Top Ten Tips Palliative Care Clinicians Should Know About Physical Medicine and Rehabilitation

Abstract

Physical medicine and rehabilitation (PM&R) is a specialty of medicine focused on optimizing function and quality of life for individuals with physical impairments, injuries, or disabling illnesses. Given the sometimes acute nature of the loss of function and even loss of independence, there are significant palliative care (PC) needs within patients seen by PM&R. This article, written by a team of PM&R and PC specialists, aims to help the PC team better understand the world of postacute care, expand their toolkit for treating musculoskeletal and neurological symptoms, improve prognostication for patients with brain and spinal cord injuries, and decide when patients may benefit from PM&R consultation and support. There is significant overlap between the populations treated by PM&R and PC. Better integration between these specialties will help patients to maintain independence as well as advance excellent patient-centered care.

Introduction

Physical Medicine and Rehabilitation (PM&R), also known as physiatry or rehabilitation medicine, was first recognized by the American Board of Medical Specialties in 1947. As defined by the American Academy of PM&R, the specialty aims to enhance and restore functional ability and quality of life for those with physical impairments or disabilities affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. Postgraduate training involves completion of four years of residency with the first year being a preliminary medicine, preliminary surgery, or transitional year, followed by three years of core PM&R rotations.

PM&R clinicians, also commonly known as physiatrists, may choose to pursue subspecialization in the following domains: spinal cord injury (SCI) medicine, brain injury medicine, sports medicine, neuromuscular medicine, pain medicine, hospice and palliative medicine, cancer rehabilitation, and pediatric rehabilitation medicine. PM&R physicians practice in a variety of settings, but the common themes of optimizing function and quality of life through patient-centered treatment plans are widespread.

Many patients with serious illnesses who are treated by palliative care (PC) clinicians have functional deficits that greatly impact their quality of life. In addition to wanting to be comfortable, patients also prioritize maintaining their independence.¹ Given the expertise that PM&R doctors have regarding restoring and optimizing function, great potential for collaboration between the specialties of PM&R and PC exists.

This article aims to familiarize PC clinicians with the specialty of PM&R, different levels of postacute care (PAC), and treatment strategies for common diagnoses found in patient populations who have both rehabilitative and palliative needs.

Tip 1: Physical, Psychosocial, and Spiritual PC Needs Are Common in Patients in Acute and Subacute Rehabilitation Facilities, and Opportunities Exist for Collaboration Between PC and PM&R

Many patients in the inpatient rehabilitation setting fall into diagnostic groups associated with high symptom burden and diminished life expectancy. These groups include SCI, brain injury, stroke, amputation, burns, cardiopulmonary disease, and cancer.^2–8 Aging of the general population and increasing rates of chronic disease compound the impact of injury and illness across diagnostic groups.⁹

Beyond the traditional focus on optimizing function and independence, discussions of life expectancy and end-of-life care are increasingly important in the inpatient rehabilitation setting.

Many opportunities for PM&R/PC collaboration exist in the rehabilitation setting since this is where patients and families begin to navigate the realities of life with catastrophic illness or injury. For example, patient and family decision making would be enhanced by inclusion of both PM&R expertise in setting and achieving functional goals and PC expertise in defining goals for medical treatment and end of life.

The core PM&R skill set includes managing complications of disability; providing bedside pain interventions; and managing spasticity, bowel, and bladder. PC input, including escalation of pharmacological pain management and identification and management of active dying, would add a meaningful dimension to patient care. PC could also facilitate goal discussions and transition to hospice care when appropriate.

PM&R/PC collaboration could also enhance psychosocial and existential support for patients and families. Adding to existing PM&R experience around planning for lives changed by disability, PC could provide grief support; assistance navigating complex decision making; and support for religious needs, existential concerns, and completing life's unfinished work.

