Role of rehabilitation in palliative care after the COVID-19 pandemic: a narrative review

Introduction

For individuals facing a serious or life-threatening illness, rehabilitation is often not prioritized during the medical management of their disease and symptoms (1). Rehabilitation care faces time and resource constraints, inconsistent understanding of the role of rehabilitation services for patients with a serious illness, as well as limited education on interdisciplinary care (2,3). Furthermore, there continues to be opportunities to improve the body of evidence for the short- and long-term benefit of multidisciplinary rehabilitation for patients facing a serious or life limiting condition (2). These factors were further accentuated by the coronavirus disease 2019 (COVID-19) pandemic as the healthcare system faced unprecedented strain in the volume and criticality of the patients being managed (4). The pandemic provided a unique challenge for the interdisciplinary palliative care team, including rehabilitation professionals, as most palliative care programs traditionally cared for patients with cancer diagnoses, frailty, and degenerative neurologic disorders as opposed to cardiovascular and pulmonary conditions such as severe acute respiratory syndrome (SARS) presented by the COVID-19 virus (2,5,6). Rehabilitation is delivered by a diverse team of professionals, with physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) commonly recognized as core rehabilitation providers (7,8). Physical therapy in palliative care focuses on improving balance, mobility, pain control, respiratory function, strength, and safety. Common interventions include strength and aerobic exercises, balance and flexibility training, use of medical equipment or orthotics, manual therapy, breathing exercises, posture correction, and functional retraining. Occupational therapy supports daily living activities, cognitive function, home safety, and emotional well-being. Interventions include adapting ADLs, home modifications, cognitive retraining, family education, psychosocial support, and mindfulness or social engagement strategies. SLPs address communication, speech, voice, swallowing, and cognitive processing. Strategies include speech and voice exercises, dietary and swallowing modifications, safe eating positioning, cognitive training, and use of adaptive communication tools (7,8).

To the uninitiated, palliative care and rehabilitation services may appear to have opposing aims (2,9,10). Palliative care often focuses on symptom management, comfort, and eventually facilitating a good death as a person’s disease advances, while traditional rehabilitation often focuses on restoration of strength and function, which may not be achievable for a person facing a life-threatening illness (10). Yet, palliative care and rehabilitation teams share aligned goals towards quality of life (QoL), promoting dignity, and active participation in meaningful activities; together, these approaches can elevate the quality of care and patient experience (2,9). Despite the absence of the potential for long term retention of strength and function, rehabilitation interventions can assist a person to live optimally and engage in consequential life events even in the presence of a serious or advancing illness (11,12). These interventions may include modification of activities of daily living (ADL), functional mobility, pain management techniques, and symptom alleviation techniques (e.g., chest pulmonary hygiene techniques, assisted breathing techniques, positioning for comfort and function) (2,13,14).

As palliative care was traditionally developed to address the needs of those with life-threatening illnesses, such as cancer and progressive neurologic disorders, the COVID-19 pandemic required palliative care teams to provide care for a different mix of diagnoses, especially pulmonary and cardiac conditions (15,16). A review of the role and utilization of palliative care services for patients with COVID-19 identified several themes that remained consistent despite this being a non-traditional diagnosis for palliative care (17). Those themes included “good symptom control, open and sensitive communication, and caring for the whole team. COVID-19 patients should have access to specialist palliative care services when suffering is unrelieved” (17). Interestingly, despite the substantial physical limitations, pain, weakness, and difficulties performing basic ADLs experienced by these patients, rehabilitation was not appreciably considered or discussed in this review. Therefore, our narrative review aims to describe the impact of the COVID-19 pandemic on the role and scope of rehabilitation within the context of serious illness and palliative care. We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-6/rc).

Methods

Search strategy

A systematic search of peer-reviewed literature was carried out using electronic databases, including PubMed, CINAHL, and Google Scholar (Table 1). The date range for searches was from January 2020 through January 2025 to capture studies published after the onset of the COVID-19 pandemic.

