Current Geriatric Diagnosis & Treatment, 1st Edition

Section IV - Special Situations

37. Principles of Rehabilitation

Laura Mosqueda MD

Chinh D. Le MD

Rehabilitation is one of the most basic components of comprehensive care for the elderly. It is more than a process: it is a philosophical approach that emphasizes function, autonomy, and quality of life. Rehabilitation is defined as restoration of the ill or injured to an optimal functional level in the home or community in relation to physical, psychosocial, vocational, and recreational activity. The American Geriatrics Society defines rehabilitation as the maintenance and restoration of physical and psychological health necessary for independent living and functional independence.

In general, rehabilitation is concerned with lessening the impact of disabling conditions on individuals and their family members. This is especially important in the elderly, who often have multiple comorbid conditions. Although it is possible that a single event such as a stroke leads to the need for rehabilitation, this may be complicated by coexisting morbidity (eg, Alzheimer's disease). In other cases, there may be multiple concomitant conditions that lead to the need for rehabilitation, such as occurs in a person who has severe osteoarthritis, emphysema, depression, and diabetic neuropathy.

As the population ages, the prevalence of chronic diseases increases as does the rate of disability, defined as an inability to perform 1 or more activity of daily living (ADL) or instrumental ADL (IADL). Although there are reports of a decline in disability in the over-65 population, the prevalence of disability among people older than 65 remains quite high (~20%) and significantly increases with age (Figure 37-1).

DISEASE, IMPAIRMENT, DISABILITY, HANDICAP

In 1980, the World Health Organization (WHO) International Classification of Impairments, Disabilities, and Handicaps (ICIDH) used a model of disease, impairment, disabilities, and handicaps to characterize the disablement process. Disease is the underlying diagnosis or pathological process, noticeable at a microscopic level. It may progress to a point at which an organ system is unable to function normally, causing an impairment. An impairment of an organ system that causes a restriction or lack of ability to perform ADLs is a disability. A person with a disability who is unable to fulfill social roles is said to be handicapped. A person is not handicapped by virtue of a disability; rather, it is society that handicaps an individual by not providing adequate accommodations. In May 2001, the WHO released a revision of ICIDH, known as International Classification of Functioning, Disability, and Health (ICF), which introduced the concepts of body functions and structures, activities and participation, and environmental and personal factors to replace the concepts of impairments, disabilities, and handicap. In this model, the function of an individual in a specific domain is an interaction of the complex relationship between the health condition and contextual factors (Figure 37-2).

REHABILITATION SITES

In theory, rehabilitation can and should be given in all care settings. Although a rehabilitative philosophy may be used in all settings, medical reimbursement and the patient's overall condition usually decide the site of rehabilitation practice. Rehabilitation should be started as soon as a patient is able to tolerate the exercises to prevent secondary functional loss and promote early restoration of function. Each setting has its own advantages and disadvantages (Table 37-1).

Acute Inpatient Rehabilitation

Acute inpatient rehabilitation is usually provided for the patient who needs at least 2 different therapies (ie, physical therapy, occupational therapy, speech therapy), is able to tolerate therapy at least 3 h/day 6 days/week, and is likely to show significant improvement. The patient is usually monitored by an interdisciplinary team that includes a physician who is experienced in rehabilitation. Weekly team meetings allow for review, discussion, and planning of the rehabilitation process. The duration of inpatient rehabilitation varies from days to months depending on many factors (eg, clinical diagnoses, potential for functional gain, rate of recovery, family support, and insurance issues).

Subacute Rehabilitation

Patients who are not appropriate candidates for acute inpatient rehabilitation may benefit from subacute rehabilitation in a skilled nursing facility. Medicare and

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fee-for-service insurance cover physical therapy, occupational therapy, and speech therapy in the nursing home as long as the patient has been recently hospitalized for at least 3 consecutive days and the patient's condition is expected to improve with therapy. Many managed-care plans do not require a qualifying 3-day hospital stay. The patient is also eligible for rehabilitation in the skilled nursing facility if he or she has been home < 30 days after a 3-day hospitalization. The patient must be able to tolerate two 30-min sessions of therapy per day and must require at least 1 skilled nursing need. Medicare gives a 100-day benefit for each qualified skilled nursing home admission. When this period ends, the patient must be reevaluated to determine whether he or she qualifies for another 100-day benefit period.

 

Figure 37-1. Age at onset of activity of daily living disability for all persons (N = 1244). From Jagger C et al: Patterns of onset of disability in activities of daily living with age. J Am Geriatr Soc 2001;49:406. Used with permission.

 

Figure 37-2. Interactions between the components of ICF. From World Health Organization.

Table 37-1. Advantages & disadvantages of rehabilitation setting.