Tip 2: Each of the Different Levels of PAC, Including Long-Term Acute Care, Acute Inpatient Rehabilitation, and Subacute Rehabilitation, Have Different Admission Criteria, and There Are Distinct Differences in Terms of the Medical Diagnostic Tools and Interventions Available

Many patients with advanced chronic illness are discharged from acute care settings with PAC rehabilitation services. PAC rehabilitation is generally delivered in the home, inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or long-term acute care hospitals (LTACHs). The optimal setting depends on a patient's care requirements, need for physician oversight, prognosis, and goals.

For patients preferring to return home or those transitioning to home hospice, physical therapy (PT) and occupational therapy (OT) assessments may be helpful before hospital discharge to determine a patient's functional abilities, limitations, and durable medical equipment needs. Encouraging family members to participate in PT and OT sessions during the acute hospitalization is highly recommended to ensure that needed care can be delivered safely at home by those planning to be caregivers.

For patients appropriate for inpatient PAC rehabilitation, LTACHs, IRFs, and SNFs differ with respect to cost, service intensity, and participation expectations. LTACHs are facilities designed to offer more therapy services than acute care hospitals while maintaining a hospital level of care and are often used for ventilator weaning and treatment of complex wounds.¹⁰ IRFs, sometimes called acute rehabilitation hospitals, have admission requirements that include the need for an intensive multidisciplinary team approach and supervision by a physician.¹¹ Patients receive at least 15 hours of PT and OT per week. In contrast, SNFs require only one hour of therapy per day and patients are seen by a physician every 30 days.¹²

Given the increased cost of IRF relative to SNF care, payer approvals depend on the demonstration of rehabilitation goals that require IRF-level care and a high likelihood of home discharge. Such goals may include recovery of autonomous mobility and capacity for the performance of activities of daily living (ADL), caregiver training on durable medical equipment, and management of symptoms. Table 1 outlines the key differences between inpatient PAC rehabilitation levels of care.

Table 1.

Comparison of Inpatient Postacute Care Rehabilitation Services^10–¹²

Facility type	Average length of stay	Physician involvement	Daily routine	Diagnostic and intervention limitations
LTACH¹¹	∼27 days	Daily assessment	Continued hospital-level care. OT and/or PT and/or speech therapy up to one hour per day if indicated	Generally restricted to complex medical conditions, severe wounds/burns, and vent weaning
IRF¹⁰	∼13 days	Daily assessment	Three hours of PT/OT, five days per week, or in limited cases, ≥15 hours of PT/OT within a 7 consecutive-day period	Expensive disease-directed therapy, e.g., oral biological therapies may be financially unfeasible for IRFs; treatment needs cannot undermine PT/OT schedule
SNF¹²	∼28 days	Comprehensive initial assessment, followed by a visit every 30 days	OT and/or PT and/or speech therapy one to two hours per day	Complex high-need care, e.g., 1:1 supervision, suctioning, and tube management, may limit acceptance

IRF, inpatient (acute) rehabilitation facility; LTACH, long-term acute care hospital; OT, occupational therapy; PT, physical therapy; SNF, skilled nursing facility.

Tip 3: Patients with Serious Illnesses Frequently Suffer from Common Musculoskeletal Diagnoses, Such as Bursitis, Tendonitis, Arthritis, and Myofascial Pain, Which Can Be Treated with Specific Interventions, Not Just Palliated with Medications

Patients suffering from complex medical diagnoses are at high risk for polypharmacy and resultant complications. Utilizing nonpharmacological treatments and targeted interventions can be a safe and effective way to treat musculoskeletal diagnoses.

Bed rest and immobilization are known to result in muscle atrophy, loss of bone density, and soft tissue contractures, accelerating development of musculoskeletal disorders.¹³ Stretches and range of motion can slow atrophy and delay the development of noncontractile proteins in soft tissue,¹⁴ which can put patients at risk for contractures, wounds, and pain. Strengthening exercises are generally a key component of the treatment of soft tissue disorders, such as bursitis and tendinopathies, and many of these exercises can be done in the home or even in bed. In addition, education can be provided to the patient and caregiver to avoid prolonged pressure on affected areas by repositioning and off-loading with pillows.