The search strategy included combinations of keywords and Medical Subject Headings (MeSH) terms related to “rehabilitation”, “palliative care”, and “COVID-19”, as well as terms associated with rehabilitation for other diagnoses and symptoms commonly managed in palliative care. Examples of search terms included: (“Rehabilitation” OR “Physical Therapy” OR “Occupational Therapy”) AND (“Palliative Care” OR “End-of-Life Care”) AND (“COVID-19” OR “Post-COVID” OR “Pandemic Recovery”).

Inclusion and exclusion criteria

Articles were considered for inclusion if they:

• Discussed rehabilitation interventions in the context of palliative care;
• Addressed issues related to rehabilitation for critical/serious/terminal illness related to COVID-19 or long COVID;
• Addressed issues related to the provision of rehabilitation services for patients facing a life-threatening illness or advanced chronic disease during or after the COVID-19 pandemic;
• Were published in English;
• Were peer-reviewed original research articles, study protocols, literature reviews or were position statements by professional organizations.

Articles were excluded if they:

• Focused on populations or medical management outside the scope of palliative care (e.g., prevention and early disease management);
• Did not include subject matter related to rehabilitation;
• Were opinion pieces, editorials, case series, case reports, or conference abstracts without sufficient data.

Study selection

Titles and abstracts retrieved from the search were independently screened by two reviewers to identify relevant articles. Full texts of potentially eligible studies were obtained and reviewed for inclusion. Discrepancies in study inclusion were resolved through consensus of all four authors.

Data extraction and analysis

Key data from the included articles were extracted, including study objectives, population characteristics, intervention types, outcomes, and relevance to palliative care and rehabilitation during or after the COVID-19 pandemic. Findings were synthesized narratively, with a focus on identifying themes and gaps in the literature related to two main topics: (I) the evidence related to rehabilitation for those with serious or life-threatening COVID-19 during the pandemic (by authors C.M.W. and A.N.) and (II) how rehabilitation for patients with serious illness has been transformed after emerging from the pandemic (including non-COVID diagnoses such as cancer, neurologic conditions, etc.) (by authors L.E.B. and A.M.H.). All authors reviewed the relevance and content of selected articles and inconsistencies or disagreement was resolved by consensus of all authors.

Key content and findings

Key takeaways related to rehabilitation for serious illness during the COVID-19 pandemic

Articles related to rehabilitation during the COVID-19 pandemic were examined by the authors with an emphasis on the unique management needs of patients with serious COVID-19 illness. Themes identified included: (I) a need for an interdisciplinary approach; (II) need for early rehabilitation; (III) cardiopulmonary considerations following the COVID-19 pandemic; (IV) the emerging role of telerehabilitation; and (V) evidence and need for clinical guidelines for rehabilitation during long COVID and serious illnesses.

Need for an interdisciplinary approach

The need for an interdisciplinary approach to caring for patients was found to be a common theme during the COVID-19 pandemic including the key role of rehabilitation professionals for patients with serious illness (18). This approach generally included the general practitioners, nursing, as well as healthcare and support workers who have potential to deliver palliative care alongside their assigned role (19); however, recent studies also demonstrated the importance of rehabilitation involvement in this team including PTs and OTs. One of the most prominent examples of interdisciplinary teamwork during the pandemic was the relatively novel concept of proning teams. These teams leveraged the rehabilitation skills and safe patient handling techniques of intensive care unit (ICU)-trained PTs and OTs with the medical team in ICUs to position patients in prone to facilitate recovery during severe COVID-19 illness (20).

In a survey to assess perceptions of healthcare providers on the impact of the COVID-19 pandemic on delivering rehabilitation services in post-acute care and long term care facilities, physical function and motivation for recovery worsened when a patient was quarantined or was socially isolated (21). To address potential deficits arising from lack of accessibility to rehabilitation services during the pandemic due to COVID-19 containment strategies, health systems and rehabilitation professionals identified a responsibility to advocate for integration of their services to prevent functional decline, facilitate timely recovery, and reduce hospital length of stay (18).

