Overview of Geriatric Rehabilitation - Program Components and Settings For Rehabilitation

7/15/2014 Overview of geriatric rehabilitation: Program components and settings for rehabilitation
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Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Authors
Helen Hoenig, MD, MPH
Patrick M. Kortebein, MD
Section Editor
Kenneth E Schmader, MD
Deputy Editor
H Nancy Sokol, MD
Overview of geriatric rehabilitation: Program components and settings for rehabilitation
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2014. | This topic last updated: Oct 11, 2012.
INTRODUCTION The primary purpose of rehabilitation is to enable people to function at the highest possible level
despite physical impairment. Rehabilitation includes a vast array of interventions provided by a diverse group of providers
across the entire continuum of care. While rehabilitation may be provided to all age groups, the fastest growing population
of persons requiring rehabilitation services is adults over 65 years of age. This is because of the aging of the US and
worldwide population [1,2].
Improvements in both medical and rehabilitative care have helped to reduce prevalence of old age disability [3], but it
comes with a substantive price in demands for both medical and rehabilitation care [4]. Moreover, there is concern that
improvements in health and disability gained over the last several decades may not impact the generation just entering
retirement. The increasing numbers in this population, and the apparent increases in disability related to musculoskeletal
disorders (as well as depression, diabetes, and neurological disorders) affecting mobility-related activities in particular, will
likely further drive needs for rehabilitation [5].
Making good use of rehabilitation resources is facilitated by an appreciation for how disability occurs and the mechanisms
by which rehabilitation is effective. This knowledge leads to understanding of which specific rehabilitation services might
best be provided, where to provide them, and by whom. This topic will review aspects of geriatric rehabilitation related to
types of involved providers, interventions, and settings. Indications for rehabilitation and patient assessment are addressed
separately.
CONCEPTUAL MODELS FOR DISABILITY There are two major conceptual models for understanding disability and
where rehabilitation services can be most effective:
The International Classification of Function, Disability, and Health (ICF), developed by the World Health Organization
[6], and
A model variably known as the Environmental Press, Ecological, or Person-Environment Fit model, originally
described by Lawton [7].
The World Health Organization model (ICF) The International Classification of Function, Disability, and Health (ICF)
model (figure 1) indicates that an individuals level of function (body function, ability to execute a task [activity], and
participate in life activities) is determined by his or her health condition(s) within the context of environmental and personal
factors. Medical and surgical interventions are directed at the underlying health conditions causing disability; rehabilitation
services target the impairment, activities, and participation levels of the disablement process, as well as personal and
environmental contextual factors that influence activity and participation.
Multiple health conditions or comorbidities, with concomitant impairments, are common in older persons and influence the
disablement process. Effective treatment of late-life disability, therefore, is typically multimodal [8]. Decline in late-life
disability from 1980 to 2010 can be attributed to the combination of advances in medical care, improved socioeconomic
factors, and innovations in mainstream and assistive technology [3,9].
The ecological model Disability results from a mismatch between individual capacity and task demands, which in turn
are influenced by the environment and the way in which tasks are performed [7,10]. For example, walking imposes different
physical demands when performed atop Mt. Everest versus at sea level. Thus, the ecological model helps to explain how
personal and particularly environmental contextual factors described in the WHO ICF model interact with physical
limitations to result in disability [6,7]. In the ecological model, remediation of disability occurs through treatments that
either increase individual capacity or reduce task demand.
Medical treatment (eg, oxygen supplementation or medication) or surgical treatment (eg, cataract surgery, joint
replacement) have the potential to increase capacity. Rehabilitation interventions may improve capacity, reduce task
demands, or accomplish both. Examples of such interventions follow [11,12]:
Improve capacity:
Exercise
Hearing aids, reading magnifiers
Artificial limbs
Orthotics (ie, braces, splints)
Reduce task demands:
A raised toilet seat or bath bench, which reduce the effort required to rise to a standing position
A ramp or elevator to replace stairs
Both increase capacity and reduce demand:
A cane that can enhance sensory capacity by providing proprioceptive feedback to improve balance, and it can
reduce demand, for example, by offloading body weight from the leg to the arm to relieve arthritic joints or weak
lower extremities.
TYPES OF REHABILITATION PROVIDERS Disability has many diverse causes and often occurs through the
interaction of one or more medical conditions with both personal and environmental contextual factors. Therefore, a wide
variety of providers may be involved in treating rehabilitation.
A list of types of rehabilitation providers, the typical rehabilitation interventions used by various disciplines, and the
aspect(s) of the disablement process targeted by the provider types is provided in a table (table 1). Treatment by a provider
in a single discipline is often sufficient for patients with uncomplicated conditions or with minimal disability (eg, physical
therapy for osteoarthritis of the knee or a home safety evaluation by an occupational therapist for a patient with fear of
falling). However, for more complex or catastrophic disability, a multidisciplinary team of providers is optimal to address the
rehabilitation needs related to progressive disability and the interaction of multiple contributing conditions and contextual
factors.
Multidisciplinary care is a cornerstone of rehabilitation. The efficacy of coordinated multidisciplinary rehabilitation for a
number of conditions affecting older adults, including stroke, rheumatoid arthritis, falls, and frailty, is supported by
numerous studies [13-19]. Geriatric evaluation and treatment units provide multidisciplinary care with medical, social
service, nursing, and rehabilitation personnel (typically physical and occupational therapy) working together in a
coordinated fashion [13]. Inpatient stroke rehabilitation teams include a variety of rehabilitation personnel (eg, speech
therapy, occupational therapy, physical therapy) to target rehabilitation therapies to the specific stroke-related deficits, as
well as medical, nursing, and other staff [14]. Coordination of care may be achieved with weekly team meetings and/or
scripted protocols to facilitate care coordination.
Benefits from coordinated multidisciplinary rehabilitation accrue from systematically targeting the multiple factors that
interact to cause and exacerbate disability. For example, stroke may adversely affect visual perception, speech, and
cognition as well as cause paralysis. Members of the multidisciplinary team often have both unique and overlapping
expertise, reinforcing the interventions of each other.
INTERVENTIONS
Exercise Physical activity is defined as bodily movement that is produced by skeletal muscle contraction and that
substantially increases energy expenditure. Exercise, a type of physical activity, is defined as a planned, structured, and
repetitive bodily movement done to improve or maintain one or more components of physical fitness (eg, muscle strength,
flexibility, balance).
Physical activity is beneficial for reducing overall morbidity and mortality in older adults (table 2) [20]. Exercise
recommendations for all individuals >65 years of age are shown in a table (table 3) and discussed separately. (See
"Physical activity and exercise in older adults".)
The physical activity recommendations intended for all older adults may need to be modified for particular medical
disorders, using specific types of exercise to correct or ameliorate identified impairments and functional limitations.
Common conditions in older adults that would necessitate exercise modification include acute cardiac conditions (eg,
cardiac rehabilitation), orthopedic and neurosurgery procedures, osteoporosis, acute/postacute stroke, or chronic
respiratory disease (eg, pulmonary rehabilitation). Physical therapists, exercise physiologists, and physicians specializing
in rehabilitation (physiatrists) can help to tailor the exercise prescription to meet particular patient needs.
Certain types of exercise may be particularly beneficial for specific patient populations. As an example, resistive exercise
and power training have been found to improve function in frail older adults [21]. A systematic review found that progressive
resistance exercise (ie, weightlifting) can significantly improve muscle strength and, to a lesser extent, functional activities
such as rising from a chair and ambulation [22].
During acute hospitalization, early mobilization seems to offer particular benefit, improving outcomes in multiple patient
populations, including patients with hip fracture, acute pneumonia, or critical illness in the intensive care unit [23-25].
Assistive technology Assistive technology and adaptive methods encompass a diverse group of interventions designed
to enable people with physical limitations to participate in a broad range of activities.
Assistive technology refers to devices that may be used to make tasks easier or safer (eg, a reacher can be used
by someone with limited upper or lower extremity range of motion to make it easier to pick something up).
Adaptive methods refers to changing the way a task is done so as to make it safer or easier (eg, a stroke patient
might don a sweater more easily by putting the sleeve on the paralyzed arm first, then on the non-paralyzed arm,
and then over the head).
Often the two methods are used together. These interventions can act at all levels of the disablement process, targeting
particular organ system impairments (eg, a prosthetic leg after an amputation), particular types of activities (eg, a cane
used when walking), or broadly enhancing access and opportunities for participation (eg, ramps allowing access to public
buildings).
Assistive technology is a particularly common way of coping with disability [26]. Assistive technology includes mobility
aids such as canes and walkers, bathroom safety devices such as raised toilet seats and grab bars, self-care devices
such as reachers and built up utensils, as well sophisticated computerized and electronic technology. Use of assistive
technology has increased substantially in recent years, far exceeding the growth and aging of the US populations [27,28].