Directed corticosteroid injections can be an effective treatment for bursitis and arthritis-associated pain and can be done by landmarks or ultrasound guidance. This may be especially useful in patients who cannot take anti-inflammatory medications and/or are at high surgical risk for joint replacements.¹⁵ For those where steroids are contraindicated or are ineffective, nerve blocks and radiofrequency ablation may be considered. Additional physical modalities prescribed by physiatrists, such as a transcutaneous electrical nerve stimulation unit or the use of heat and cold therapies, can be applied.¹⁶

Tip 4: Fatigue and Immobility Can Profoundly Worsen Quality of Life in Patients with Advanced Cancer, and Illness-Appropriate Exercises Can Decrease Fatigue and Minimize Complications of Immobility

Patients with advanced cancer experience a multitude of symptoms, but fatigue has been reported as the most distressing symptom.^17,18 It is extremely common, with nearly 75% of individuals receiving cancer therapy reporting fatigue.^19,20

Increased levels of fatigue worsen immobility and thus disablement. Immobility is associated with various complications, including the development of pressure sores, loss of muscle mass contributing to weakness and poor endurance, and cardiovascular deconditioning leading to hemodynamic instability.²¹ Treating fatigue has the potential to slow or reverse this proposed functional decline and help maintain independence. About 50% of patients with cancer have reported a preference for nonpharmacological interventions to manage fatigue.²² Several single-arm studies and randomized control trials have identified significant improvements in fatigue from exercise interventions with various levels of intensity.²³

For patients with advanced cancer and a high functional status (Eastern Cooperative Oncology Group 0–1), the benefits of a supervised, high-intensity exercise program in decreasing fatigue have been reported.^24,25 Patients with advanced cancer and moderate functional deficits leading to difficulty with transportation can decrease their fatigue by participating in a home exercise program that includes simple upper and lower extremity-strengthening exercises and a walking program.²⁶ Even chair exercise programs for the most debilitated patients have been found to help with fatigue.²² Importantly, a study evaluating resistance versus cardiovascular exercise programs did not show significant differences in their effects on reducing fatigue, so either type of exercise is thought to be helpful.²⁷

Tip 5: The Level of Injury and Its Complete Versus Incomplete Status Can Help Predict Functional Outcomes for Patients Experiencing a Traumatic SCI, and Effective Communication Regarding Functional Prognosis Can Help Providers Support Goal-Concordant Care for Patients

Patients sustaining traumatic SCIs frequently face dramatic changes to their daily function. Providing prognosis on functional outcomes is integral to managing expectations both in the short term (goals in the rehab setting) and long term (returning home, to the workplace, and to the community). Communication on goal planning with patients can improve their physical and psychological adjustments to their SCI.²⁸

The type and degree of SCI have important implications for prognosis. The American Spinal Injury Association (ASIA) Impairment Scale is frequently used by clinicians to determine the extent of SCI and can be used to predict the outcome.^29,30

The neurological level of injury refers to the most caudal segment of the spinal cord with both normal sensory and motor functions (bilaterally). Injuries can be further divided into complete and incomplete injuries. Those with complete injuries have no motor or sensory function in the lowest sacral segment, while those with incomplete injuries have preservation of some sensory and/or motor function below the neurological level. Greater neurological recovery is seen in those with more sacral components spared in the initial injury.³¹ Importantly, preservation of a pinprick below the zone of injury is associated with good prognosis for eventual functional ambulation.³²

The level of injury provides information on expected functional independence in mobility and activities of daily living. For example, the highest complete SCI level for living independently is one where the patient has a C6 complete injury, but that individual would be expected to require equipment for activities such as feeding, bathing, and transfers.