In a report on the early findings from rehabilitation services delivered in a COVID-19 field hospital, a core team of PTs and OTs demonstrated the feasibility of rehabilitation services to reduce frequency of hospital acquired-disabilities, length of hospital stay, and promote safe and long-term performance of ADLs by maximizing patient activity and communicating with the interdisciplinary team (22). Rehabilitation professionals played a key role in promoting interdisciplinary care by educating hospital staff on the importance of early mobility and its aims of reducing the risk of secondary illnesses or injuries, shortening hospital stays, and facilitating safe discharge recommendations (22). This interdisciplinary approach for providing rehabilitation services to patients with COVID-19 was well supported in the literature for facilitating safe and timely discharge, preventing secondary or hospital-acquired illnesses, promoting long-term safety and stability in the home, and maximizing physical strength and endurance in the hospital (22).

Interdisciplinary rehabilitation programs have been shown to improve physical symptoms in patients hospitalized with COVID-19 including aerobic capacity, pulmonary function, ADL independence, muscle mass and strength, dynamic balance, and QoL (23). One scoping review found that over half of hospitalized patients who required rehabilitation services received care in the ICU; it was postulated that interdisciplinary care was crucial in promoting early recovery and preventing functional decline in physical and mental health (23). This was especially important considering that symptoms persisted in many patients after hospital discharge after a COVID-19 infection, including fatigue and muscle weakness, chest pain, psychiatric dysfunction, and dyspnea, all of which negatively affected QoL (23).

It was recommended that in order to achieve the benefits of rehabilitation for symptoms of acute or long COVID, barriers to accessing consistent, high quality, interdisciplinary rehabilitation care should be prioritized across the continuum of care (24). As rehabilitation interventions should be a priority of all healthcare team workers (not just PTs, OTs, and SLPs), the World Health Organization noted that “a workforce for the rehabilitation of adults with post COVID-19 condition may include but is not limited to physiotherapists, occupational therapists, nurses, psychologists, speech and language therapists, physicians and social workers” (25). The publication states that rehabilitation of individuals post-COVID-19 requires a “well led coordinated and transdisciplinary team with a range of health care professionals, which may need support from other services, community health care workers and volunteers” (25).

Need for early rehabilitation

As early mobility and rehabilitation has grown to be the standard of practice in ICUs prior to the COVID-19 pandemic, this was found to be similarly important for patients diagnosed or hospitalized with COVID-19 (20,22). Stripari Schujmann et al. found that delays in achieving out-of-bed patient mobilization in the ICU were the strongest predictor of loss of physical independence (26). As with other ICU diagnoses, early rehabilitation for patients with COVID-19 was important to reduce hospital length of stay and facilitate discharge home (as opposed to a subacute or inpatient rehabilitation setting) (27). A multicenter prospective cohort study examined adults who had been hospitalized for COVID-19 and compared those who had received rehabilitation after hospitalization with those who did not participate in rehabilitation. Patients’ leg strength improved regardless of their participation in structured rehabilitation, however patients who participated in rehabilitation also demonstrated improvements in physical function compared to those who did not (28). Notably, patients who initially demonstrated severe impairments and participated in rehabilitation at an inpatient or skilled nursing facility achieved equal physical performance at one year compared to patients with less severe illness who did not require any structured rehabilitation (28).

As resources were limited during the pandemic, rehabilitation services were frequently prioritized for patients who had barriers to discharge including physical impairments, severe illness, or complex medical or psychosocial situations (27). This prioritization of services was aimed to help facilitate discharge home, reduce likelihood of readmission, and maximize physical outcomes after their hospitalization (27). For patients with COVID-19 who did not require formal rehabilitation, the interdisciplinary team facilitated general physical activity, education on bed-based exercises, and diaphragmatic breathing to reduce incidence of iatrogenic pulmonary disease and improve long-term outcomes after hospitalization (27). Finally, in addition to the long-term physical benefits of early rehabilitation during acute COVID-19 infection, there was a noted reduction in long-term mental and cognitive impairments (29).