By some reports, technological advances may account for half of the decline in disability in recent years [3]. There has
been both an increase in evidence to support its effectiveness [29-31] as well as major improvements in the technology
itself, with improved ergonomics, ease of use, and durability [32]. The internet provides a wealth of information about
diverse assistive devices. Abledata is one such resource, providing objective information on assistive technology and
rehabilitation equipment available from sources within the United States and internationally.
Mobility aids With the aging of the population, there is increasing need for mobility aids. In the United States in
2000, among adults 65 years and older, 10 percent used canes and 4.6 percent used walkers [33]. Mobility devices may
be used for diverse types of physical limitations affecting mobility, including weakness, sensory limitations (vision or
proprioception), impaired balance, and/or limited endurance. While such devices are intended to improve mobility, activity,
foster independence, and provide some protection against falls, evidence from high-quality studies on the impact of these
devices is sparse.
There are multiple options for mobility aids, and their appropriate use is outlined below. An algorithm for selecting among
mobility aids and a table that reviews indications and the relative pros and cons of various mobility aids are provided
(algorithm 1 and table 4).
Despite availability of insurance coverage, many older adults purchase mobility aids over the counter on their own or borrow
them from friends or relatives without professional guidance, which can lead to problems using the device [34]. Mobility
aids that are not properly fit or are used incorrectly can increase the risk of falls and injury. Falls directly related to mobility
devices account for over 50,000 visits annually to emergency departments in the United States [35]. Moreover, 30 to 50
percent of wheelchair users report tips and falls [36]. It is vital to observe older patients actually using their mobility aid to
verify proper fit and correct use and to refer the patient to expert consultation with a certified Assistive Technology Provider
(ATP), physical therapist (PT), or occupational therapist (OT) if there is any question.
Canes Canes are the most commonly used type of mobility device [37,38]. Most persons are not properly
instructed in cane use, and up to 70 percent of canes are used incorrectly or are the wrong height or design [33]. As a
result, almost 30 to 50 percent of individuals abandon use of the cane after receiving it.
Typically, canes are used to reduce the weight borne across an arthritic joint, thereby reducing pain, or to assist with
balance when the balance problem is due to impaired sensation and/or mild leg weakness. A cane can transmit
proprioceptive input to the hand and arm, which can be helpful to people with neuropathic problems or visual deficit. Canes
are lightweight and versatile, but require good hand and arm strength and provide only minimal support. Canes are most
useful when the gait problem is unilateral and/or mild.
A variety of options are available in canes. For most patients, a simple cane with an ergonomic grip is most effective [39].
A quad cane with four tips provides a broader base of support but is clumsier to use. A cane with a pistol grip handle can
increase weight support.
The cane needs to be at the right height so as not to throw off balance and to provide proper biomechanical support, with
the handle of the cane at the level of the wrist with the arm fully extended. Most canes can be adjusted by cutting the cane
at the tip or, for adjustable canes, with the button on the side of the cane. Most canes have a rubber tip to improve traction
that should be inspected for wear and replaced when worn.
A cane should be used in the hand opposite to the affected limb to preserve a normal gait pattern and keep the body
weight over the base of support to ensure good balance.
Crutches Like canes, crutches come with various options (eg, axillary, forearm, and platform crutches). However,
as all crutches require excellent arm strength and coordination for effective use, they are seldom used with older patients.
Improper use of crutches, especially the more common axillary crutches, can result in injury to the shoulder (eg, brachial
plexopathy and rotator cuff tendinitis). There are several different ways to use crutches (eg, swing through gait, touch-down,
etc.) and most require learning a novel gait pattern, which can be challenging in the presence of even mild cognitive
impairment.
Walkers Walkers are the second most commonly used type of mobility aid [34,35]. Walkers generally are used
to treat bilateral gait problems or when more body-weight support or balance support is needed than a cane can provide.
Walkers come with many options in the number of wheels and type of support.
One of the most commonly used types of walker is a two-wheel or front-wheel walker. A four-point or pick-up walker is
seldom used any more, as it is harder to use and offers little additional stability [40]. Forearm supports can be attached to
a two-wheel walker to enable use by persons with weak grip or hand deformities.
Increasingly common is a four-wheel walker with brakes located on the handles like a bicycle (sometimes called a rollator
or Canadian walker). Four-wheel walkers come with and without a seat and with or without a basket. A four-wheel walker
is less stable than a two-wheel walker. It requires good hand coordination to use the brakes and is more expensive than a
two-wheel walker; but it is more maneuverable, and the seat affords an opportunity to rest at will. It is a good choice for
someone whose main problem is poor endurance from pain or shortness of breath (such patients often have the necessary
balance and hand coordination to safely use this type of walker, and the seat allows for rest breaks). A three-wheel walker
can provide similar balance support as a four-wheel walker, but it is lighter weight and more maneuverable so it is
particularly useful for patients dealing with mobility in narrow confines (eg, a trailer) [41]; however, it is does not come with
a seat or basket so it is less useful for people with limited endurance or who need to transport items while walking (eg,
shopping).
A Merry Walker has four wheels, a sling seat, and railings on four sides so that the patient is protected from falling yet
can propel themselves. The Merry Walker is larger than other walkers and is best used in an institutional setting with wide
doorways/hallways.
A Knee Walker is a relatively new wheeled mobility device. It is similar to the foot-propelled or kick scooters used by
children but with a platform on which the patient can rest their knee while walking. It is especially useful for people who
must be non-weight-bearing after surgery or injury to the foot or ankle as it is easy to use and it avoids the need for a
wheelchair or crutches.
Wheelchairs Wheelchairs may be used when weightbearing is prohibited or in patients with significant functional
impairments (eg, bilateral leg weakness, impaired balance, and/or motor coordination too severely impaired for safe use of
a walker). The most commonly used wheelchair is a manual wheelchair with a sling seat that folds and has removable
footrests and armrests.
Many older individuals pay for wheelchairs and other assistive devices themselves [42] and may be tempted to save money
by use of non-removable foot rests or by using a second-hand wheelchair. Fixed foot rests are a fall hazard and make it
harder to get in and out of the chair and should be avoided. Borrowing a wheelchair can be problematic if the fit is not
adequate or the seat is worn, reducing comfort and increasing the risk of pressure ulcers [43].
Important aspects of wheelchair fit for all wheelchair users include seat width and height. The seat width should allow about
one inch between the thighs and the armrests, such that there is no pressure or rubbing on the lateral thighs while still
allowing good biomechanics when propelling the chair. The seat length should allow about two inches between the end of
the seat and the knees, and the foot rests are positioned so the thighs are slightly elevated or level such that the seat
provides even support to the buttocks and thighs. Patients who use their feet to propel the wheelchair (eg, stroke patients)
require a hemi-height wheelchair with a seat height that is lower to the ground. A seat cushion generally should be used
with a wheelchair and a specialized pressure-reducing cushion is appropriate for persons in the wheelchair full-time or who
have difficulty with limited ability to shift their weight while seated [44,45]. Specialized seating systems can be provided for
persons with truncal instability.
Shoulder pain is common in manual wheelchair users, and it is likely that elders with arthritic joints and women whose
upper extremities are weaker are at particular risk for developing shoulder problems with prolonged manual wheelchair use
[46]. Patients who develop shoulder pain with wheelchair use should be evaluated for rotator cuff tendinitis. (See
"Evaluation of the patient with shoulder complaints".)
A variety of options are available to treat shoulder pain in manual wheelchair users, including exercises to strengthen the
shoulder musculature, training on how to most efficiently propel the wheelchair, and/or providing a lightweight wheelchair
that is easier to propel or even a power wheelchair [47,48]. Ultra lightweight manual wheelchairs can be adjusted for
optimal biomechanical advantage when propelling the wheelchair, and interchangeable power assist wheels are available
that can reduce the force needed to propel the wheelchair. Wheelchairs with special adaptations to meet specialized
needs (eg, ultra lightweight, elevating leg rests, reclining backrests, power wheelchairs, etc.) may require additional
justification to ensure reimbursement [49].
Motorized wheelchairs and scooters are increasingly common and are most helpful for community mobility [50]. Even the
most compact motorized wheelchair has a larger footprint than a manual wheelchair, making it hard to maneuver in the
home. The cost-benefit trade-offs for these devices need to be considered carefully: financial costs include not only the
device, but a car lift to transport the device and an entry ramp if it is to be used in the home. There also is a risk of
accidents (collisions, tipping over); however, the risk of deconditioning appears minimal.