Tip 6: Severe Traumatic Brain Injury Is Particularly Difficult to Prognosticate in the Immediate Postinsult Period, and Functional Gains Can Continue to Occur Over Months to Years

Severe traumatic brain injuries (TBIs) can cause long-term impairments in physical, cognitive, emotional, vocational, and relational functioning. Classification of a severe TBI has generally been defined as a Glasgow Coma Scale (GCS) score of 3–8 in the first 24 hours.³³

Physician approaches regarding timing of and recommendations for withdrawing life-sustaining therapy (LST) can have a significant impact on mortality from severe TBI. Decisions to withhold or withdraw LST are largely based on prognosis for meaningful neurological recovery provided to surrogates by physicians. Even when uncertainty exists, surrogates appreciate admission of this and still wish to be given short- and long-term prognoses.³⁴

Factors associated with poor prognosis include duration of coma (time to follow commands) >1 month, length of post-traumatic amnesia (PTA) >3 months, age >65, and Abbreviated Injury Scale score of 4–6.³⁵ Severe disability is unlikely if coma is less than two weeks or PTA is less than two months.³⁴ Historically, the presence of diffuse axonal injury (DAI) on early imaging was associated with poor outcomes, but a recent study found that while useful in predicting hospital functional outcomes, DAI was not associated with long-term TBI outcomes.³⁶ Despite its use in defining TBI severity, initial GCS has not shown to be a reliable predictor of functional outcomes at three months.³⁷

Most functional and cognitive recovery occurs at the quickest rate during the first six months after severe TBI. However, follow-up timelines of five years have been published highlighting some patients with initially poor prognoses who have continued to show slow and steady improvements well beyond six months.³⁸

Tip 7: Adaptive Equipment for Grooming, Dressing, Toileting, and Mobility Can Help Maintain Independence in Patients with Functional Limitations from an Acute Injury or a Progressive Disease Such as Cancer, Heart Failure, or Neurodegenerative Disease

PM&R clinicians are experts in prescribing adaptive equipment to enhance independence and mitigate functional limitations from weakness, fatigue, poor balance, and pain.³⁹ In the PC population, these limitations frequently result from underlying injury or disease, prolonged immobility, cachexia, glucocorticoid use, neuromuscular dysfunction, cardiorespiratory impairment, and medication side effects.⁴⁰ Both prefabricated and custom-made devices are available, and PM&R clinicians individualize recommendations to meet patient needs.^41,42

Mobility aids, including canes, walkers, and wheelchairs, are prescribed when ambulation is limited by weakness, falls, poor endurance, weight-bearing restrictions, or other factors. For individuals with substantial mobility impairment and poor postural control, customized manual or power wheelchairs may be appropriate. PM&R clinicians evaluate patient suitability, write specialized prescriptions, and advocate with vendors for insurance approvals and timely delivery.

Equipment for activities of daily living includes built-up handles on toothbrushes and utensils to augment the handgrip and sock donners to aid lower extremity dressing. Specially installed grab bars and raised toilet seats enhance bathroom safety for individuals with proximal weakness and/or impaired balance. For patients who cannot access a bathroom, bedside commodes provide a more typical toileting experience and require less energy expenditure than bedpans. Adaptive communication devices assist patients with weak voices and/or hands, providing independence for directing their own care, interacting socially, and contacting emergency services.⁴²

In conjunction with adaptive equipment, supportive or compressive orthoses can off-load painful joints and reduce musculoskeletal back pain. Often, over-the-counter orthoses are sufficient, but PM&R referral is recommended if there are questions about fitting or orthotic selection.

Tip 8: Spasticity Is Difficult to Manage, Although Oral Medications, Such as Baclofen, Tizanidine, Diazepam, and Dantrolene, As Well As Botulinum Toxin Injections, Can Decrease Pain and Skin Breakdown, Improve Function, and Allow for Easier Hygiene Care

Spasticity is defined as a velocity-dependent increase in muscle tone. It is one component of the upper motor neuron syndrome that leads to weakness, increased tendon reflexes, dystonia, rigidity, and involuntary spasms. It is commonly seen in patients with SCI, multiple sclerosis, brain injury, cerebral palsy, and tumors of the central nervous system (CNS).⁴³ Uncontrolled spasticity can profoundly affect quality of life in patients with advanced or terminal neurological disorders. Severe spasticity can be painful, interfere with functional activities such as mobility and activities of daily living, limit hygiene, and lead to skin breakdown.

