Abstract
Yet, 65% of inpatient and outpatient patients with cancer show indications for physical therapy and rehabilitation (pain, lymphedema, incontinence, respiratory problems, musculoskeletal problems, mobility problems), although only 12.8% receive physical therapy. 3 Also, in our study, a physical therapy consultation was only requested for 2.3% of the patients. 4 However, most patients would like to and can participate in the physical activity intervention treatment. 5 For this reason, interdisciplinary coordination and team work is very important for patients with cancer. Most of the rehabilitation team members do not have experience with management of the dying patient whereas most members of palliative care staff are not experienced in rehabilitation approaches. In palliative care, planning effective educational programs about physical therapy, rehabilitation, and exercise can help achieve the desired multidisciplinary team.
Effects of Exercise in Palliative Care for Patients with Cancer
The evidence of beneficial effects of exercise during rehabilitation of cancer patients and during palliative care has been increasing. 6 In patients who are incurable and have short life expectancy, approaches related to the prevention and improvement of physical function are rarely found in palliative care literature. 6 Nevertheless, it is known that physical function is the most important determinant of survival and QOL.1,5,6 Patients with cancer who participated in exercise programs experienced an increase in their cardiovascular capacity and QOL; their fatigue and sleep problems decreased, body composition and immune functions improved; a general sense of wellness and respect developed, along with an increase of energy.1,6,7 Indeed, findings showed that even patients who are bed-bound or in late stages of disease benefited from exercise.2,6–8 Although QOL decreases in advanced cancer, the decline is less when the patient is receiving exercise intervention. 9 Segal et al. 10 showed that resistance training increases muscle fitness and reduces fatigue in both curative and palliative patients with prostate cancer. However, it would not be appropriate to generalize these results for those with short life expectancy, since patients expect at least 2–3 years of survival. In their study, Oldervoll et al. 6 have obtained positive results in physical performance, fatigue, and emotional functions using an exercise program with patients with short life expectancy, such as 3–12 months. Exercise studies on incurable patients indicate only small patient groups and programs that are not well defined. Therefore, it is hard to determine which patient group benefits from exercise, which type of exercise and which stage of palliative care is more appropriate for the patient. Types of exercise that are preferred by patients are walking and home-based programs. 5 Generally, aerobic exercises are discussed whereas studies on resistance training are fewer.2,7
Guides about exercise type, frequency, intensity, time and programs prepared for different stages of the disease are still missing.6,11 Lack of guidelines regarding exercise complicate clinical practice and create questions about the trust of other disciplines in the treatment programs.
Patient Compliance
Most patients prefer starting exercises immediate after finishing their treatment, instead of during the treatment period. 7 Additionally, many patients wonder how long and what kind of exercise is appropriate and answers from doctors remain vague and inadequate. Reasons for leaving exercise programs are defined as follows; lack of interest, nature of exercise, medical complications, exercise duration, setting, program length, and disease status. This is especially true for patients continuing treatment and for patients with advanced stages of cancer. 12 For these reasons, the preparation of modified and custom tailored programs would be more appropriate.
Exercise Effect on Fatigue in Palliative Care Patients
Fatigue stands out as the most frequent symptom in palliative care patients (80%–90%). Fatigue was found to be associated with anxiety–depression, pain, dyspnea, insomnia, anorexia, nausea, and drowsiness. Specifically, fatigue reduces daily life activities and effects QOL. Although it is an important symptom, doctors do not necessarily talk about fatigue with their patients and do not know effective treatment for it. 13 It is indicated that exercise can be effective on fatigue.6,13 Yet, oncologists are having a difficult time promoting exercise to their patients. Even in patients with short life expectancy, exercise was found to be effective on fatigue. However, in this group of patients, exercise should be modified based on reduced performance. For instance, for a bed-bound patient, sitting up in bed, performing simple movements in bed, and standing up, could provide enough training. In terminal patients, it is important to keep a good balance between the effect of fatigue and effect of treatment. This approach should not inflict further stress on the patient.
Conclusion
In the palliative care approach for patients with cancer, physical therapy and rehabilitation practices can have a positive impact on symptoms, functional capacity, and QOL. Including physiatrists in the overall plan for palliative care is likely to increase the success of general treatment in addition to patient–family satisfaction.