists play an essential role in the interdisciplinary approach to palliative care by providing increased quality of life, function, and overall experience through physical and functional dimensions of care.[5] Essentially, a physical therapist aims to maintain optimal function, prevent atrophy and soft tissue deformities, influence pain control, foster independence and educate each patient with the resources they need to make all other goals attainable.[6]

In the literature, many authors write that a physical therapist's role in palliative oncological care is as follows: gait training, therapeutic exercise, neuromuscular re-education, modalities, manual therapy and patient education.[6][7][8][9]

Interventions[edit | edit source]

Physical therapy in palliative care is often directed toward controlling symptoms and compensating for lost function.[10] Pain, symptoms arising from skeletal metastases, impaired muscle strength and endurance, neurological symptoms, pulmonary secretions, dyspnoea, lymphedema, and venous thrombosis are common symptoms that are treated by physical therapists.[11]

Physical therapists should seek to maintain strength, make environmental modifications, furnish necessary assistive equipment, teach energy management techniques, provide family education; achieve safety, independence, meaning, and quality of life, despite the physical and mental decline which is expected.[12]

Palliative Care Models[13][edit | edit source]

The patient and family is at the center of care, and addressing their desires is reflected in palliative physical therapy models.These models consider the extreme variations of the end-of-life course which may include periods of improvement, stabilization, and decline; also included within the models is the limited reimbursement structure of managed care. These models include

Rehab light
When symptoms have been managed and the person is feeling trail though somewhat better, they may express a desire to regain strength and mobility, even with the awareness that their condition is life limiting. A gentle rehabilitation program with weekly or biweekly visits can be applied, with instruction in limited but effectively targeted home exercise program and measured sitting or walking for endurance.
Case Management
Often proceeds with a monthly, bimonthly, or “as needed” visit schedule to re-evaluate physical and functional status changes as a result of knowing that care needs will arise because of the progressive nature of the illness. It monitors conditions, to anticipate changes in care needs, and to provide ongoing training for often elderly family caregivers.
Rehabilitation in reverse
As impairments of strength and motor control change, it may threaten the patients ability to remain safely at home in the care of those they love. At various thresholds of decline, more support or assistance will be required to successfully navigate the environment and may require the use of a properly fitted cane, walker, or other assistive device. Physical assistance by caregivers is also likely to be required at some point as well, whether with ambulation, transfers or even moving in bed. Skilled physical therapy intervention and training can be provided throughout the course of decline, as it reflects the broad knowledge and teaching provided by therapists in more traditional settings, but in reverse order. This care can meet the patient’s desire to maintain maximal independence and mobility, and the family’s desire to successfully care for their loved one at home.
Sklled maintenance
In some complex situations with issues such as balance, tone, and coordination, it may not be possible to train a caregiver to manage this activity safely and may require skilled physical therapy intervention.
Supportive Care
Steps are taken to enhance patient comfort and improve quality of life and are essential to effective end-of-life care. Demonstration and teaching of appropriate techniques by the therapist to caregivers such as:
Massage-provides temporary relief, long term management of edema, somato-sensory stimulus, and reduces muscle tension.
Active, assistive, or passive range of motion-eases discomfort of inactivity and prevents contractures.
Guided imagery-provides a common pleasant experience when combined with range of motion activities
Vestibular stimulation-a gentle rocking motion and provide comfort.
Conversation-provides sharing of information, meaning, and understanding which can support the end-of-life process.

Patient Experience[14][edit | edit source]

A study by Dahlin & Heiwe that interviewed patients who participated in physical therapy within palliative cancer care, found that they experienced the feeling of motivation and encouragement, relief and well-being, hope for a time-limited improvement in a specific area, independence, and security. Patients also expressed that their own knowledge was insufficient of what physical therapy could do for them and it was hard for them to know what they could ask for during their sessions. In some cases physical therapy has not been offered to them at all, or patients felt they did not have enough treatment.

Physical Therapy Pain Management (current best evidence)[edit | edit source]

Cancer pain can be classified as one of the three types; symptom-based, syndrome-based, or mechanism-based.[15] According to the literature, classification based upon mechanism not only addresses the underlying pathology but also provides us with an understanding behind patient’s symptoms and treatment responses.[16] The evolution of cancer pain classification has been the direct result of the need to adequately address the underlying source of the patient’s cancer pain. This void in the literature shifted the attention and focus to mechanism-based classification and the non-pharmacological approach to symptom control.[15] Studies conducted by different authors found that using qualitative methodology of expect physical therapists who used this form of pain classification during the evaluation of patients pain were more likely to improve the quality of life and decrease the amount of pain experienced after treatment.[15][16][17][18][19] The five categorized mechanisms and their descriptions are defined below in addition to the recommended intervention strategies to be imployed by a physical therapist.