Cardiopulmonary considerations following the COVID-19 pandemic

Recent studies outlined the association between COVID-19 and cardiopulmonary conditions such as arrhythmia, myocardial infarction, and respiratory distress syndrome (27). As many individuals experience significant cardiopulmonary decline and weakness resulting from a COVID-19 diagnosis, the examination of efficacy of cardiopulmonary rehabilitation interventions was warranted. Hermann et al. described the efficacy of a 2–4-week inpatient cardiopulmonary rehabilitation program consisting of aerobic exercise and strength training wherein all patients were able to return home upon discharge without need for continued nursing support (30). With proper infection control practices, medical monitoring, safety precautions, and access to supplemental oxygen, inpatient cardiopulmonary rehabilitation programs were shown to improve deconditioning typically observed in hospitalized patients (30). Improvements were noted in the 6-minute walk test after the study protocol (30).

With the two most reported symptoms following a COVID-19 diagnosis being fatigue and shortness of breath, integrating pulmonary rehabilitation interventions to improve lung function and strength is warranted (31). A majority of patients reported difficulty at 6–12 months performing one or more ADLs due to similar symptoms of those with chronic lung diseases; these symptoms include shortness of breath, muscle weakness, and balance impairments (28,31). Burnett et al. found that pulmonary rehabilitation, physical rehabilitation, and telerehabilitation programs (including exercise training) have been shown to improve functional exercise capacity, dyspnea, fatigue, and QoL in patients following a COVID-19 diagnosis (31).

The emerging role of telerehabilitation

Due to the substantial impact on the healthcare system, the COVID-19 pandemic brought forth the underutilized and poorly understood role of telehealth, which also included telerehabilitation and remote patient monitoring. Articles identified through this literature review identified that rehabilitation services may be delivered via telehealth and may not always require in-person management, especially when there is an increased risk of acquiring communicable diseases (18,21,29,31-33). One of the challenges during the pandemic was lack of clear guidelines regarding when a telerehabilitation session would be safe or effective (31). Telehealth-delivered cognitive rehabilitation to address COVID-related cognitive impairment related to long COVID is modeled after evidence-based telehealth approaches to cognitive rehabilitation for neurological diagnoses (34). Furthermore, as there was general consensus that there would likely be an ongoing role for telerehabilitation services after the pandemic, training courses, skill validations and guidelines for safe and effective use should be a priority (33). Issues such as informed consent, confidentiality, and patient safety were key areas that required consideration (32). Finally, clear and sustainable payment was determined to be a priority for ongoing telerehabilitation coverage (21,31).

Evidence and need for clinical guidelines for rehabilitation during long COVID and serious illnesses

An additional theme identified by the authors during this narrative review was the efficacy and applicability of rehabilitation interventions utilized during the COVID-19 pandemic. Although there was preliminary evidence of the effectiveness of rehabilitation interventions during the pandemic, most articles highlighted the need for more evidence-informed clinical guidelines (23,33,35,36). The rehabilitation approaches that were required for individuals with serious COVID-19 illness and long COVID during the pandemic may have applicability for other patients with serious illness or in palliative care. As it relates to long COVID, a narrative review by Burnett et al. found that exercise interventions improved functional exercise capacity measures and related symptoms (dyspnea, fatigue) measured one year after COVID-19 infection (31). Additionally, Wasilewski conducted a scoping review that included 128 articles which emphasized that individualized rehabilitation programs should be provided across the continuum of care by an interdisciplinary team of professionals and that the nature and extent of rehabilitation should be informed by the care setting and COVID severity (24). This preliminary evidence of effectiveness should be translated into clinical practice guidelines to further improve outcomes and reduce unwarranted variability in rehabilitation care.

The state of palliative rehabilitation since the COVID-19 pandemic

As the COVID-19 pandemic transformed healthcare delivery, articles were sought that illustrated potential changes to palliative rehabilitation after emerging from the pandemic. The authors identified the following themes based on this hypothesis: (I) emphasis on coordination of care and resource allocation; (II) increased focus on social and mental health for patients and providers; (III) a continued trend of increased volume and rigor of palliative rehabilitation studies; and (IV) an increased focus on organized advocacy and public policy initiatives.

