Physical Therapy's Role in Opioid Use and Management During Palliative and Hospice Care

Physical Therapy's Role in Opioid Use and Management During Palliative and Hospice Care Opioid Campaigns: Impact on Hospice and Palliative Care There has been a significant amount of necessary publicity and attention related to America's opioid crisis.1,2 In 2015 and 2016, multiple governmental agencies and professional associations endorsed a variety of aggressive measures to combat this critical problem.3–5 As this growing epidemic has caused addiction and deaths of thousands of Americans, these campaigns are well intentioned and important.6 With the level of focus that these campaigns are receiving, however, there are concerns of potential unintended negative consequences of the resulting regulatory reform and public perceptions, especially in regard to patients with life-threatening diagnoses or those in hospice and palliative care (HPC). The American Physical Therapy Association's (APTA’s)ChoosePT campaign has been extremely successful and advocates a conversation between the patient and prescriber about pursuing physical therapy before receiving a prescription for an opioid medication.7,8 Highly visible campaigns such as these might cause an increased social stigma related to opioids that could influence treatment decisions. Within the context of a terminal illness, these treatment decisions may include a decreased receptiveness for opioids and altered prescribing practices. These utilization changes could result in a reduction in quality of life and participation in vital physical therapist interventions. In our clinical observations, there is a subset of individuals and families who will decline needed pain medications due to perceived concerns about side effects or even addiction in terminal situations. This decision may result in challenges in pain control, which has the potential to reduce quality of life and cause detrimental alterations to medical care. Both the Centers for Disease Control and Prevention (CDC) and APTA’s campaigns do note that cancer pain and end-of-life situations require different approaches than traditional opioid reforms, but these clarifications are outweighed greatly by the campaigns’ overall portrayal of the negative effects of prescription opioids.9,10 In 2016, the American Society of Clinical Oncology chose not to endorse a draft of the CDC’s opioid management plan and stated that patients with cancer are a unique population that “should be exempt from regulations restricting access or limiting doses of prescription opioids in recognition of the unique nature of their disease.”11 In addition, multiple clinical commentaries related to the national campaigns against opioid abuse have emphasized a balanced and common sense approach to avoid negative, unintended consequences.12–14 If the campaigns and the subsequent reforms result in an increase in regulatory burdens to prescription practices or public stigma, there might be unintentionally negative outcomes for patients receiving palliative care or hospice services. Physical Therapists’ Role in 
Nonopioid Pain Management Physical therapy is an essential part of pain management in all treatment realms. This is especially important for both short-term and long-term pain control with progressively declining and terminal conditions seen throughout the palliative care spectrum into hospice, where opioids—delivered orally by pill or liquid, transdermally, by inhaler, or intravenously—are a common and effective method of pain control.15,16 Pain near the end of life often has multiple components: physical, psychological, and existential and spiritual. It is important to differentiate these varied aspects through a thorough evaluation shared with an interdisciplinary palliative care or hospice team. Physical therapists must recognize that many types of pain need such pharmacologic intervention, yet they also need to be aware that a physical therapist's knowledge of biomechanics and skills of instruction in positioning and mobility are invaluable in promoting patient comfort, supporting pain control and mobility, and preventing overmedication and the unintended side effects of decreased levels of cognitive ability, constipation, and sedation.17,18 Illustrative is a case example of a 72-year-old man with prostate cancer that had metastasized to his spine, causing significant vertebral body erosion. Like many such patients, he wanted to maintain maximal physical mobility.19 While lying supine, he was quite comfortable with pain rated between 0 and 2. He was taking a relatively modest dose of long-acting opioid twice a day. Upon sitting or standing to toilet or participating in mobility and activities of daily living, his pain progressively increased to the 8–10 range. Nursing, using an algorithm for management, instituted progressively larger doses of both short-term and long-acting opioids in an effort to allow mobility with tolerable pain. This was not effective and caused him to become both obtunded and constipated. The rhetorical question this situation begs is: how much medication would it take to allow a hot poker or sharp knife blade to be inserted into the spine? The answer is: there is not enough. Physical therapy can