At least in the short term, power scooters do not appear to be overused or to cause deconditioning [51]. It appears that
most wheelchair users pick and choose locations where they use their wheelchair depending on needs, abilities, and
environmental constraints [52]. Benefits from wheelchairs relate to increased mobility and participation in activities that
would be prohibitive otherwise [53].
A systematic review of the evidence regarding the best way to obtain the optimal wheelchair found that there is only limited
evidence to determine best practices [54]. There is some evidence that expert assistance, fitting, and training is helpful for
improving wheelchair use [55-57]. For patients with complex rehabilitation and seating needs (eg, deformities, increased
muscle tone/spasticity), a multidisciplinary team can be helpful, including a rehabilitation physician (physiatrist), an
occupational therapist (OT) or physical therapist (PT) with expertise in wheelchairs, a certified rehabilitation technology
supplier, and/or a rehabilitation technician [54]. For individuals with complex needs, several components of a wheelchair
program will help to assure a good outcome: education to reduce accidents and maximize mobility; involving the individual
in the prescription process; and active follow-up to reduce accidents and make adjustments, as needed, to improve fit and
usage [54]. Expert evaluation and training is also important for patients who will use the wheelchair full-time, who are at
increased risk for pressure sores (eg, due to incontinence or inability to weight shift), for persons with postural problems, or
if a motorized wheelchair or scooter is being considered. However, even short-term and intermittent wheelchair users likely
benefit from fitting and training by an OT or PT in use of the device, with beneficial effects related to comfort and ability to
safely navigate with the wheelchair [56].
Reimbursement for mobility aids in the US Medicare (Centers for Medicare and Medicaid [CMS]) will pay for
durable medical equipment (DME), including all types of mobility aids, but it is important to follow their guidelines to
ensure coverage (table 5) [58]. Medicare guidelines for Mobility Assistive Equipment (MAE) favor use of a cane or walker
over a manual wheelchair and a manual wheelchair over a power wheelchair scooter, approving the higher-level device only
if the patient has a mobility limitation that is not adequately compensated with the lower-level device [59]. Generally,
Medicare reimbursement is limited to one type of mobility aid per qualifying illness (ie, the patient isnt provided both a
quad cane and a wheelchair for mobility needs after a stroke). Face-to-face evaluation by a physician or midlevel provider
and substantive medical justification is required by CMS for power mobility devices [60].
Some medical supply stores and vendors employ a certified Assistive Technology Professional (ATP) especially for
provision of complex devices (eg, power wheelchairs). Medicare/CMS covers consultation with an OT or PT for fitting and
training in use of any type of durable medical equipment, including mobility aids.
The Veterans Health Administration (VHA) will also cover most types of mobility aids and without some of the restrictions
in the Medicare system (eg, more than one type of mobility aid may be provided for a particular medical problem so long as
it is medical necessary), although medical justification by a VHA medical provider is required and training in use of the
device by a VHA rehabilitation provider is also usually required.
Typically, Medicare will pay for rental of a standard manual wheelchair, with the patient owning the wheelchair after 13
months of rental [61]. Wheelchairs for nursing home residents are provided by the institution rather than Medicare/CMS, so
it can be difficult to obtain a specialized wheelchair in that setting. Veterans own the mobility aids provided to them by the
VHA, and they do not need to be returned when they are no longer needed, although they may need to be returned to get a
new or replacement device.
Bathroom and self-care aids A wide variety of devices and environmental modifications can be used to make self-
care tasks easier and improve safety, particularly in the bathroom. While the evidence to support the efficacy of particular
bathroom devices is limited [62], the theoretical rationale for their provision is strong. Several randomized clinical trials have
demonstrated beneficial clinical outcomes (eg, physical function, and/or balance confidence and/or reduced falls) from
home health interventions that include provision of assistive devices, environmental modifications, and home visits by
rehabilitation therapists [63-67]. Evidence suggests that simply providing home safety assessments and equipment without
involvement of a professional such as an OT is less effective [68].
Useful information on bathroom design and other types of environmental modification to enhance independence and safety
is available at the websites for the Center for Inclusive Design and Environmental Access
(www.ap.buffalo.edu/idea/home/index.asp) and the Center for Universal Design (www.design.ncsu.edu/cud/index.html).
Commonly-used bathroom equipment includes raised toilet seats, seats in the tub/shower, hand-held showers, and grab
bars.
Raised toilet seats It is easier to rise to standing when starting from a higher level than a lower level [69], so a
raised toilet seat or tub/shower bench may be helpful to someone with weak legs, painful joints, or poor balance.
Raised toilet seats may be free standing (eg, bedside commode) or attached directly to the toilet. Tub/shower
benches also come in a variety of shapes and sizes.
Grab bars Bars may allow patients to rise more safely by enabling use of the arms to compensate for weak legs
or limited sensation. Patients may rely on items already in their home such as a nearby sink or towel bar for this
purpose, which is fine if they are stable or securely attached to the wall, but can be dangerous if the item is
unstable. Placement of grab bars can eliminate some of the risk.
There is considerable variety in grab-bar technology [70], with options such as direct attachment to the toilet or a
raised toilet seat, swing away bars, attachment to the side of the tub, or directly to the wall itself.
For patients who need help from another person for transfers, use of a gait belt can improve safety, and hydraulic lifts are
available that can be easily used even by quite frail caregivers.
Prosthetics and orthotics A prosthesis is an artificial device that replaces a missing body part (eg, artificial limb)
while an orthosis is an external device applied to the body to support or improve the function of that body segment/joint (eg,
ankle foot orthosis, carpal tunnel splint).
Prostheses Prosthetic devices require detailed patient evaluation for optimal prescription. Careful consideration of
medical comorbidities and the premorbid functional status is required, particularly in older persons. Such factors may be of
lesser importance for younger patients with traumatic amputation.
Lower extremity amputations are the second most common type of amputation (with digit amputation most common), and
up to 90 percent are due to peripheral vascular disease in diabetic patients. The underlying disease that resulted in an
amputation (eg, diabetes, peripheral vascular disease) often affects the function of other organ systems and the patients
ability to cope with the increased work of walking required with a prosthesis. Comorbid conditions such as cognitive
impairment, arthritis, pulmonary disease, or stroke can also affect the use of a prosthesis. A systematic review noted that
the following factors were most predictive of functional walking ability after a prosthetic limb: cognition, fitness, preoperative
mobility, ability to stand on one leg, and independence in activities of daily living [71].
For some severely debilitated amputees, a manual or power wheelchair with a cosmetic leg may provide the best functional
outcome. For other amputees, functional needs may be met with a low-tech prosthesis, such as a simple knee or ankle
joint rather than a computerized knee or multiaxial ankle joint. In contrast, those with an above-knee amputation who are
likely to be able to ambulate in the community may benefit from a high-tech prosthesis with a computerized knee [72].
A multidisciplinary amputee clinic including a physiatrist, a physical therapist, and a prosthetist is the optimal resource for
determining the proper prosthesis and assuring correct fit and function. If this is not available, it is vital for the ordering
physician to work closely with a certified prosthetist and include a PT early in the process. In general, obtaining proper
prosthetic fit and function requires a skilled prosthetist. Unfortunately, there is limited research available to assist in
determining the optimal prosthesis for an individual patient [73]. Prosthetic training is typically completed on an outpatient
basis by a physical therapist who may then work with the prosthetist to modify the prosthesis if abnormal gait patterns or
skin breakdown are noted; ideally, there are intermittent evaluations and supervision by a physiatrist skilled in amputee
rehabilitation.
Orthoses Orthoses (ie, splints and braces) are available for virtually every joint in the body including the spine.
There are a number of prefabricated, off the shelf orthoses (eg, carpal tunnel splints, soft cervical collar). Custom orthoses
are generally fabricated by an orthotist although occupational therapists may also perform this function, particularly for
upper-extremity joints. Prefabricated splints and braces are most appropriate for uncomplicated conditions that dont have
substantial deformity.
Commonly used prefabricated lower-extremity braces in the geriatric population include those for the knee (eg, knee
sleeve, knee unloader braces), ankle foot orthoses for foot drop, and heel cushions for plantar fasciitis/heel pain. There are
few randomized trials with any braces. The available evidence indicates that knee braces may reduce pain and improve
function for patients with osteoarthritis [74,75].
Knee sleeves may be used for mild to moderate severity knee osteoarthritis (OA); devices to control patellar motion
(eg, patellar cutout) may be beneficial for patellofemoral OA. Due to the limited evidence of benefit for any particular
knee sleeve, patient preference should be the deciding factor. (See "Nonpharmacologic therapy of osteoarthritis",
section on 'Braces'.)