Coordination of care and resource allocation

The growth of palliative care programs across large and small hospitals was rising steadily prior to the pandemic and this trajectory has continued (37). The need for holistic, person-centered, collaborative care with a focus on QoL was illuminated in the midst of suffering and fear around COVID-19 and providing this care requires coordinated and collaborative efforts. Several studies in this narrative review highlighted the need for enhanced coordination of care, access to practice resources, clear guidelines for prioritization of patients, effective communication tools and the need for best practice protocols (36,38). In a retrospective study, Harrington et al. concluded that interdisciplinary teamwork improved functional outcomes (mobility and self-care) from admission to discharge in an inpatient rehabilitation facility (35). This study of 126 patient records used the Self-Care and Functional Mobility CARE Tool and identified the need for further review of allocation of therapy resources (i.e., PT, OT, and SLP services). Additionally, they recommended that outcome measures include cognitive and swallowing domains.

A scoping review of rehabilitation for patients recovering from COVID-19 noted the need for interdisciplinary approaches, including rehabilitation services, specifically for patients with comorbidities (24). Notably, among the 128 articles in this review, none centered around the role of families/support systems in the recovery and rehabilitation process. This study recommends utilizing video-conferencing and other technologies to enhance collaboration across patients, families, and members of the healthcare team. A well-resourced, carefully allocated, evidenced-based interdisciplinary team, with the patient and family/support system at the center, is a consistent recommendation of the articles reviewed. The growth of palliative care and the integration of rehabilitation services within the palliative care team demands an interdisciplinary and systematic approach and the need for this integration became even more evident during the COVID-19 pandemic.

Social and mental health incorporation into palliative rehab

The holistic foundation of palliative rehabilitation was reshaped during the pandemic, with heightened emphasis on mental health and well-being for both patients and the healthcare team supporting this vulnerable population. Awareness of mental health challenges and the interplay of physical and psychosocial connectedness was steadily gaining recognition prior to the pandemic and has now emerged as a core concept within palliative rehabilitation. The social isolation required during the pandemic has been linked to deterioration in mental health and overall QoL across populations. A study of community-dwelling older adults using the COV19-QoL Scale revealed decreased social support, increased reliance with instrumental ADLs, perceptions of reduced social support, self-reported feelings of depression, and overall mental health deterioration (39). Similarly, an observational study of individuals in an outpatient rehabilitation setting for persistent COVID symptoms reported lower health-related QoL than the general population, notably even lower than patients with chronic health conditions (40). In addition to high rates of depression (43%) and severe anxiety (38%) in this population, this study found disparities across socioeconomic and racial groups. Black patients with COVID were 1.8 times more likely than White patients with COVID-19 to experience severe anxiety and 2.5 times more likely to report post-traumatic stress disorder (PTSD) symptoms (40). In a mixed methods study of medical record reviews (n=24) and interviews (n=10), Scott and colleagues highlighted the value of occupational therapy in addressing the mental health symptoms for patients with COVID-19 (41). Lastly, Van Laake and Hitch interviewed rehabilitation therapists in acute and subacute settings who reported that patients with COVID-19 receiving rehabilitation services exhibited increased anxiety and loss of self-confidence (36). The psychosocial toll of the pandemic impacted patients and caregivers as well as members of the healthcare team and the impact was more pronounced in marginalized communities across the globe (24).

In addition to the mental health concerns of patients, health care workers across disciplines caring for patients with serious illness during the COVID pandemic experienced significant mental health challenges, including anxiety (38%), depression (34%), and post-traumatic stress (26%) (42). Concerns for personal safety, the physical and psychological toll, and the volume and criticality of patients resulted in job dissatisfaction (42). Increased rates of burnout, emotional exhaustion, and decreased motivation as well as breaches of trust between health care workers and the organizations in which they worked were outlined in a large mixed methods study of over 1,000 health care and hospital workers (38). Feelings of institutional betrayal (assessed through questions around institutional responsiveness, focus on safety, and advocacy for employee needs) were reported at 57.8%, burnout at 47.2%, and career choice regret at 36.7% (38). Resources such as Yale’s “Collective Well Being” (https://online.yale.edu/courses/science-well-being), Center to Advance Palliative Care (CAPC)’s “Well Being Debriefings” (https://www.capc.org/documents/929/), and others emerged to virtually address the psychosocial impact of the pandemic on health care workers and teams. Efforts to build organizational trust and create supportive work environments, specifically in times of crisis, lead to increased job satisfaction and psychosocial well-being of healthcare workers. Greater attention to the mental health needs of patients, caregivers, and members of the healthcare team, combined with an emphasis on self-reflection and team debriefings, may prove to be a lasting contribution of the pandemic to palliative rehabilitation.