be beneficial in such cases.20 Evaluation first identifies the likely compression of the spinal cord or nerve roots from the structural bone deterioration during increased weight bearing and pain from more upright positioning. Intervention options can be explored, including the use of gradual elevation of the head of the bed, trial of a soft or hard corset to provide trunk support, use of a recliner wheelchair for mobility with support, or possibly bilateral upper-extremity weight bearing in sitting or standing to relieve the compression. Any of these options can allow for acceptable mobility with tolerable pain and sufficient but not excessive opioid use, with the ultimate goals of quality of life as identified by the patient and family caregivers. Physical therapists and physical therapist assistants also have an array of measures that can ease pain symptoms, including but not limited to, touch and massage, breathing, and mindfulness techniques.21 The physical therapist also can facilitate the conversation that mobility without pain may no longer be a feasible possibility with even the best technique or medication practices. Opioids and anxiolytics are often used together in a quest to decrease restlessness and increase comfort with individuals who are unable to get out of bed. This may have an undesired side effect of accelerating a loss of awareness and communication. Again, physical therapists can play a significant role in establishing optimal position, body alignment, and pressure relief for the person who is bedfast. This often allows for patient relaxation and easier breathing with concomitant decreased need for medication use. Better patient care and satisfaction will result. Physical Therapists and the HPC Interdisciplinary 
Care Team An additional role that the physical therapist can play on the palliative care or hospice team is as an observer and reporter of the changes in function and consciousness that occur with increased dosing or conversion from one medication regimen to another. Hospice nursing providers, with their relative comfort in using such powerful medications and familiarity with the dying process, can at times unintentionally blur these events, when in fact changes in consciousness may be a drug response instead of a terminal process. It is not the mission of terminal care to accelerate the dying process while seeking to otherwise manage symptoms, and close interdisciplinary collaboration can help parse out these challenging issues. With the recent findings of misuse and pervasive opioid addiction as a national issue, there is a significant social stigma attached to opioid use, even in the highest-quality hospice or palliative care settings. As a team member, the physical therapist can reassure a patient and family as to the importance and efficacy of using such medications, especially when our physical interventions are insufficient to alleviate pain. Within HPC, health care providers are less likely to be concerned about addiction near the end of life, as the opioid medication will be metabolized at the pain site. There is no risk of an individual turning to crime to finance their need; the medical provider will supply the necessary drug. Within this setting, the interdisciplinary team is highly aware and cognizant of the potential for diversion and use of opioids by others while developing a safe and secure management plan. Concerns about addiction in terminal cases are not well founded. A key issue related to integration of physical therapy during hospice and palliative care situations is the disjointed nature of physical therapy within hospice and palliative care teams. The additional pain management options available through physical therapy might not be available to patients in HPC due to a physical therapist not being a consistent member of the hospice and palliative care team. In addition, when physical therapists are involved in hospice and palliative care, interventions are often focused on increasing strength or improving functional capacity as opposed to providing specific treatment care plans for pain management and coordination of nonopioid pain management with concurrent opiate administration. Common locations for these interdisciplinary communication conversations include palliative care rounds, multidisciplinary clinics, and tumor boards. In order for physical therapists to appropriately offer these interventions, it is essential for physical therapists to be present at these meetings and rounds. In light of common patient care productivity expectations at many institutions, these interdisciplinary care activities may not always be accessible to the physical therapists—and, by proxy, to the patients. Conclusion The aggressive measures related to combating the opioid epidemic are important and extremely necessary for the public health of Americans, and these campaigns promise to improve opioid practices nationally. Policy makers and health care providers must advocate for the judicious use of opioids in palliative care and hospice situations, as opioids are and should continue to be a primary measure for pain control at the end of life. Physical therapists’ lack of consistent integration into HPC teams is often a barrier to provision of some nonopioid alternatives. Nonetheless, physical therapy has an essential role to play in managing opioid use in a way that best supports patient and family wishes for safe and comfortable dying with attention to quality of life. Acknowledgments The authors would like to thank Steve Morris, Lucinda Pfalzer, Deb Doherty, APTA’s Hospice and Palliative Care Special Interest Group, and the Michigan Physical Therapy Association's Oncology Special Interest Group for assistance with facilitating this manuscript. References 1 Opioid overdose: understanding the epidemic. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugoverdose/epidemic/index.html. Updated December 16, 2016. Accessed October 26, 2017. 2 The impact of the opioid crisis on the healthcare system: a study of privately billed services. A FAIR Health White Paper . Available at: http://www.khi.org/assets/uploads/news/14560/the_impact_of_the_opioid_crisis.pdf. Published September 2016. Accessed October 26, 2017. PubMed PubMed  3 Comprehensive Addiction and Recovery Act of 2016, Pub L No. 114–198, §524 (2016). Congress.gov website. https://www.congress.gov/bill/114th-congress/senate-bill/524/text. Accessed October 26, 2017. 4 Prevention of prescription drug overdose and abuse. National Conference of State Legislatures website. http://www.ncsl.org/research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx. Published May 23, 2016. Accessed October 26, 2017. 5 Edlin M. How four health plans are fighting the opioid epidemic. Managed Healthcare Executive . Available at: http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/how-four-health-plans-are-fighting-opioid-epidemic?page=0,0&cfcache = true. Published July 10, 2016. Accessed October 26, 2017. 6 Opioid overdose. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugoverdose/index.html. Updated October 23, 2017. Accessed October 26, 2017. 7 #ChoosePT momentum continues to build with national advertising. American Physical Therapy Association website. http://www.apta.org/PTinMotion/News/2016/11/1/ChoosePTPhase2/. Published November 1, 2016. Accessed April 25, 2017. 8 American Physical Therapy Association, House of Delegates. Endorsement of National Efforts Addressing the Opioid Health Crisis . (HOD P06-16-14-14). Alexandria, VA: American Physical Therapy Association; 2016. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/EndorsementOfNtlEffortsAddressingOpioidHealthCrisis.pdf#search=%22opioid%22 Accessed October 26, 2017. 9 Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep . 2016; 65( 1): 1– 49. Google Scholar CrossRef Search ADS PubMed  10 #ChoosePT opioid awareness campaign toolkit. American Physical Therapy Association website. http://www.moveforwardpt.com/ChoosePT/Toolkit. Accessed October 26, 2017. 11 American Society of Clinical Oncology. ASCO policy statement on opioid therapy: protecting access to treatment for cancer-related pain. American Society of Clinical Oncology website. https://www.asco.org/advocacy-policy/asco-in-action/asco-releases-principles-balancing-appropriate-patient-access. Published May 23, 2016. Accessed April 25, 2017. 12 Renthal W. Seeking balance between pain relief and safety: CDC issues new opioid-prescribing guidelines. JAMA Neurol . 2016; 73( 5): 513– 514. Google Scholar CrossRef Search ADS PubMed  13 Wilson CM. Opioid campaigns’ impact on advanced cancer and hospice and palliative care: an invited commentary. Rehabil Oncol . 2017; 35( 2): 94– 98. 14 Weeks J. Common sense: use all proven pain methods in a comprehensive strategy to prevent opioid abuse: building the case for integrative approaches for long-term users. J Altern Complement Med . 2016; 22( 9): 677– 679. Google Scholar PubMed  15 Clark D. From margins to centre: a review of the history of palliative care in cancer. Lancet Oncol . 2007; 8: 430– 438. Google Scholar CrossRef Search ADS PubMed  16 Portenoy RK, Sibirceva U, Smout R et al.   Opioid use and survival at the end of life: a survey of a hospice population. J Pain Symptom Manage . 2006; 32( 6): 532– 540. Google Scholar CrossRef Search ADS PubMed  17 Briggs R. Clinical decision making for physical therapists in patient-centered end-of-life care. Top Geriatr Rehab . 2011; 27( 1): 10– 17. Google Scholar CrossRef Search ADS   18 Wilson CM, Stiller CH, Doherty DJ, Thompson KA. The role of physical therapists within hospice and palliative care in the United States and Canada. Am J Hosp Palliat Care . 2017; 34( 1): 34– 41. Google Scholar CrossRef Search ADS PubMed  19 Mueller K, Matas K. Promoting participation in the presence of peril: collaborative intervention by a physical therapist and nurse practitioner in a patient with cervical spine metastases. J Hosp Palliat Nurs . 2016; 18( 3): 194– 198. Google Scholar CrossRef Search ADS   20 Abraham JL. Assessment and treatment of patients with malignant spinal cord compression. J Support Oncol . 2004; 2: 377– 401. Google Scholar PubMed  21 Cherkin DC, Sherman KJ, Balderson BH et al.   Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA . 2016; 315( 12): 1240– 1249. Google Scholar CrossRef Search ADS PubMed  © 2017 American Physical Therapy Association http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Physical Therapy Oxford University Press