First-line treatment for spasticity involves evaluating for and reversing potential sources of painful nociceptive input. Most commonly, this includes bladder and bowel dysfunction, but other causes include infection, ingrown toenail, fracture, or deep venous thrombosis. Nonpharmacological treatments include stretching and splinting. Pharmacological treatment for spasticity is outlined in Table 2.⁴³

Table 2.

Commonly Used Oral Antispasticity Medications, Dosing, and Side Effects⁴³

Medication	Typical dosing	Side effects
Baclofen	Start 5 mg TID; increase dose by 5 mg every three to five days up to 80 mg/day	Sedation, nausea, constipation, dizziness, decreased seizure threshold, respiratory failure. Abrupt withdrawal can cause seizures, rebound spasticity, and fever
Tizanidine	4–8 mg TID	Sedation, liver dysfunction, hypotension, dizziness, constipation, or dry mouth
Dantrolene	25 mg daily to 100 mg BID	Liver dysfunction, weakness, dizziness, GI disturbance, or mild drowsiness
Diazepam	2–8 mg every six to eight hours	Sedation, confusion, ataxia, or respiratory depression
Gabapentin	100 mg TID to 900 mg TID	Somnolence, ataxia, tremor, or dizziness
Clonidine	0.1 to 0.3 mg transdermal	Hypotension, bradycardia, dry mouth, constipation, or sedation

BID, twice daily; TID, three times daily.

For patients who are unable to tolerate oral medications due to side effects or who have very localized symptoms, botulinum toxin injections targeted to spastic muscles can provide pain relief and improve function. These positive effects have been demonstrated even in patients with life-limiting illness.⁴⁴ Onset of effects is typically noted as soon as three days following injection, with maximum benefit achieved by three weeks. Repeat injections can occur no sooner than every three months.

Tip 9: There Are Distinct Differences in Presentation and Management of Upper Motor Neuron Bowel and Bladder Disorders from Lower Motor Neuron Bowel and Bladder Disorders

Neurological compromise of bowel and bladder function can undermine patients' comfort, dignity, and health. The exact prevalence of neurogenic bowel and bladder among palliative populations remains uncharacterized. However, the principal sources, malignant infiltration, ischemia, and infection of the central and peripheral nervous systems, commonly occur in the advanced stages of many illnesses. Neurogenic compromise should therefore be in the differential diagnosis among patients experiencing problems with bowel or bladder evacuation.

Rehabilitation clinicians are well positioned to offer PC teams direction in developing effective individualized programs for patients' comfortable controlled elimination. Perhaps most importantly, they can assist patients in adapting their programs to meet changing lifestyle and clinical requirements.

Effective management requires making the diagnostic distinction between upper and lower motor neuron involvement. Upper motor neuron lesions generally produce urinary and fecal retention due to external sphincter hyperreflexia, while lower motor neuron lesions produce incontinence due to sphincter flaccidity. Management is largely empirical.⁴⁵

Retention, both fecal and urinary, generally requires a combined approach that reduces sphincter tone and triggers bowel/bladder contractions to promote voiding in controlled circumstances. Bowel regimens typically include osmotic agents, such as polyethylene glycol, and dietary approaches to keep the stool soft.

Management of incontinence requires the opposite approach of increasing sphincter tone and inhibiting bowel/bladder contractions. Medications are frequently used to achieve these goals, although manual stimulation may be a useful adjunct. Scheduled voiding efforts are an important program component, with lower motor neuron dysfunction requiring more frequent elimination.⁴⁶ Evacuation schedules are highly individual and generally reflect a balance between convenience, comfort, and continence.