Increased volume and rigor of palliative rehabilitation studies

Since the pandemic, there have been several notable large-scale and rigorous studies that investigated various aspects of palliative rehabilitation. A recent systematic review and meta-analysis by Pryde et al. aimed to determine the impact of interdisciplinary palliative rehabilitation on QoL for adults with advanced life limiting illness (43). This systematic review identified 27 randomized controlled trials published over the past 27 years, 12 of which (44%) were published since the pandemic (Figure 1) (43). When examining multiple diagnosis groups (e.g., cancer, nonmalignant respiratory diseases, and heart failure), there was low to moderate evidence that palliative rehabilitation has a positive impact on QoL (43). Additional metrics evaluated included hospital days, readmissions, and cost effectiveness. The evidence supported reduced hospital days and improved cost effectiveness when palliative rehabilitation was compared to usual care (43).

Figure 1 Frequency count of randomized controlled trials for palliative rehabilitation by year. Data obtained from the study of Pryde et al. (43). The data from the cited article was not originally presented in figure or table form, we have solely based our figure on the textual content. One article identified in 2024 by Pryde et al. was not included in the graph as the systematic review only included the first 2 months of 2024. Dashed line is a trendline of annual frequency of published articles calculated using Microsoft Excel 365. RCTs, randomized controlled trials.

Due to advancements in medical management as well as screenings and early detection, cancer is increasingly considered a chronic illness as opposed to a terminal one. Concurrently, the palliative rehabilitation research reflects this trend where rehabilitation therapists are increasingly utilizing a chronic-disease management model for patients with advanced cancer (44-46). Specifically, evidence from the Pal-Rehab study demonstrated statistically significant (P<0.001) improved QoL for individuals with advanced cancer when palliative rehabilitation is implemented early (44). Additionally, connectedness and convenience were meaningful reported outcomes that contributed to greater comfort and confidence among individuals with lung cancer (45). Barriers to implementation and integration of palliative rehabilitation included lack of funding, well defined access pathways, and clinician competence; however, there was general agreement on the importance of comprehensive interdisciplinary approaches that align with individual goals and needs (46).

A national cross-sectional survey explored the impact of the COVID-19 pandemic on the delivery of rehabilitation services within palliative care in the United Kingdom (33). Researchers noted changes including remote care delivery and/or reduced caseloads, as well as clinical staffing issues related to clinicians off work due to illness, redeployment, or furlough (33). The study concluded that COVID-19 served as a catalyst for change, highlighting the potential of hybrid models of care to enhance access and extend the reach of palliative rehabilitation services (33). The Integrated Short-term Palliative Rehabilitation (INSPIRE) project is a large multinational research initiative to be conducted across five European countries. It aims to evaluate the effectiveness of palliative rehabilitation for individuals with incurable cancer, focusing on QoL, disability, symptom burden, and goal attainment (47).

Increased advocacy and public policy initiatives

In addition to more structured research activity, our narrative review revealed more collaboration and infrastructure focused on advocating for high quality palliative care and palliative rehabilitation since the pandemic. Many of the aforementioned authors advocated for improved integration of interdisciplinary rehabilitation services across disease types (33,43,45,46,48). In addition, several World Health Organization (WHO) initiatives have emerged since the COVID-19 pandemic, increasing the focus on global advocacy and public policy for palliative care. Moving beyond the traditional emphasis on pain management and end-of-life disease-specific support, the WHO now prioritizes interdisciplinary collaboration and the early integration of palliative care services for individuals with serious illnesses and cancer (49). Additionally, promoting well-integrated public health efforts that address the physical, emotional, and spiritual needs of patients, as well as those of their families and caregivers, is essential (49). However, challenges remain that must be addressed, particularly in care settings with limited resources and in ensuring accessibility of services (49).