Physical Therapy's Role in Opioid Use and Management During Palliative and Hospice Care

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Abstract

Opioid Campaigns: Impact on Hospice and Palliative Care There has been a significant amount of necessary publicity and attention related to America's opioid crisis.1,2 In 2015 and 2016, multiple governmental agencies and professional associations endorsed a variety of aggressive measures to combat this critical problem.3–5 As this growing epidemic has caused addiction and deaths of thousands of Americans, these campaigns are well intentioned and important.6 With the level of focus that these campaigns are receiving, however, there are concerns of potential unintended negative consequences of the resulting regulatory reform and public perceptions, especially in regard to patients with life-threatening diagnoses or those in hospice and palliative care (HPC). The American Physical Therapy Association's (APTA’s)ChoosePT campaign has been extremely successful and advocates a conversation between the patient and prescriber about pursuing physical therapy before receiving a prescription for an opioid medication.7,8 Highly visible campaigns such as these might cause an increased social stigma related to opioids that could influence treatment decisions. Within the context of a terminal illness, these treatment decisions may include a decreased receptiveness for opioids and altered prescribing practices. These utilization changes could result in a reduction in quality of life and participation in vital physical therapist interventions. In our clinical observations, there is a subset of individuals and families who will decline needed pain medications due to perceived concerns about side effects or even addiction in terminal situations. This decision may result in challenges in pain control, which has the potential to reduce quality of life and cause detrimental alterations to medical care. Both the Centers for Disease Control and Prevention (CDC) and APTA’s campaigns do note that cancer pain and end-of-life situations require different approaches than traditional opioid reforms, but these clarifications are outweighed greatly by the campaigns’ overall portrayal of the negative effects of prescription opioids.9,10 In 2016, the American Society of Clinical Oncology chose not to endorse a draft of the CDC’s opioid management plan and stated that patients with cancer are a unique population that “should be exempt from regulations restricting access or limiting doses of prescription opioids in recognition of the unique nature of their disease.”11 In addition, multiple clinical commentaries related to the national campaigns against opioid abuse have emphasized a balanced and common sense approach to avoid negative, unintended consequences.12–14 If the campaigns and the subsequent reforms result in an increase in regulatory burdens to prescription practices or public stigma, there might be unintentionally negative outcomes for patients receiving palliative care or hospice services. Physical Therapists’ Role in 
Nonopioid Pain Management Physical therapy is an essential part of pain management in all treatment realms. This is especially important for both short-term and long-term pain control with progressively declining and terminal conditions seen throughout the palliative care spectrum into hospice, where opioids—delivered orally by pill or liquid, transdermally, by inhaler, or intravenously—are a common and effective method of pain control.15,16 Pain near the end of life often has multiple components: physical, psychological, and existential and spiritual. It is important to differentiate these varied aspects through a thorough evaluation shared with an interdisciplinary palliative care or hospice team. Physical therapists must recognize that many types of pain need such pharmacologic intervention, yet they also need to be aware that a physical therapist's knowledge of biomechanics and skills of instruction in positioning and mobility are invaluable in promoting patient comfort, supporting pain control and mobility, and preventing overmedication and the unintended side effects of decreased levels of cognitive ability, constipation, and sedation.17,18 Illustrative is a case example of a 72-year-old man with prostate cancer that had metastasized to his spine, causing significant vertebral body erosion. Like many such patients, he wanted to maintain maximal physical mobility.19 While lying supine, he was quite comfortable with pain rated between 0 and 2. He was taking a relatively modest dose of long-acting opioid twice a day. Upon sitting or standing to toilet or participating in mobility and activities of daily living, his pain progressively increased to the 8–10 range. Nursing, using an algorithm for management, instituted progressively larger doses of both short-term and long-acting opioids in an effort to allow mobility with tolerable pain. This was not effective and caused him to become both obtunded and constipated. The rhetorical question this situation begs is: how much medication would it take to allow a hot poker or sharp knife blade to be inserted into the spine? The answer is: there is not enough. Physical therapy can be beneficial in such cases.20 Evaluation first identifies