Knee unloader braces are designed to alleviate pain by unloading the osteoarthritic medial or lateral compartment of
the knee. Medial/lateral unloader braces should be reserved for patients with more severe knee OA and are best
prescribed by an orthopedic surgeon, rehabilitation physician/physiatrist, or with input from a physical therapist.
Patients with knee instability may be prescribed a hinged knee brace that can be set to limit range of motion to a
particular arc; however, such braces should only be prescribed under the direction of a rehabilitation or orthopedic
provider as they should be used in conjunction with a rehabilitation program.
Foot drop occurs most commonly after a stroke but may also be seen with a neuropathy affecting the
fibular/peroneal nerve. Ankle foot orthoses (AFOs) maintain the foot in a neutral position during ambulation and can
improve gait speed and self-confidence in patients with foot drop [76,77].
There is fair evidence that heel cushions may be beneficial for plantar fasciitis, and pre-fabricated heel cushions
appear to be just as effective as higher-cost custom-molded foot orthoses [78,79]. (See "Plantar fasciitis", section
on 'Treatment'.)
Patients at prolonged bedrest benefit from a protective orthosis to maintain the foot in a neutral position, preventing
Achilles tendon contractures and protecting the heels from skin breakdown/pressure ulcers.
For the upper extremity, carpal tunnel functional wrist splints are effective for reducing numbness and pain [80]; over
the counter splints are as effective for treating carpal tunnel syndrome symptoms as custom fit splints [81].
However, the patient should be referred for neurological evaluation (eg, electrodiagnostic testing) and possible
surgery if there is any evidence of thenar muscle weakness or atrophy. (See "Treatment of carpal tunnel syndrome",
section on 'Treatment'.)
Osteoarthritis of the first metacarpal phalangeal joint is common and it can be effectively treated with an opponens
splint. These splints typically are hand crafted by an occupational therapist, hand therapist (PT or OT), or
prosthetist.
Environmental modification Environmental modification and universal design describe interventions and methods
to minimize the effects of the environment in exacerbating disability and enhance accessibility for all persons irrespective
of their abilities. The term universal design highlights an overarching goal of enabling access for the widest possible
breadth of physical abilities. However, the effects of medical conditions on physical function are variable among individuals
[82]; similarly, interactions with the environment are not uniform across conditions and impairments. The
environment/person interface can be particularly important for persons with impairments affecting mobility and also for
persons with low vision.
Environmental modification may be used in isolation or in conjunction with assistive technology to enhance access and
utility of both public and private spaces for persons with disability [64]. Increasing evidence supports the influence of the
physical environment (ie, terrain, housing) on functional outcomes in older adults [83]. For example, elders who live in
neighborhoods with a mixture of residential and business facilities (ie, mixed use) and higher-density neighborhoods
report greater independence with Instrumental ADLs, with the effect most prominent among those with greater physical
limitations [84].
The Americans with Disabilities Act (ADA) of 1990 directed that new public and private business construction must be
accessible, and it supports widely used guidelines for accessibility. Technical information on the ADA is available at
www.adata.org, and information on accessibility is available from the US Access Board (www.access-board.gov/the-board).
Helpful information on environmental modification and universal design pertinent to both public and private spaces can be
found at the websites for the Center for Inclusive Design and Environmental Access
(www.ap.buffalo.edu/idea/Home/index.asp) and the Center for Universal Design (www.design.ncsu.edu/cud/index.html).
Occupational therapists have particular expertise in the person-environment interface within the home environment and can
work in conjunction with architects and structural engineers to recommend the most beneficial modifications; physical
therapists are particularly helpful with mobility impairments, equipment, and methods for coping with environmental
challenges both inside and especially outside the home; low-vision specialist provide unique expertise for these same
kinds of problems in older adults coping with low vision (eg, macular degeneration).
Modalities for pain Several therapeutic modalities are available for the treatment of pain.
Heat/Cold Two of the most commonly used therapeutic modalities are heat and cold. Both heat and cold may
be delivered to the patient in several different ways. Mechanisms of thermal transfer include conduction (eg, hot or
cold pack), convection (eg, whirlpool bath), and conversion (eg, ultrasound, diathermy). The effect of commonly used
modalities for delivering heat and cold is at the superficial level of the body; core temperature is altered very little by
localized thermal modalities. Ultrasound, particularly low-frequency ranges, is used to heat deeper tissues (up to
several cm in depth). Heating modalities include heating pads/hydrocollator packs, heat lamps, hot tub/whirlpool,
paraffin baths (paraffin mixed in mineral oil heated to 45 to 54C), and ultrasound (0.5 to 3.0 MHz). Heat causes
local vasodilatation and hyperemia. Cooling modalities for rehabilitation include ice cubes/packs/wraps
(recommended duration 10 to 20 minutes per session; thin damp towel between skin and ice), ice massage, and
whirlpool baths.
While both heat and cold are most frequently utilized for their pain relieving effects, other indications include muscle
relaxation for heat, and relief of swelling and edema for cold (table 6). Contraindications for thermal modalities must
be considered (table 7). Heat is generally contraindicated in patients with acute injury and application of cold is to
be avoided for patients with insensate skin or Raynaud phenomenon.
Evidence for the relative benefits of different methods to provide heat is limited and comparisons of modalities (eg,
hot pack versus diathermy) appear to show equal benefit for pain relief [85]. Although one study showed more rapid
resolution of calcific rotator cuff tendinitis with ultrasound compared to exercise alone, there was no difference
between the groups at nine months [86].
Transcutaneous electrical nerve stimulation (TENS) TENS is primarily used for musculoskeletal pain relief.
The mechanism of action for TENS is uncertain, although it has been postulated that TENS modulates pain
perception through the gate control pain theory. Well-controlled investigations have not demonstrated significant
benefit of TENS for musculoskeletal pain disorders beyond placebo or heat alone [87,88].
Iontophoresis/Phonophoresis These modalities utilize electric current (iontophoresis) or ultrasound energy
(phonophoresis) to force a therapeutic medication (eg, glucocorticoid) into tissues. Both are used to treat soft tissue
musculoskeletal injuries. Although evidence is limited, the few randomized controlled trials indicate that these
modalities are generally no more effective than placebo [89,90].
Other Persons with dysphagia may be helped by special feeding techniques (eg, tucking the chin, swallowing a second
time after every bite) and/or dietary modifications (eg, use of gelatin to thicken liquids) [91]. A speech language pathologist
(speech therapist) can use radiographic and/or endoscopic studies to clarify the nature of the dysphagia and fine-tune
recommendations. Treatment of dysphagia may be directed by the speech language pathologist individually or in
collaboration with a nutritionist and/or occupational therapist.
Reimbursement (US, other than mobility aids) The Veterans Health Administration (VHA), but not Medicare/CMS,
will pay for bathroom safety devices such as raised toilet seats, tub/shower seats, or grab bars, considering these items
not medical equipment and/or needed for personal convenience; however, Medicare will pay for a free-standing bedside
commode (table 5) [92].
Medicare/CMS will not pay for other assistive devices related to self-care (eg, specialized eating utensils), although the
VHA does provide these items. Consultation with a rehabilitation therapist (eg, OT, PT) for evaluation, fitting, and training in
use of any type of assistive devices is paid for by both Medicare and the VHA, and such consultation can help assure the
prescribed device will meet the patients needs and that they can use it safely [93].
Medicare/CMS provides coverage for many prosthetic and orthotic devices, although generally the patient is responsible for
a 20 percent co-pay (table 5) [58].
Medicare will cover fabrication of a prosthetic limb and related follow-up visits with a prosthetist, as does the
Veterans Health Administration (VHA). Per Medicare guidelines, the functional level of the amputee must be
considered and specified in the prescription for the prosthetic limb.
Typically both Medicare and the VHA will pay for a splint fabricated by an orthotist or occupational therapist and
many prefabricated braces as well.
The VHA will pay for ramps and some home renovations (with a monetary cap that varies with service connection), and
some veterans are eligible for a specially adapted housing grant [94]. Medicare does not cover environmental
modifications.
REHABILITATION SETTINGS Rehabilitation therapy services can be delivered in a wide variety of settings across the
care continuum. Settings for rehabilitation include the acute hospital (eg, critical care units, general medical or surgical
units) and postacute locations including transitional care units in hospitals, rehabilitation hospitals, nursing homes/skilled
nursing facilities, outpatient facilities, and the patients home. The intensity and nature of services that can be delivered
differ across the settings.
When not delivered in a dedicated rehabilitation unit, rehabilitation treatment is often limited to services by a single
discipline (eg, physical therapy [PT] or occupational therapy [OT]). Even when more than one rehabilitation service is
involved, the degree of coordination that is possible (ie, in the hospital, largely through progress notes or discharge
planning rounds) is less optimal than the coordination through in-person contact and physician-led weekly conferences that
is required in an inpatient rehabilitation facility.