A landmark document recently published by the WHO’s European Region, entitled Policy Brief on Integrating Rehabilitation into Palliative Care not only summarized the importance of palliative rehabilitation, but also provided recommendations for integrating rehabilitation into palliative care (50). This integration was cited as a means to enhance access to palliative care, improve care coordination, increase overall quality and efficiency, and potentially reduce the cost of care (50). Key focus of this publication was identifying barriers to integrating rehabilitation into palliative care (including those stemming from the COVID-19 pandemic) and offering evidence-based recommendations to address them. For example, to address the barrier of “limited prioritization, planning, and resourcing of rehabilitation in health care,” proposed solutions included implementing practical provider training, allocating appropriate funding, and incorporating palliative rehabilitation into relevant guidelines and policy documents (50). Additionally, in order to “design and organize palliative care services for the integration of rehabilitation,” the WHO recommended providers use systematic screening and patient-reported outcome measures to identify individuals who will benefit from palliative rehabilitation services. An emphasis was placed on offering comprehensive palliative rehabilitation services across care settings (i.e., home, urban, rural) to improve access (50). The WHO is widely trusted by nations, jurisdictions, and healthcare institutions for practice guidance. This document is expected to prompt healthcare systems and government agencies to assess their current integration of rehabilitation, promoting systemic improvements that enhance patient care while also supporting the economic benefits of palliative care and rehabilitation.

Multiple articles included by the WHO concluded with a call to establish global standards of care and best practices for palliative rehabilitation in support of individuals with serious illnesses and their families (50). During the pandemic, efforts to collectively and collaboratively advocate for palliative rehabilitation intensified among disciplines, locations, and disease-specific organizations. Adopting systems-thinking approaches is essential to break down silos, address the fragmented nature of care delivery, and identify collaborative strategies to drive meaningful change. As an example, the American Palliative Rehabilitation Alliance was launched in 2022 to address the need for interdisciplinary collaborative practice for individuals with serious illness towards improved functional independence and psychosocial well-being and to promote such advocacy (www.palliativerehab.com).

Discussion

While efforts to integrate rehabilitation into palliative care teams were fragmented and inconsistent before the pandemic, evidence from this narrative review shows that the pandemic accelerated and enhanced the integration of these services (Figure 2). This may have been due in part to the clinical challenges and opportunities resulting from the disruptive nature of the pandemic. As an example, based on the literature available prior to the pandemic, there was sparse discussion of telerehabilitation and remote patient monitoring by rehabilitation therapists but since the pandemic, there has been a substantial increase in the number of articles that included telerehabilitation as a topic. Although direct provider training, patient safety, and access to devices were identified as areas of focus, system-level strategies are also essential to overcome barriers to telerehabilitation. Health systems can implement standardized digital platforms integrated with electronic health records, provide technical support infrastructure, and develop clinician training programs. Partnerships with community organizations may help address access disparities, while policy advocacy is needed to secure long-term reimbursement and regulatory support. These coordinated efforts can enhance the scalability and sustainability of telerehabilitation.

Figure 2 Visual depiction of the evolution of palliative rehabilitation within the context of the COVID-19 pandemic. COVID-19, coronavirus disease 2019.

Despite the growing scientific evidence of the efficacy and cost effectiveness of palliative rehabilitation, many barriers remain to full integration of rehabilitation for people with serious illness. The aforementioned Policy Brief on Integrating Rehabilitation into Palliative Care includes key steps for providers and organizations; however, this document was developed by the European Region of the WHO and it is unclear if this document will be generalizable or widely accepted by nations or organizations outside of Europe (50). As palliative care services are highly integrated in most European nations, these recommendations may not be applicable or relevant for lower- and middle-income nations (LMIN) (51). In some LMINs, palliative care integration, and therefore rehabilitation integration within palliative care remains sparse and inconsistent (51). In a scoping review of palliative care and rehabilitation for socioeconomically disadvantaged patients performed by Sampedro Pilegaard et al., only 11 articles were identified, none of which discussed access to rehabilitation (52). As the pandemic exposed the vulnerabilities of those with socioeconomic disadvantages, an increased emphasis on social determinants of health (SDOH) is another potential outcome of the pandemic. This should include leveraging the skills and knowledge of the rehabilitation therapist in addressing SDOH and mitigating the negative consequences of socioeconomic factors on health and QoL in the presence of serious illness. Rehabilitation therapists routinely assess and address contextual and environmental factors and should play a pivotal role in bridging the gap across SDOH domains to improve care delivery (53).