the likely compression of the spinal cord or nerve roots from the structural bone deterioration during increased weight bearing and pain from more upright positioning. Intervention options can be explored, including the use of gradual elevation of the head of the bed, trial of a soft or hard corset to provide trunk support, use of a recliner wheelchair for mobility with support, or possibly bilateral upper-extremity weight bearing in sitting or standing to relieve the compression. Any of these options can allow for acceptable mobility with tolerable pain and sufficient but not excessive opioid use, with the ultimate goals of quality of life as identified by the patient and family caregivers. Physical therapists and physical therapist assistants also have an array of measures that can ease pain symptoms, including but not limited to, touch and massage, breathing, and mindfulness techniques.21 The physical therapist also can facilitate the conversation that mobility without pain may no longer be a feasible possibility with even the best technique or medication practices. Opioids and anxiolytics are often used together in a quest to decrease restlessness and increase comfort with individuals who are unable to get out of bed. This may have an undesired side effect of accelerating a loss of awareness and communication. Again, physical therapists can play a significant role in establishing optimal position, body alignment, and pressure relief for the person who is bedfast. This often allows for patient relaxation and easier breathing with concomitant decreased need for medication use. Better patient care and satisfaction will result. Physical Therapists and the HPC Interdisciplinary 
Care Team An additional role that the physical therapist can play on the palliative care or hospice team is as an observer and reporter of the changes in function and consciousness that occur with increased dosing or conversion from one medication regimen to another. Hospice nursing providers, with their relative comfort in using such powerful medications and familiarity with the dying process, can at times unintentionally blur these events, when in fact changes in consciousness may be a drug response instead of a terminal process. It is not the mission of terminal care to accelerate the dying process while seeking to otherwise manage symptoms, and close interdisciplinary collaboration can help parse out these challenging issues. With the recent findings of misuse and pervasive opioid addiction as a national issue, there is a significant social stigma attached to opioid use, even in the highest-quality hospice or palliative care settings. As a team member, the physical therapist can reassure a patient and family as to the importance and efficacy of using such medications, especially when our physical interventions are insufficient to alleviate pain. Within HPC, health care providers are less likely to be concerned about addiction near the end of life, as the opioid medication will be metabolized at the pain site. There is no risk of an individual turning to crime to finance their need; the medical provider will supply the necessary drug. Within this setting, the interdisciplinary team is highly aware and cognizant of the potential for diversion and use of opioids by others while developing a safe and secure management plan. Concerns about addiction in terminal cases are not well founded. A key issue related to integration of physical therapy during hospice and palliative care situations is the disjointed nature of physical therapy within hospice and palliative care teams. The additional pain management options available through physical therapy might not be available to patients in HPC due to a physical therapist not being a consistent member of the hospice and palliative care team. In addition, when physical therapists are involved in hospice and palliative care, interventions are often focused on increasing strength or improving functional capacity as opposed to providing specific treatment care plans for pain management and coordination of nonopioid pain management with concurrent opiate administration. Common locations for these interdisciplinary communication conversations include palliative care rounds, multidisciplinary clinics, and tumor boards. In order for physical therapists to appropriately offer these interventions, it is essential for physical therapists to be present at these meetings and rounds. In light of common patient care productivity expectations at many institutions, these interdisciplinary care activities may not always be accessible to the physical therapists—and, by proxy, to the patients. Conclusion The aggressive measures related to combating the opioid epidemic are important and extremely necessary for the public health of Americans, and these campaigns promise to improve opioid practices nationally. Policy makers and health care providers must advocate for the judicious use of opioids in palliative care and hospice situations, as opioids are and should continue to be a primary measure for pain control at the end of life. Physical therapists’ lack of consistent integration into HPC teams is often a barrier to provision of some nonopioid alternatives. Nonetheless, physical therapy has an essential role to play in managing opioid use in a way that best supports patient and family wishes for safe and comfortable dying with attention to quality of life. Acknowledgments The authors would like to thank Steve Morris, Lucinda Pfalzer, Deb Doherty, APTA’s Hospice and Palliative Care Special Interest Group, and the Michigan Physical Therapy Association's Oncology Special Interest Group for assistance with facilitating this manuscript. References 1 Opioid overdose: understanding the epidemic. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugoverdose/epidemic/index.html. Updated December 16, 2016. Accessed October 26, 2017. 2 The impact of the opioid crisis on the healthcare system: a study of privately billed services. A FAIR Health White Paper . Available at: http://www.khi.org/assets/uploads/news/14560/the_impact_of_the_opioid_crisis.pdf. Published September 2016. Accessed October 26, 2017. PubMed PubMed  3 Comprehensive Addiction and Recovery Act of 2016, Pub L No. 114–198, §524 (2016). Congress.gov website. https://www.congress.gov/bill/114th-congress/senate-bill/524/text. Accessed October 26, 2017. 4 Prevention of prescription drug overdose and abuse. National Conference of State Legislatures website. http://www.ncsl.org/research/health/prevention-of-prescription-drug-overdose-and-abuse.aspx. Published May 23, 2016. Accessed October 26, 2017. 5 Edlin M. How four health plans are fighting the opioid epidemic. Managed Healthcare Executive . Available at: http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/how-four-health-plans-are-fighting-opioid-epidemic?page=0,0&cfcache = true. Published July 10, 2016. Accessed October 26, 2017. 6 Opioid overdose. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugoverdose/index.html. Updated October 23, 2017. Accessed October 26, 2017. 7 #ChoosePT momentum continues to build with national advertising. American Physical Therapy Association website. http://www.apta.org/PTinMotion/News/2016/11/1/ChoosePTPhase2/. Published November 1, 2016. Accessed April 25, 2017. 8 American Physical Therapy Association, House of Delegates. Endorsement of National Efforts Addressing the Opioid Health Crisis . (HOD P06-16-14-14). Alexandria, VA: American Physical Therapy Association; 2016. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/EndorsementOfNtlEffortsAddressingOpioidHealthCrisis.pdf#search=%22opioid%22 Accessed October 26, 2017. 9 Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep . 2016; 65( 1): 1– 49. Google Scholar CrossRef Search ADS PubMed  10 #ChoosePT opioid awareness campaign toolkit. American Physical Therapy Association website. http://www.moveforwardpt.com/ChoosePT/Toolkit. Accessed October 26, 2017. 11 American Society of Clinical Oncology. ASCO policy statement on opioid therapy: protecting access to treatment for cancer-related pain. American Society of Clinical Oncology website. https://www.asco.org/advocacy-policy/asco-in-action/asco-releases-principles-balancing-appropriate-patient-access. Published May 23, 2016. Accessed April 25, 2017. 12 Renthal W. Seeking balance between pain relief and safety: CDC issues new opioid-prescribing guidelines. JAMA Neurol . 2016; 73( 5): 513– 514. Google Scholar CrossRef Search ADS PubMed  13 Wilson CM. Opioid campaigns’ impact on advanced cancer and hospice and palliative care: an invited commentary. Rehabil Oncol . 2017; 35( 2): 94– 98. 14 Weeks J. Common sense: use all proven pain methods in a comprehensive strategy to prevent opioid abuse: building the case for integrative approaches for long-term users. J Altern Complement Med . 2016; 22( 9): 677– 679. Google Scholar PubMed  15 Clark D. From margins to centre: a review of the history of palliative care in cancer. Lancet Oncol . 2007; 8: 430– 438. Google Scholar CrossRef Search ADS PubMed  16 Portenoy RK, Sibirceva U, Smout R et al.   Opioid use and survival at the end of life: a survey of a hospice population. J Pain Symptom Manage . 2006; 32( 6): 532– 540. Google Scholar CrossRef Search ADS PubMed  17 Briggs R. Clinical decision making for physical therapists in patient-centered end-of-life care. Top Geriatr Rehab . 2011; 27( 1): 10– 17. Google Scholar CrossRef Search ADS   18 Wilson CM, Stiller CH, Doherty DJ, Thompson KA. The role of physical therapists within hospice and palliative care in the United States and Canada. Am J Hosp Palliat Care . 2017; 34( 1): 34– 41. Google Scholar CrossRef Search ADS PubMed  19 Mueller K, Matas K. Promoting participation in the presence of peril: collaborative intervention by a physical therapist and nurse practitioner in a patient with cervical spine metastases. J Hosp Palliat Nurs . 2016; 18( 3): 194– 198. Google Scholar CrossRef Search ADS   20 Abraham JL. Assessment and treatment of patients with malignant spinal cord compression. J Support Oncol . 2004; 2: 377– 401. Google Scholar PubMed  21 Cherkin DC, Sherman KJ, Balderson BH et al.   Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain. JAMA . 2016; 315( 12): 1240– 1249. Google Scholar CrossRef Search ADS PubMed  © 2017 American Physical Therapy Association

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Physical TherapyOxford University Press

Published: Feb 1, 2018

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