Tip 10: Patients with CNS Lesions Can Suffer from Specific Cognitive Changes, Including Agitation and Impulsivity, and Common Medication Classes Used in Management Include Beta-Blockers, Anticonvulsants, and Antipsychotics

Patients with primary or metastatic lesions of the CNS often suffer from cognitive deficits and behavioral changes that can significantly impact their function, interpersonal relationships, and ability to participate in their medical care.⁴⁷ PM&R physicians typically manage these symptoms with a variety of pharmacological and nonpharmacological tools adapted from management of patients who sustained a brain injury or stroke.

Patients' symptoms depend on the size, location, laterality of, and treatment rendered to the tumor. Cognitive and behavioral changes in patients with frontal lobe tumors may include impulsivity and aggressiveness (unfiltered speech and/or being physically aggressive). Other times, frontal lesions cause the opposite: low initiation and abulia. Patients may also suffer from severe depression, headaches, restlessness, and more.⁴⁸

The first line of treatment is almost always nonpharmacologic. Providers should remove medications that can worsen cognition (e.g., benzodiazepines and anticholinergics), reorient a confused patient, and reduce external stimuli (turn off the television, dim lights, or limit visitors). Patients who are physically impulsive and at risk of falling should have a sitter at the bedside, bed rails, or another form of nonrestrictive safety (restraints are reserved for patients who are an immediate danger to themselves or others).

The next line of treatment is typically pharmacologic. Depending on symptoms and potential drug interactions, one or more medications may be used. Some patients require multiple medications to palliate their symptoms with the fewest side effects. Table 3 outlines pharmacological options for cognitive and behavioral changes in patients with CNS lesions.^49,50

Table 3.

Medications for Cognitive and Behavioral Changes in Patients with Central Nervous System Lesions^49,⁵⁰

Indication	Medication class	Common medications and dosing ranges	Side effects
Irritability, headaches, impulsiveness, restlessness	Beta-blocker	Propranolol (20 mg BID to start, increase to 80–120 mg BID as tolerated/needed)	Bradycardia, reduced blood pressure, or bronchospasm
Poor sleep, depression, restlessness	Atypical antidepressant	Trazodone (50–100 mg QHS to start, common to go to 200 mg QHS) Mirtazapine (7.5–30 mg QHS)	Xerostomia, drowsiness, diarrhea or constipation, or appetite stimulation (Mirtazapine)
Depression, irritability, disorders of initiation, abulia	Selective serotonin reuptake inhibitors	Sertraline (50–200 mg daily) Citalopram (20–40 mg daily) Escitalopram (10–20 mg daily)	Xerostomia, serotonin syndrome, diarrhea, somnolence, or sexual dysfunction
Disorders of initiation, abulia	Neurostimulant	Methylphenidate (5–10 mg BID short acting, increase to sustained release when taking 20 mg or more a day consistently)	Anxiety, tachycardia, xerostomia, or lowers the seizure threshold
Irritability, mood lability, aggressive behavior, impulsiveness, headache	Anticonvulsant	Valproic acid (250 mg BID) Lamotrigine (start 25 mg a day, increase by 25 mg each week to 100 mg a day; taper slowly) Carbamazepine (100–200 mg BID)	Asthenia, somnolence, dizziness, thrombocytopenia, tremor, dyspepsia, or Stevens–Johnson syndrome (higher risk with lamotrigine)
Agitation, aggressive behavior, perseveration	Atypical antipsychotic	Quetiapine (start 25 mg QHS, increase by 25–50 mg as indicated, may use during the day as well if needed) Olanzapine (start 5 mg QHS, increase up to 12.5 mg as indicated/tolerated)	Somnolence, appetite stimulation, hyperprolactinemia, xerostomia, dizziness, extrapyramidal symptoms (rare), or neuroleptic malignant syndrome (rare)

Conclusions

The specialty of PM&R aims to optimize and restore functional ability for patients with physical impairments or disabilities. Patients with serious illnesses can benefit from the collaboration between PM&R and PC. PM&R clinicians can help PC specialists diagnose and treat musculoskeletal impairments, prognosticate functional outcomes following traumatic injuries, and more broadly, navigate the PAC world to promote goal-concordant patient-centered care.

Funding Information

No funding was received.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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