As most providers of palliative rehabilitation services developed their skills through mentoring and trial-and-error, future collaborative efforts should be to clearly define, describe, and identify the skills needed for palliative rehabilitation therapists (50,54). An important first step in this process would be to establish an internationally recognized consensus definition of palliative rehabilitation. After this is completed, key stakeholders can then identify the critical knowledge, skills, and attitudes that are required to provide palliative rehabilitation services across settings. Once these key learning needs have been established, training programs, certification courses, and entry level education can be developed to further integrate the unique role of rehabilitation within palliative care. One substantial barrier to establishing consensus in this area is the significant global variation in payment and regulatory infrastructures, which will likely complicate the development and implementation of these initiatives. Nonetheless, these steps remain crucial as they will enable professional organizations, institutions, and individuals to advocate for essential changes that enhance access to palliative care and rehabilitation, thereby improving cost savings and clinical outcomes.

This narrative review has several limitations that must be acknowledged. First, the aim of this article and the scope of the topic necessitated selective inclusion of literature, which may have inadvertently excluded some relevant articles, including case reports, editorials, and articles published in languages other than English. While this review highlights the benefits of rehabilitation and interdisciplinary care, it primarily relies on qualitative analysis and does not provide detailed quantitative data to substantiate these findings. While some new palliative rehabilitation programs and initiatives emerged following the COVID-19 pandemic, it is unclear whether they were directly prompted by the pandemic’s disruptions or if they would have developed independently. Finally, while an effort was made to include diverse geographic and cultural perspectives, the majority of available research originates from high-income countries, which may not represent global practices or challenges in palliative rehabilitation.

Future research should aim to address the gaps identified in this review by focusing on empirical studies that evaluate the efficacy, feasibility, and safety of rehabilitation interventions in palliative care settings. Priority should be given to exploring telehealth and hybrid care models to enhance access to rehabilitation services for individuals with limited mobility or those residing in underserved areas. Notably, there were no articles identified in this narrative review focusing on the rehabilitation management of patients diagnosed with COVID-19 with multiple complex medical comorbidities. As many patients receiving palliative care and rehabilitation have multiple serious conditions or terminal illness, further emphasis on the topic of rehabilitation management of multimorbidity in serious illness is critical for achieving optimal outcomes. Additionally, longitudinal studies are needed to assess the long-term outcomes of rehabilitation interventions on QoL, functional independence, and symptom management in palliative care populations. Research should also prioritize diverse cultural, geographic, and socioeconomic contexts to ensure findings are widely generalizable, especially in LMINs where resources and healthcare infrastructure may differ substantially. Finally, interdisciplinary studies examining the integration of rehabilitation into palliative care teams can provide valuable insights into optimizing patient-centered, relationship-focused care. These efforts will be critical in shaping future policies and practices to better serve patients with serious illness in a rapidly changing healthcare landscape.

Conclusions

Rehabilitation in palliative care is emerging as a key component of comprehensive patient-centered care since the COVID-19 pandemic, where the need for adaptable, innovative, and systems-based approaches is critical. This narrative review emphasized the potential of rehabilitation to improve QoL, preserve dignity, and support symptom management for individuals with serious illnesses—particularly amid the disruptions and challenges posed by the COVID-19 pandemic. Although the pandemic spurred meaningful progress in integrating rehabilitation into palliative care, continued research and advocacy are needed to address remaining gaps in evidence and access. By promoting interdisciplinary collaboration, leveraging technology, and prioritizing equitable care, the integration of rehabilitation into palliative care can help meet the complex needs of patients and caregivers, ensuring that care is compassionate, holistic, and impactful.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Prateek Lohia and Shweta Kapur) for the series “Latest Research on COVID-19” published in Annals of Palliative Medicine. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-6/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-6/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-6/coif). The series “Latest Research on COVID-19” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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