10d Physiotherapy

In palliative care, the role of the physiotherapist is to reduce the degree to which disabilities, caused by the disease or the treatment, interfere with everyday life. This is particularly pertinent for those patients whose disease trajectory may be short and are deteriorating rapidly.

Physiotherapists are important members of the multidisciplinary palliative care team. They may be involved in all healthcare settings in the treatment of patients with any progressive deteriorating condition, which most commonly includes cancer, chronic end-stage respiratory, neurological and cardiac disease.

As part of the rehabilitation team, the specialist physiotherapist is in a good position to identify the needs and coordinate the responses of colleagues working in a wide variety of complementary fields.

The physiotherapist, with a knowledge of the underlying pathological condition, adopts a problem-solving approach in which goals of treatment are planned jointly with the patient. This gives the patient, who may feel helpless because of a loss of independence, a measure of control. These goals must be realistic and achievable for the phase of the disease and must be continually reassessed. Goals may be simple (to be able to sit comfortably in bed) or more complex (to attend and enjoy a wedding). This is known as ‘active readaptation’.

A physiotherapist has a detailed knowledge of functional anatomy and ergonomics, and is able to analyse movement and posture in its relationship to the environment. For instance, weakness and immobility may lead to poor posture, which places a strain on muscles and ligaments and can cause pain, particularly around joints. These stresses may be relieved by strategic physical positioning.

The physiotherapist may be the first professional to be alerted to the signs and symptoms of spinal cord compression due to malignant disease. Alongside immediate medical treatment, the initial aim will be an attempt to minimize loss of function. Should a more complete picture of motor, sensory and autonomic impairment develop, the physiotherapist will be instrumental in helping the patient cope with adapting to a drastic reduction in functional ability by helping the patient to develop a strategy for the future. This may involve balance training, development of upper body strength, instruction in transfers and the use of a wheelchair. Relatives and other carers will also require instruction in passive movements, the positioning of paralysed limbs, the use of wheelchairs and in moving and handling techniques.

As diseases progress, mobility becomes more challenging. Initially, a stick or crutches may be necessary to support independence, but later the provision of a walking frame or working towards independent mobility in a wheelchair may be more appropriate. Facilitating independence of transfers by strategically positioned furniture or the use of a sliding board may allow patients to remain independent within a smaller environment.

Bone pain and neuropathic pain due to cancer are notoriously difficult to manage. Relief may be obtained by the use of transcutaneous electrical nerve stimulation (TENS). Local applications of heat, in the form of heat pads or wheat bags, are also used for pain relief. Progressive disease often leads to immobility and pain may be experienced due to stiffness of joints and poor posture.

Massage and exercise therapy are the core skills of all physiotherapists. Maintenance of joint range by the use of active or passive exercises along with therapeutic massage will be beneficial. Therapeutic massage using stroking and gentle kneading may be used to reduce muscle spasm, to relieve pain and aid relaxation.

Maintenance of joint range is also important in the management of neurodegenerative diseases, and passive movements and active assisted exercises need to be implemented and taught to relatives and other carers.

Physiotherapists also provide and fit neck collars, splints and various other supports for weakened muscles. These will help to correct posture or reduce deformities and facilitate improved function.

Breathlessness is very frightening and distressing for patients and carers, making them feel out of control. All physiotherapists are trained in giving respiratory care and can teach patients and their carers techniques to reduce the work of breathing, to encourage relaxation, to aid in the expectoration of secretions and to advise on coping strategies in order to improve breathing control. The physiotherapist is a key member of the multidisciplinary team involved in running breathlessness groups.

Some physiotherapists are trained in various complementary therapies that can be used to help the control of breathlessness, e.g. acupuncture, reflexology and aromatherapy.

Physiotherapists often help in the management of patients, using non-invasive ventilation for respiratory failure e.g. secondary to neuromuscular disability such as in Motor Neurone Disease.

( see Chapter 6F Skin problems in palliative care)

Chronic oedema may develop in an arm following treatment for breast cancer or as a manifestation of recurrent axillary lymph node disease, or in the legs secondary to impedance of lymphatic drainage from disease in the pelvis. A swollen limb is heavy and affects posture and mobility, placing stresses on weakened muscles and joints.

Lymphoedema management includes using exercise as well as correct positioning, compression hosiery, multilayer lymphoedema bandaging, manual lymph drainage techniques and skin care.

In palliative care, oedema of mixed aetiology is common, resulting in immobile, dependent limbs and oedema of the trunk. The physiotherapist may need to be adaptive in the management of these patients.

The physiotherapist often works on a one-to-one basis with patients. Patients may discuss their hopes and fears with a sensitive listener. They feel safe to ask searching questions in these situations and, therefore, the physiotherapist needs to be adequately prepared and informed to deal with these issues and to communicate relevant issues to the team, within the bounds of confidentiality.