Rehabilitation therapy in the acute hospital Rehabilitation therapy in the intensive care unit (ICU) is relatively new
[25]. Early mobilization, beginning the first day of ICU hospitalization and while the patient is still on a ventilator, can
shorten length of stay and improve functional outcomes [95-97].
Rehabilitative services for patients on medical and surgical wards typically focus on mobilization and discharge planning.
Data are accruing showing the merits of early mobilization for diverse acutely-ill patient populations [23-25]. There is good
evidence showing benefit from early intensive PT/OT in the hospital for stroke patients, and for patients with a total joint
replacement or hip fracture [23,98].
For example, early intensive rehabilitative therapy for stroke patients improves functional outcomes (eg, ability to walk and
to use the toilet independently) [99]. As another example, hip fracture patients with fewer days of immobility post-
operatively (ie, mobilized to be out of bed beyond a chair) had better ability to walk at two months and lower six-month
mortality [98]. However, it is necessary to determine if a patient has the capacity, both physically and mentally, to
participate in PT or OT. Close coordination of medical care can help, for example, by reducing delirium and by ensuring
optimal pain management [23,100]. (See "Prevention and treatment of delirium and confusional states" and "Management
of postoperative pain".)
Suggestions for parameters to determine the hospitalized patients ability to participate in PT or OT are shown in a table,
with focus on the patients cognitive, hemodynamic, musculoskeletal, and pain status (table 8).
Even for patients who cant participate in therapy, involvement of PT and OT is a necessary component of discharge
planning in any adult for whom there is concern about the ability to return home (eg, limitations in self-care or mobility are
present). This is particularly important for older adults as they are vulnerable to adverse effects from care transitions and
often require care in multiple settings over the course of illness and recovery [101].
Post-acute hospital rehabilitation A common critical decision for inpatient providers is determining the type of setting
in which post-acute rehabilitation will be delivered. Ideally, rehabilitation during the post-acute period will help to ensure
maximal recovery for patients after an acute illness.
Post-acute rehabilitation may take place in a number of different venues with differing advantages for various types of
geriatric patients. These sites include:
Inpatient rehabilitation facilities (IRF or acute rehabilitation)
Long-term acute care hospitals (LTACH)
Skilled nursing facilities (SNF) with Medicare certified therapy services (sometimes referred to as subacute or
transitional care units)
http://www.uptodate.com/contents/overview-of-geriatric-rehabilitation-program-components-and-settings-for-rehabilitation?topicKey=PC%2F16852&elap 10/37
The Geriatric Evaluation and Management inpatient rehabilitation program (within the Veterans Administration)
Home health
Outpatient therapy services
Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, the level of medical and
nursing support, and reimbursement. The options and considerations when considering continued rehabilitation upon
discharge from the acute hospital setting are summarized in a table (table 9).
Multiple factors are to be considered when determining an appropriate location for post-acute rehabilitation for a particular
geriatric patient. Definitive research is lacking to guide decisions. Key factors to consider include:
Medical diagnosis
Functional abilities (pre-morbid, admission and current)
Medical stability
Cognition
Therapy tolerance and motivation
Types of therapy services needed
Psychosocial factors such as patient/family preference, geographic location
Third party reimbursement
(See "Hospital discharge", section on 'Determining the post-discharge site of care'.)
Medical diagnosis The medical diagnosis is an important determinant of eligibility for admission to an inpatient
rehabilitation facility (IRF or acute rehabilitation hospital). Under the Centers for Medicare and Medicaid (CMS) guidelines,
60 percent of patients admitted to an IRF must have 1 of 13 medical diagnoses (table 10). These guidelines therefore
influence the availability of beds and acceptance of particular patients referred for IRF care.
Diagnoses that often warrant a higher level of post-acute care (ie, intensive rehabilitation in an IRF) include stroke, spinal
cord injury, and traumatic brain injury. General orthopedic patients (eg, patients recovering from hip fracture, ischemic
amputation, or total joint replacement) may not gain particular benefit from intensive rehabilitation, and may recover function
just as well with rehabilitation in a subacute or skilled nursing facility [102-104]; each patient should be evaluated
individually to determine their most appropriate postacute rehabilitation setting. Frailty in patients with hip fracture or
ischemic amputation may limit their ability to tolerate more intensive rehabilitation while patients with an elective total joint
replacement may have good general health and be able to rehabilitate with home health therapy followed by therapy in an
outpatient facility. In contrast, patients with traumatic amputation often have other concomitant injuries requiring intensive
rehabilitation.
Optimal level of post-acute rehabilitation Even within groups of patients who can benefit from intensive post-
acute inpatient rehabilitation, a variety of considerations are important when determining the optimal level of post-acute
care. The following describes some key considerations across most diagnostic groups that pertain to determining the
optimal level of post-acute rehabilitation.
Prehospital and current functional abilities Information about functional abilities may be obtained from PT
and/or OT evaluations and from the nursing service, although a history of prehospital function is best obtained from
the patient/family directly. PT/OT consultations should be made early on during an acute hospitalization. This will
help to ensure optimal clinical outcomes and allow sufficient time for the evaluation, equipment to be obtained if
needed, and the patient trained in its use.
Therapy assessments should include an evaluation of ambulatory function and the patients ability to perform basic
activities of daily living (ADLs) (table 11 and table 12). At a minimum, it should be determined whether the patient is
independent or requires assistance from another person. For example, most individuals who resided in a nursing
home setting pre-hospitalization will return to a nursing home, as it is unlikely they would make sufficient functional
gains to become independent again and would be unlikely to have an independent living situation to return to after
rehabilitation. Rehabilitation for such patients would best be met in a skilled nursing facilitylevel setting, rather than
in an IRF or with a home health service.
Medical stability Medical stability assists in determining both the patients ability to participate in therapy while
in the hospital and the type of post-acute setting needed after discharge. Inpatient rehabilitation facilities have
physicians on staff to see patients daily and treat complex rehabilitation medical problems (eg, spasticity,
autonomic dysreflexia); in contrast, a skilled nursing facility has skilled nurses on staff to monitor patients
conditions and provide skilled nursing services with intermittent support (eg, once weekly) from medical staff who
typically have general expertise in geriatric medicine. Thus, patients with active medical problems requiring close
physician and nursing care are best discharged to either a long-term acute care hospital (LTACH) or an inpatient
rehabilitation facility (IRF).
Cognition Participation in therapy is dependent, at a minimum, on the ability to follow one-step commands and
to sufficiently recall so that learning is possible and therapists are not repetitively instructing the same task.
Therapeutic goals are constrained when such abilities arent present, with interventions limited to recommendations
for equipment, environmental modifications, and caregiver training to enhance safety with functional tasks (eg,
ambulation and bathing) and caregiver training on interventions to help maintain physical/functional abilities (eg,
range of motion exercises, proper use of splints and braces).
Therapy tolerance and motivation While rehabilitation therapy in and of itself can help reduce depression and
restore confidence, patients must be willing to participate. The patients motivation may be gleaned from their
participation and motivation during therapy sessions in the acute hospital setting and their willingness to work with
nursing staff during daily care. Tolerance for the more intensive therapy program required in an IRF (three hours of
therapy per day, five days per week) also may be inferred from patient participation with PT/OT during their acute
hospitalization.
Types of needed therapy services Patients discharged to an IRF must have a demonstrated need for at least
two therapy disciplines (ie, PT/OT/speech therapy). These services may be offered in other settings, but anticipated
use of these therapies is not a requirement for admission to other settings.
Psychosocial factors Social support, financial resources/insurance, and personal preference (eg, facility close
to home) are important considerations in determining the best location for post-acute rehabilitation.
Reimbursement (US) Medicare uses a prospective payment for rehabilitation in many postacute settings, for
which a predetermined amount is provided for particular diagnoses, with consideration for the severity of the
condition and comorbid conditions (eg, mild stroke versus severe stroke with diabetes and hypertension). Social
workers can often provide helpful information about available payment rates.
A general example of these considerations for a stroke patient are as follows: Medicare prospective payment for
intensive inpatient rehabilitation after an acute stroke (without additional comorbid conditions) is approximately 12 to
14 days. In contrast, the same stroke patient may receive up to 100 days of therapy (20 days at 100 percent
coverage and 80 days at 80 percent coverage) in a skilled nursing facility. Thus, if the patient is likely to benefit from
prolonged therapy, but at a lower intensity, a skilled nursing home for rehabilitation might be the best choice.
Prospective payment is also in place for home health services. In that setting, a stroke patient might receive three
weeks of therapy (physical therapy, occupational therapy, and/or speech therapy) up to three times per week with
another one to two weeks with less frequent visits per week. Preceding treatment in an inpatient setting does not
preclude payment for home health therapies or outpatient therapies after discharge home.
In all three of these settings (inpatient rehabilitation, skilled nursing, home health), the patient must require skilled
services to qualify for Medicare payment. For home health coverage in particular, a single visit by an occupational
therapist (eg, for a home safety and falls assessment) would not be covered. Home health aid services, in the
absence of other skilled nursing or therapy series, would also not be reimbursed. In addition, home health services
are only covered for homebound patients, defined as being unable to leave home except for medical care and
infrequent non-medical reasons such as to go to religious services; the ordering physician must have had a face-to-
face visit with the patient in the preceding 30 days and document this [105].
Outpatient rehabilitation services continue to be paid for by Medicare as fee for service but the total number of
visits for all conditions are limited (to a total of $1870/year for PT plus speech therapy with an additional $1870/year
for OT in 2012). These limits may be exceeded for some medically necessary therapies with appropriate justification
from the medical provider and/or when provided in hospital emergency rooms or outpatient departments [106,107].
There is no requirement for skilled services by physical therapy or nursing for outpatient therapy services to be
covered.
Medicaid also covers rehabilitation services with variation from state to state. The VHA provides rehabilitation
throughout the continuum of care with either no charge for services or a modest co-pay (depending on level of
service connection and/or finances).
SUMMARY
A model from the World Health Organization describes disability as determined by an individuals health condition(s)
within the context of environmental and personal factors; rehabilitation services target the impairment as well as
personal and environmental contextual factors that influence activity and participation. In another model, disability
results from a mismatch between individual capacity and task demands; remediation of disability occurs through
treatments that either increase individual capacity or reduce task demand. (See 'Conceptual models for disability'
above.)
Rehabilitation treatment by a provider in a single discipline is often sufficient for patients with uncomplicated
conditions or with minimal disability. For more complex or catastrophic disability (eg, stroke, amputation), a
multidisciplinary team of providers as part of inpatient rehabilitation is optimal to address the interaction of multiple
contributing conditions and contextual factors. (See 'Types of rehabilitation providers' above.)
The physical activity recommendations intended for all older adults may need to be adapted to meet particular
needs, using specific types of exercise to correct or ameliorate identified impairments and functional limitations.
Physical therapists, exercise physiologists, and physicians specializing in rehabilitation (physiatrists) can help to
tailor the exercise prescription to meet particular patient needs. (See 'Exercise' above.)
An increasing variety of patient assistive technology aids can improve capacity for activity and/or reduce task
demands, but they can be hazardous if not used properly. Physical and occupational therapists can provide
prescription guidance as well as fitting and training in use of these devices to enhance functional benefits and
safety. Mobility aids (canes, crutches, walkers, wheelchairs) meet different needs (table 4) and, in the US, are
variably reimbursed depending upon insurance and the patients qualifying illness. (See 'Mobility aids' above and
'Reimbursement for mobility aids in the US' above.)
Orthoses (ie, splints and braces) are available for virtually every joint in the body including the spine; prefabricated
splints and braces are most appropriate for uncomplicated conditions that dont have substantial deformity. A
multidisciplinary team including a physical therapist, prosthetist, and/or physiatrist can provide guidance and fitting
as may be needed for more complex devices such as a prosthetic limb. (See 'Prosthetics and orthotics' above.)
Occupational therapists (OTs) have particular expertise on the self-care skills, person-environment interface within
the home environment, and can recommend the most beneficial assistive devices and home modifications; physical
therapists (PTs) are particularly helpful with mobility impairments and equipment, as well as exercise interventions
to treat physical impairment; speech therapists have expertise in treatment of impaired speech and swallowing; low
vision specialists provide unique expertise for older adults coping with low vision; a variety of other specialized
personnel may provide rehabilitation care in particular settings (eg, recreational therapists, rehabilitation nursing).
(See 'Environmental modification' above.)
Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Early
mobilization, beginning the first day of ICU hospitalization and while the patient is still on a ventilator, can shorten
length of stay and improve functional outcomes. Involvement of PT and OT is a necessary component of hospital
discharge planning, particularly for older adults, in patients for whom there is concern about the ability to return
home (eg, limitations in self-care or mobility are present). The options and considerations when considering
continued rehabilitation upon discharge from the acute hospital setting are summarized in a table (table 9). (See
'Post-acute hospital rehabilitation' above.)
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70. Sanford JA, Arch M, Megrew MB. An evaluation of grab bars to meet the needs of elderly people. Assist Technol
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71. Sansam K, Neumann V, O'Connor R, Bhakta B. Predicting walking ability following lower limb amputation: a
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72. Highsmith MJ, Kahle JT, Bongiorni DR, et al. Safety, energy efficiency, and cost efficacy of the C-Leg for
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73. Cumming JC, Barr S, Howe TE. Prosthetic rehabilitation for older dysvascular people following a unilateral
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74. Brouwer RW, Jakma TS, Verhagen AP, et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane
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76. de Wit DC, Buurke JH, Nijlant JM, et al. The effect of an ankle-foot orthosis on walking ability in chronic stroke
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77. Nolan KJ, Savalia KK, Lequerica AH, Elovic EP. Objective assessment of functional ambulation in adults with
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81. Tijhuis GJ, Vliet Vlieland TP, Zwinderman AH, Hazes JM. A comparison of the Futuro wrist orthosis with a synthetic
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September 11, 2012).
Topic 16852 Version 6.0
GRAPHICS
International classification of functioning, disability,
and health (ICF) model
Towards a Common Language for Functioning, Disability, and Health: ICF -
The International Classification of Functioning, Disability and Health. World
Health Organization, Geneva, Switzerland, 2002. Copyright 2002. Available
at: http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf.
(Accessed September 11, 2012.)
Graphic 86412 Version 1.0
Primary roles and functions of members of the multidisciplinary
rehabilitation team
Discipline
Evaluation and treatment
methods
Targeted aspect of the
disablement process
Assistive Technology
Provider (ATP*)
Determine need for assistive
technology and optimal technology
to best meet needs
Activities
Participation
Dietician Assess nutritional status
Alter diet to maximize nutrition
Health condition
Hand therapist Exercise
Physical modalities (heat,
ultrasound, etc.)
Fabrication of splints
Impairment (upper extremity)
Medical provider Assess health conditions
Treat health conditions
(medications, surgery)
Health condition
Nursing Assessment of physical condition
Wound care and medication
management
Evaluate self-care skills
Evaluate family and home care
factors
Self-care training
Patient and family education
Health condition
Impairment
Activities
Contextual factors (especially
social)
Occupational therapist Evaluate self-care skills and other
activities of daily living
Home safety evaluation
Self-care skills training
Recommendations for assistive
technology
Fabrication of splints
Treatment of upper extremity
deficits
Impairment (upper extremity)
Activities
Participation
Contextual factors (especially
environment)
Physical therapist Assessment of range of motion and
strength
Assessment of gait and mobility
Exercise training
Treatment with physical modalities
(heat, cold, ultrasound, massage,
electrical stimulation)
Impairment (lower extremity, back,
shoulder)
Activities (mobility)
Prosthetist Fabricate prosthetic limbs and
other prosthetic devices (eg,
prosthetic eye)
Impairment
Psychologist/psychiatrist Assessment of mental and
emotional function
Treatment of mental/emotional
disorder (medication, counseling)
Health condition
Impairment (psychological)
Context (personal)
Recreation therapist Assess leisure skills and interests
Involve patients in recreational
activities to maintain social roles
Participation
Speech/language
therapist
Assessment of all aspects of
communication
Assessment of swallowing
disorders
Treatment of communications
deficits
Recommendations for alterations of
diet and positioning to treat
dysphagia
Impairment
Participation
Social worker Evaluation of family and home care
factors
Assessment of psychosocial factors
Counseling
Liaison with the community
Participation
Context (social)
* Successful completion of a certifying exam offered by the Rehabilitation Engineering and Assistive
Technology Society of North America.
Occupational or physical therapist who has complete additional training and passed a national
certification exam in hand therapy.
Depending on the settings, the medical provider may be a physician such as a physical medicine and
rehabilitation specialist ("physiatrist"), neurologist, orthopedic surgeon, or geriatrician and/or mid-level
practitioners such as nurse practitioner or physician assistant.