Setting

Advantage

Disadvantage

Acute inpatient

Early start

Therapy can be bedside or in the gym
Interdisciplinary team approach

Not all patients are eligible (must be able to tolerate therapy ≥ 3 h day 6 days/week)
High cost
Uses acute Medicare days

Skilled nursing facility

No requirement for 3 h of therapy/day

Does not use acute Medicare days
Length of stay longer than acute inpatient

Eligibility criteria required (3-day hospitalization, need of ≥ 1 nursing skill, able to tolerate two 30-min sessions of therapy per day)
Length of therapy somewhat limited by Medicare

Home

Usually preferred by patient
Therapist is able to evaluate home environment and need
Covered by Medicare
No transportation required

Usually not well equipped
May be burden on family

Only a certain number of visits allowed
No peer group

Outpatient

Access to equipment
Covered by Medicare and most insurance
Peer interaction and support

Transportation required

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Home Rehabilitation

Home is often the best site for the rehabilitation process. A home evaluation by the therapist helps to determine how the physical environment can be adapted to meet the needs of the patient. Home rehabilitation is covered under Medicare and requires ongoing supervision by a physician, who certifies continuing benefit and continuing need.

Outpatient Rehabilitation

For some patients, outpatient rehabilitation is the best option. Outpatient rehabilitation is suited for those who can be at home, have adequate resources for transportation to appointments, and benefit from the equipment in an outpatient rehabilitation department. Another, somewhat hidden, advantage to outpatient rehabilitation is peer interaction. Peers may encourage each other to achieve more.

PROCESS OF REHABILITATION

A comprehensive geriatric assessment is often helpful before the initiation of a rehabilitation program to assist with setting realistic goals with each patient. The assessment should include measures of a person's ability to perform tasks necessary to daily living, leisure activities, and social interactions. Several standardized assessment scales have been developed to facilitate and standardize the assessment process. The functional assessment scale selected should be multifaceted; ideally, it measures the disability of concern, monitors progress, enhances communication between team members, including patient and family, and measures the effectiveness of rehabilitation interventions. Regardless of whether a standardized instrument is used, a thorough multidisciplinary assessment is essential at a very early stage of the process.

The ultimate goal of a rehabilitation process is to attain optimal function at home and in the community, as defined by the patient. A patient's autonomy must be taken seriously, and time and effort should be spent to ascertain the patient's true wishes. Two people with the same impairment and resulting disability may have very different goals. One may want to return to a very active lifestyle involving exercise, volunteer activities, and baby-sitting grandchildren. The other may wish to return to a sedentary lifestyle that involves staying at home and watching television. The patient and the team will become very frustrated if the patient and team goals are not aligned.

Another important aspect in geriatric rehabilitation is understanding the availability and capability of family caregivers if assistance will be needed after discharge. Many families are willing to provide both emotional and practical support to their loved ones. To minimize caregiver burden and maximize the likelihood of a successful transition to home, the team needs to determine what level of functional recovery is necessary in order for the caregiver to assume care.

The outcome of the rehabilitation process and effectiveness of the rehabilitative intervention can be measured by assessing the patient's function at appropriate intervals and comparing the changes over periods of time. Therefore,

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it is important to select the functional assessment instruments that are valid and reliable for this purpose. The Functional Independence Measure (FIM; Figure 37-3) was designed as a comprehensive functional assessment instrument, usable by any trained health care professional regardless of discipline. It is short, practical, and easy to use and measures physical function as well as areas of communication and social cognition. It has been proven to have high validity and reliability. However, the FIM does have some limitations. Although it is designed to be scored by any rehabilitation team member, some disciplines may have more difficulty than others in assessing particular items in FIM. In addition, it may not be sensitive enough to measure change in disability among some patient populations (eg, patients with high-level spinal cord injury [C4-5 and C5-6], chronic pain, and traumatic brain dysfunction).

Geriatric rehabilitation (particularly in the inpatient setting) is ideally delivered via an interdisciplinary team, typically including a physician, nurse, physical and occupational therapists, speech and language pathologist, psychologist, social worker, dietitian, and recreational therapist (Table 37-2). Usually the physician is the team leader. In many rehabilitation programs, the physician team leader is a specialist in physical medicine and rehabilitation. In many geriatric programs, it is the geriatrician who leads the interdisciplinary team.

Nursing staff play a key role in the rehabilitation process, especially in inpatient rehabilitation. The nurse provides nursing care, ensures that all orders from all disciplines are performed, and trains family members to assist the patient on discharge. The nurse interacts most frequently with the patient and thus is able to reinforce and apply therapy interventions during daily activities on the ward.

The physical therapist focuses on promoting mobility (eg, ambulation and transfer), whereas the occupational therapist helps with performance in other ADLs and IADLs. The speech and language therapist evaluates and treats communication problems (such as aphasia), cognitive problems, and dysphagia, and the recreational therapist helps modify the treating environment according to patient preferences and prepares the patient to return to leisure activities. