Background: This article was chosen as follow up reading to the Oxford Textbook of Palliative Medicine chapter on Rehabilitation Medicine¹ and its role in palliative care practice. This author hoped to follow up on the most current research data related to effectiveness of rehabilitation modalities in patients on home hospice.

Design and Participants: This was a one group pre-test post-test study undertaken between March to June 2019 in southern Poland. The study involved 60 home-based hospice patients with a mean age of 66.3 years (range 55 to 89), 53.3% were male, and 60% had some type of cancer vs. chronic disease. A special multi-component individualized program based on the physiotherapy focused biopsychosocial model of the WHO International Classification of Functioning, Disability and Health (ICF) was designed for each participant, utilizing validated assessment scales to track progress including the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales, the World Health Organization Quality of Life - Bref (WHOQOLBREF), the Visual Analogue Scale (VAS) pain scale, the Tinetti POMA Scale, and the Geriatric Depression Scale (GDS). A “quasi-blind test was used, in which one physiotherapist performed the pre- and post-tests while another specialist carried out the physiotherapy program” 2 times per week for 6 weeks. The exclusion criteria were: age < 55, cognitive state ≤6 points on the AMTS scale or unconsciousness, terminal stage (close to death), and lack of informed consent of the subjects to participate in the program.

Results: After the completion of the intervention, statistically significant improvements were found in several scores including ADL (mean 2.9 increased to 4.0), IADL (mean 11.9 increased to 13.9), WHOQOL-BREF (mean 46.4 increased to 52.6), VAS pain scale (mean decreased 5.8 to 5.1 with the same standard deviation), risk of falling (the number of patients at high risk of falling decreased from 86.7 to 65.0%.), and GDS scores (mean 16.7 improved to 15.7, number of people with deep depression decreased from 23.3 to 18.3%.). The most common ADL problem identified pre-test was showering/bathing (73.3% were dependent on assistance), decreasing to 53.3% being dependent which was, again, statistically significant (p<0.002) After the completion of the study, statistically significant improvements were noted on the ADL scale (mean 4.0 increased from a mean of 2.9), IADL (mean increased from 11.9 to 13.9), WHOQOL-BREF (mean 52.6 increased from a low of 46.4), VAS pain scale (mean 5.1, down from 5.9 with same standard deviation), risk of falling (the number of patients at high risk of falling decreased from 86.7 to 65.0%.), and GDS scores (mean 15.7, down from 16.7, with number of people with deep depression decreasing from 23.3 to 18.3%). Showering was the most common dependency noted on the pre-test evaluation among all participants (73.3%), decreasing to 53.3% after the intervention, yet remaining the most common problem affecting the ability to stay independent with ADLs. The ability to assist with transfers, which is an important issue often related to caregiving burden, improved with dependence on transfers decreasing by half. It was interesting to note that the pain scales only came down a small amount and remained within the moderate category, yet with a significant improvement in quality-of-life measure. A key measure of quality of life using the WHOQOL-BREF is scored on a range of 0-100, with a statistically significant improvement to overall 52.6, and a special focus on the psychological domain which was very low (29.3) and improved to a mean of 37.7.

Commentary: There were a few areas which are worth pointing out despite the overall positive outcomes. It is important to note, for example, that in this cohort most of the respondents lived with family (95%), which may have affected the degree of support and ability to follow up with rehabilitation activities.In addition, one of the important aspects of this study was that the physiotherapy program was based on the WHO’s biopsychosocial model which required that the patient actively participate in making decisions about goals of rehabilitation. This means that it would be important to properly select a population that would benefit from these rehabilitation activities, providing an answer to whether patients with some degree of cognitive impairment related either to disease process or treatment can still actively participate, which this study wasn’t set up to do. On the other hand, the study aimed to minimize the diversity of tools that are used in the handful of other small studies on this topic, by using the WHO ICF framework to design the individualized programs, which allowed “normalized, standard language and a comprehensive framework for describing health and health-related conditions.” This meant that the qualifiers used were more consistently able to define what improvement looked like in objective terms, which would allow studies that follow to use consistent language of what constitutes improvement.

Bottom Line: This study was well designed and aimed to introduce a more qualitative approach into an inadequately studied area. Despite a population that probably does not equate to that found in countries like the US (Poland remains fairly homogenous in ethnic background and language), the fact that a well-designed physiotherapy program did have significant benefits on several validated scales including overall quality of life is an important outcome. It certainly informs this author’s continued practice to allow physiotherapy referrals for incoming hospice patients for whom rehabilitative activities are an important part of maintaining quality of life for as long as possible.

References: 1. Cole, AM. Medical Rehabilitation and the Palliative Care Patient. In Cherny, N, Fallon MT, Kaasa, S, Portenoy RK, Currow DC, eds. Oxford Textbook of Palliative Medicine, 5 edn. Oxford University Press, 2105: 259-268. Accessed Jan 22, 2023 at https://doi.org/10.1093/med/9780199656097.001.0001

Source: Ćwirlej-Sozańska A, Wójcicka A, Kluska E, Stachoń A, Żmuda A. Assessment of the effects of a multi-component, individualized physiotherapy program in patients receiving hospice services in the home. BMC Palliat Care. 2020;19(1):101. Published 2020 Jul 9. doi:10.1186/s12904-020-00600-6