Benefits of regular physical activity
Reduces the risk of dying prematurely
Reduces the risk of dying from heart disease
Reduces the risk of stroke
Reduces the risk of developing diabetes
Reduces the risk of developing high blood pressure
Helps reduce blood pressure in people who already have high blood pressure
Reduces the risk of developing colon cancer
Reduces feelings of depression and anxiety
Helps control weight
Helps build and maintain healthy bones, muscles and joints
Helps older adults become stronger and better able to move about without falling
Promotes psychological well-being
Physical activity counseling for older adults: An evidence-based quick guide
Recommendations:
Aerobic:
30 min or three bouts of 10 min/day
5 days/week
Moderate intensity = 5 to 6 on a 10-point scale (where 0 = sitting, 5 to 6 = "can talk," and 10 =
all-out effort)
In addition to routine ADL's
Strength:
8 to 10 exercises (major muscle groups), 10 to 15 repetitions
2 nonconsecutive days/week
Moderate to high intensity = 5 to 8 on a 10-point scale (where 5 to 6 = "can talk" and 7 to 8 =
SOB)
Flexibility/balance:
10 min 2 days/week
Flexibility to maintain/improve range of motion (ie, stretching of major muscle/tendon groups,
yoga)
Balance exercises for those at risk for falls (ie, tai chi, individualized balanced exercises)
Prevention:
Create a single physical activity plan that integrates preventive and therapeutic treatment of
chronic conditions
Sample endurance (walking) and strength plan
Weeks Walking Strength
Weeks 1 to 2:
Introduction and
acclimatization
Walk 10 min
Three days/week
Intensity level = 5 to 6 on
a 10-point scale
4 to 5 exercises for major muscle groups
using weight bearing calisthenics, elastic
bands, free weights or weight machines
One set of 10 to 15 repetitions on 2
nonconsecutive days/week
Intensity level = 5 to 8 on a 10-point scale
Weeks 2 to 6:
Begin
progression
First increase to five
days/week
Gradually increase time to
either 20 min or two
bouts of 10 min/day
Gradually add 4 to 5 exercises, totaling 8 to
10 major muscle group exercises
One set of 10 to 15 repetitions on two
nonconsecutive days/week
Intensity level = 5 to 8 on a 10-point scale
Weeks 6+:
Continued
progression and
exercise routine
refining
Progress time to meet
guideline of at least 30
min, in at least 10 min
bouts
Five or more days/week
Add a third nonconsecutive day/week
Increase resistance by 2 to 10 percent
depending on patient's progress and
comfort level
Emphasize pain free exercising
Recognize your role for PA advocacy
Tips for physical activity counseling:
If patient is: Planned approach:
[1]
[2]
Not ready to
change
Educate on benefits of exercise
Ready to change Develop a specific physical activity plan
Active Support continued activity
Assess current physical activity (type, frequency, duration, intensity)
Advise benefits relative to medical history
Tailor realistic plan (consider chronic illness, current physical activity level, functional limits, and
preferred activities)
Specify what to do where and when
Look for barriers and strategize solutions
Encourage social support: who and how
Confirm patient is "very sure" of physical activity success
Chart plan and give written physical activity Rx to patient
In follow-up, revise physical activity plan to enhance progress
Reinforce positive behavior and activity documentation
Reaffirm that more physical activity enhances benefits
For more resources and handouts see:
American College of Sports Medicine. Exercise is Medicine website. Available at:
www.exerciseismedicine.org/resources.htm. (Accessed December 17, 2011).
Veterans Health Administration Research and Development. Project LIFE Modules: Changing the
PACE for Seniors. US Department of Veterans Affairs. Available at:
www.research.va.gov/resources/pubs/LIFE-modules.cfm. (Accessed December 17, 2011).
National Center for Health Promotion and Disease Prevention (NCP). MOVE! Handouts. US
Department of Veterans Affairs. Available at: www.move.va.gov/handouts.asp. (Accessed
December 17, 2011).
ADL: activites of daily living; SOB: short of breath.
References:
1. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for
adults from the American College of Sports Medicine and the American Heart Association. Circulation
2007; 116:1081.
2. Morey MC. Celebrating 20 years of excellence in exercise for the older veteran. Federal Practitioner 2007;
24:38.
Determining which gait aid to prescribe for issues of endurance, balance,
or weight-bearing
When more than one gait aid is listed in a box, they are listed in order of increasing support.
Comorbid conditions would influence which gait aid to chose when more than one option is
available and/or would influence use of a more supportive device (eg, some with a little impairment
in endurance plus a little impairment in balance might require a wheelchair for community mobility
but be able to use a walker at home).
COPD: chronic obstructive pulmondary disease; HF: heart failure.
Attributes for selection of particular mobility aids

Body
weight
supported
Unilateral/bilateral
support
Balance
required
Coordination
needed
Arm
strength
needed
Cane Minimal (10
to 15
percent)
Unilateral Good Good Good
Two-wheel walker Moderate
(15 to 30
percent)
Bilateral Moderate Moderate Moderate
Four-wheel walker Moderate
(15 to 30
percent)
Bilateral Good Good Moderate
Crutches, swing-
through motion
Full (100
percent)
Unilateral Good Good Excellent
Crutches,
alternating motion
Partial (30 to
50 percent)
Bilateral Good Good Good
Manual wheelchair Full (100
percent)
Bilateral Minimal Minimal-
moderate*
Minimal-
good*
Power
wheelchair/scooter
Full (100
percent)
Bilateral Minimal-
moderate
Moderate Minimal
* Amount of coordination and arm strength for manual wheelchair depends on if it is self-propelled or
propelled by another person.
Good sitting balance is required for a scooter but may not be required for a power wheelchair.
Medicare coverage of durable medical equipment and prosthetic and
orthotic items
What Medicare covers What the patient pays
Durable medical equipment
Air fluidized beds The patient pays 20 percent of the Medicare-
approved amount after paying Medicare Part B
deductible for the year. Medicare pays the other
80 percent. The Medicare-approved amount is
the lower of the actual charge for the item or the
fee Medicare sets for the item. However, the
amount the patient pays may vary because
Medicare pays for different kinds of durable
medical equipment in different ways. Some
equipment may be able to be rented or
purchased.
Blood glucose monitors
Bone growth (or osteogenesis) stimulators
Canes (except white canes for the blind)
Bedside commode
Crutches
Home oxygen equipment and supplies
Hospital beds
Infusion pumps and some medicines used in
them
Lymphedema pumps/pneumatic compression
devices
Nebulizers and some medicines used in them
Patient lifts
Scooters and power wheelchairs
Traction equipment
Transcutaneous electronic nerve stimulators
(TENS)
Ventilators or respiratory assist devices
Walkers
Wheelchairs (manual and power)
Prosthetic and orthotic items
Arm, leg, back, and neck braces Patient pays 20 percent of the Medicare-
approved amount after paying Medicare Part B
deductible for the year. Medicare pays the other
80 percent.
Artificial limbs and eyes
Breast prostheses (including a surgical
brassiere) after a mastectomy
Ostomy supplies for people who have had a
colostomy, ileostomy, or urinary ostomy (per
physician order)
Prosthetic devices needed to replace an
internal body part or function (eg, Foley
urinary catheter)
Therapeutic shoes or inserts for people with
diabetes who have severe diabetic foot
disease (prescribed by the doctor treating the
diabetes or a podiatrist, and provided by
doctor or other qualified individual such as a
podiatrist)
Adapted from: Medicare Coverage for Durable Medical Equipment and Other Devices. Medicare Website. Available
at: http://www.medicare.gov/publications/pubs/pdf/11045.pdf (Accessed January 28, 2012).
Indications for heat and cold therapeutic modalities
Heat Cold
Analgesia Analgesia
Muscle relaxation Muscle relaxation (eg, spasticity)
Assist with connective tissue extensibility (ie,
joint contracture, musculotendinous stretching)
Edema/hemorrhage resolution (eg, initial 24 to
48 hours after acute musculoskeletal trauma)
Hyperemia/acceleration of metabolic processes
(eg, tenosynovitis, bursitis)
Reduction of metabolic processes
Hematoma resolution
Adapted with permission from: DeLisa's Physcial Medicine and Rehabilitation: Principles and Practice, 5th
edition, Frontera WR (Ed), Lippincott Williams & Wilkins, 2010. Copyright 2010 Lippincott Williams & Wilkins.
www.lww.com.
Contraindications for heat and cold therapeutic modalities
Heat Cold
Acute injury/trauma/hemorrhage Ischemia
Insensate skin Insensate skin
Ischemia Inability to communicate/respond to pain
Edema Impaired thermal regulation
Inability to communicate/respond to pain Raynaud's phenomenon
Impaired thermal regulation Pronounced cold pressor response
Malignancy
Cardiac disorders (eg, decompensated heart
failure)
Adapted with permission from: DeLisa's Physcial Medicine and Rehabilitation: Principles and Practice, 5th
edition, Frontera WR (Ed), Lippincott Williams & Wilkins, 2010. Copyright 2010 Lippincott Williams & Wilkins.
www.lww.com.