Central sensitization, neurogenic and nociceptive mechanism
[edit | edit source]

Defined as increased sensitivity of a higher order neuron within the central nervous system, that causes constant pain in the absence of a peripheral nociceptive stimulus.[15]

Interventions to Employ[20][edit | edit source]

  • Patient Education
    • Transcutaneous electrical stimulation (low-frequency)
    • Neuromuscular electrical stimulation
  • Relaxation
    • Deep Cutaneous Pressure
    • Biofeedback
  • Guided, Mental, Motor Imagery
  • Mirror Therapy
  • Virtual Reality
  • Manual Therapy

Peripheral sensitization and neurogenic mechanism[edit | edit source]

Defined as neuropathies to the brachial plexus and cranium, as well as chemotherapy-induced, post-herpetic and surgical neuropathy in addition to post-radiation plexopathies.[15]

Interventions to Employ[edit | edit source]

Peripheral nociceptive mechanism[edit | edit source]

Defined as pain secondary to non-use, deconditioning and/or improper posture and movements resulting from symptoms of cancer pain.[15]

Interventions to Employ[edit | edit source]

Sympathetically maintained and dependent pain mechanism[edit | edit source]

Defined as the over activation or under activation of the sympathetic nervous system. This has further been broken down into identifying whether it is sympathetic dependent or sympathetic maintained pain.[15]

Interventions to Employ[edit | edit source]

Cognitive-affective mechanism[edit | edit source]

Defined as cancer-related or treatment-related pain that can be characterized as anxiety, depression or guilt. Patients might become preoccupied by pain and have low self-confidence while becoming highly stressed with social/environmental factors.[15]

Interventions to Employ[edit | edit source]

Case Reports/ Case Studies[edit | edit source]

Mechanism based Classification and Physical Therapy Management of Persons with Cancer Pain A Prospective Case Series

Resources[edit | edit source]

How physical therapy can help patients who need palliative care


World Confederation for Physical Therapy


Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ WHO Definition of Palliative Care. Geneva: World Health Organization; c2003. Available from: http://www.who.int/cancer/palliative/definition/en/
  2. ↑ Chochinov HM. Dignity-conserving care - a new model for palliative care: helping the patient feel valued. JAMA 2002; 287(17); 2253-60.
  3. ↑ Machkey KM, Sparling JW. Experiences of older women with cancer receiving hospice care: significance for physical therapy. PhysTher 2000; 80(5);459-68.
  4. ↑ World Confederation for Physical Therapy. Policy Statement: Description of Physical Therapy What is Physical Therapy? London, UK. Available from http://www.wcpt.org/policy/ps-descriptionPT [last accessed on 2014 March 25]
  5. ↑ Eagan KA, Abbott P. Interdisciplinary team training- preparing new employees for the specialty of hospice and palliative care. J Hosp Palliat Nurse. 2002; 4:161-171.
  6. ↑ 6.0 6.1 Kumar SP, Jim A. Physical Therapy in Palliative Care: From Symptom Control to Quality of Life: A Critical Review. Indian J Palliative Care. 2010; 16(3): 138-146.
  7. ↑ Flomenhoft D. Understanding and helping people who have cancer: A special communication. Phys Ther. 1984; 64:1232-1234.
  8. ↑ Rashleigh LS. Physiotherapy in palliative oncology. Aust J Physiother. 1996; 42:307-312.
  9. ↑ Santiago-Palma J, Payne R. Palliative care and rehabilitiation. Cancer. 2001; 92:1049-1052.
  10. ↑ Carter H, MacLeod R, Brander P, McPherson K. Living with a terminal illness; patients’ priorities. J Adv Nurs 2004; 45(6): 611-620.
  11. ↑ Donnelly S, Walsh D. The symptoms of advanced cancer. Semin Oncol 1995; 22(2 suppl 3): 67-72
  12. ↑ Pizzi MA, Briggs R. Occupational and physical therapy in hospice: the facilitation of meaning, quality of life, and well-being. Topics in Geriatric Rehabilitation 2004; 20(2): 120-130.
  13. ↑ Briggs R. Clinical decision making for physical therapists in patient-centered end-of-life care. Topics in Geriatric Rehabilitation 2011; 27(1): 10-17.
  14. ↑ Dahlin Y, Heiwe S. Patients’ experiences of physical therapy within palliative cancer care. Journal of Palliative Care 2009; 25(1): 12-20.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 Kumar SP. Cancer Pain: A Critical Review of Mechanism-based Classification and Physical Therapy Management in Palliative Care. Indian J Palliat Care. 2011; 17(2): 116-126.
  16. ↑ 16.0 16.1 Kumar SP, Saha S. Mechanism-based Classification of Pain for Physical Therapy in Palliative Care: A Clinical Commentary. Indian J Palliat Care. 2011; 17(1): 80-86.
  17. ↑ Smart K, Doody C. Mechanism-based clinical reasoning of pain by experienced musculoskeletal physiotherapists. Physiotherapy. 2006; 92: 171-178.
  18. ↑ Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Man Ther. 2007; 12:40-49.
  19. ↑ Levin M. Changing the face of pain management- mechanism-based treatment most likely to succeed. Postgrad Med. 2004; 116:45-48.
  20. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named K&S2011
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