Criteria to identify patients able to participate in occupational
therapy/physical therapy treatment in the acute hospital setting
Health
characteristic
Criteria
Cognition Able to follow one-step commands
Oriented to person
Remember one of three items
Hemodynamic Mean arterial pressure 65 to 110 mm Hg (resting systolic blood pressure 85 to
160 mm Hg, and <200 mm Hg with exertion)
Heart rate 40 to 130 beats per min
Respiratory rate 5 to 40 breaths per min
Oxygen saturation 88 percent, with or without supplemental O and at rest
or with activity
Change in vital signs with activity <20 percent
Hematocrit >25 percent
No unstable angina (eg, change in ECG with activity)
Musculoskeletal
stability
Fracture/open wounds require explicit physician guidance with regards to
physical activity (eg, weight-bearing status, orthoses/braces, etc.)
Pain No acute exacerbation of pain during OT/PT
OT: occupational therapy; PT: physical therapy; ECG: electrocardiogram.
2
Characteristics of US postacute care settings where rehabilitation may be
provided
Rehabilitation
site
Facility
characteristics
Medical
coverage
Therapy
services
Nursing Insurance
Inpatient
rehabilitation (acute)
Multidisciplinary
team patient care
conferences
required within
four days of
admission and
weekly thereafter
Physician
available 24
hours/day, 7
days/week;
active medical
problem(s)
requiring
physician
supervision
with visit five
or more
days/week
PT, OT,
and
speech
therapy
available.
Patients
must need
two or
more
therapy
services
and must
receive
therapy
three or
more
hours per
day, five
days per
week.
24-hour
care
Medicare
Part A: days
1 to 20: 100
percent;
days 21 to
100: 80
percent plus
co-payment;
>100 days:
no coverage
Skilled nursing facility
(subacute/transitional
care unit)
Physician
supervised;
physician
evaluation
within two
weeks of
admission and
every 30
days;
physician
available in
emergencies
PT and OT
available;
typically
one or
more
session
per day
24-hour
care
Same as
inpatient
rehabilitation
Long-term acute care
hospital (LTACH)
Physician
available 24
hours/day;
active/ongoing
medical
condition
requiring
physician-level
care (eg,
ventilator
dependent)
PT and OT
available
24-hour
care
Same as
inpatient
rehabilitation
Home
therapy/nursing
Physician
referral and
recertification
every 60 days
PT, OT,
and
speech
therapy
available
Home
health
nursing
Typically one
to three
visits per
week by
OT/PT for
one to three
weeks, one
visit per
week with
RN, daily
home health
aid
Outpatient (hospital
or free-standing
clinic)
Physician
referral and
recertification
every 30 days
PT, OT,
and
speech
therapy
available
N/A May be
limitations in
number of
visits per
year
OT: occupational therapy; PT: physical therapy.
Adapted from: Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed, Pacala JT, Sullivan
GM (Eds), American Geriatrics Society, New York, 2010.
Medicare qualifying medical conditions for intensive rehabilitation facility
Stroke
Spinal cord injury
Congenital deformity
Amputation
Major multiple trauma
Femur fracture (hip fracture)
Brain injury
Neurological disorders (including multiple sclerosis, muscular dystrophy, Parkinson disease)
Burns
Active polyarticular rheumatoid/psoriatic arthritis and seronegative arthritides, with qualifiers
Systemic vasculitides with joint inflammation, with qualifiers
Severe or advanced osteoarthritis involving two or more major weight-bearing joints, with qualifiers
Hip or knee joint replacement, or both, with qualifiers
Source: CMS Manual System. Pub. 100-04, Medicare Claims Processing, Transmittal 347. Department of Health
and Human Services, Centers for Medicare and Medicaid Services 2005. Available
at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R347CP.pdf (Accessed
September 11, 2012).
Katz index of independence in activities of daily living
Activities Independence Dependence
Points (1 or 0)
Points (1)
NO supervision, direction, or personal
assistance
Points (0)
WITH supervision, direction,
personal assistance or total care
Bathing (1 point) Bathes self completely or
needs help in bathing only a single part
of the body such as the back, genital
area or disabled extremity.
(0 points) Needs help with bathing
more than one part of the body,
getting in or out of the tub or
shower. Requires total bathing.
POINTS:_____
Dressing (1 point) Gets clothes from closets and
drawers and puts on clothes and outer
garments complete with fasteners. May
have help tying shoes.
(0 points) Needs help with dressing
self or needs to be completely
dressed.
POINTS:_____
Toileting (1 point) Goes to toilet, gets on and
off, arranges clothes, cleans genital
area without help.
(0 points) Needs help transferring
to the toilet, cleaning self or uses
bedpan or commode.
POINTS:_____
Transferring (1 point) Moves in and out of bed or
chair unassisted. Mechanical
transferring aides are acceptable.
(0 points) Needs help in moving
from bed to chair or requires a
complete transfer.
POINTS:_____
Continence (1 point) Exercises complete self
control over urination and defecation.
(0 points) Is partially or totally
incontinent of bowel or bladder.
POINTS:_____
Feeding (1 point) Gets food from plate into
mouth without help. Preparation of food
may be done by another person.
(0 points) Needs partial or total
help with feeding or requires
parenteral feeding.
POINTS:_____
Total points:_____
6 points: high (patient independent).
0 points: low (patient very dependent).
Reproduced with permission from: Katz S, Down TD, Cash HR, Grotz RC. Progress in the development of the
index of ADL. Gerontologist 1970, 10:20. Copyright 1970 Oxford University Press.
The Lawton instrumental activities of daily living scale
Activities Points
Ability to use telephone
1. Operates telephone on
own initiative; looks up
and dials numbers
1
2. Dials a few well-known
numbers
1
3. Answers telephone,
but does not dial
1
4. Does not use
telephone at all
0
Shopping
1. Takes care of all
shopping needs
independently
1
2. Shops independently
for small purchases
0
3. Needs to be
accompanied on any
shopping trip
0
4. Completely unable to
shop
0
Food preparation
1. Plans, prepares, and
serves adequate meals
independently
1
2. Prepares adequate
meals if supplied with
ingredients
0
3. Heats and serves
prepared meals or
prepares meals but does
not maintain adequate
diet
0
4. Needs to have meals
prepared and served
0
Housekeeping
1. Maintains house alone
with occasion assistance
(heavy work)
1
2. Performs light daily
tasks such as
dishwashing, bed making
1
3. Performs light daily
tasks, but cannot
maintain acceptable level
of cleanliness
1
Activities Points
Laundry
1. Does personal laundry completely 1
2. Launders small items, rinses socks,
stockings, etc.
1
3. All laundry must be done by others 0
Mode of transportation
1. Travels independently on public
transportation or drives own car
1
2. Arranges own travel via taxi, but does
not otherwise use public transportation
1
3. Travels on public transportation when
assisted or accompanied by another
1
4. Travel limited to taxi or automobile with
assistance of another
0
5. Does not travel at all 0
Responsibility for own medications
1. Is responsible for taking medication in
correct dosages at correct time
1
2. Takes responsibility if medication is
prepared in advance in separate dosages
0
3. Is not capable of dispensing own
medication
0
Ability to handle finances
1. Manages financial matters independently
(budgets, writes checks, pays rent and bills,
goes to bank); collects and keeps track of
income
1
2. Manages day-to-day purchases, but
needs help with banking, major purchases,
etc.
1
3. Incapable of handling money 0
4. Needs help with all
home maintenance tasks
1
5. Does not participate in
any housekeeping tasks
0
Scoring: For each category, circle the item description that most closely resembles the client's
highest functional level (either 0 or 1).
A summary score ranges from 0 (dependent, requires significant assistance to live in the community)
to 8 (independent, no assistance required to maintain self in community).
Reproduced with permission from: Lawton MP, Brody EM. Assessment of older people: Self-maintaining and
instrumental activities of daily living. Gerontologist 1969, 9:179. Copyright 1969 Oxford University Press.
Di scl osures: Helen Hoenig, MD, MPH Nothing to disclose. Patrick M. Kortebein, MD Employment: Novartis Pharmaceuticals
Corporation (myoanabolic agent). Kenneth E Schmader, MD Grant/Research/Clinical Trial Support: Merck [Herpes Zoster (Zoster
vaccine)]. H Nancy Sokol, MD Employee of UpToDate, Inc.
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Overview of Geriatric Rehabilitation - Program Components and Settings For Rehabilitation

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Overview of Geriatric Rehabilitation - Program Components and Settings For Rehabilitation

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7/15/2014 Overview of geriatric rehabilitation: Program components and settings for rehabilitation

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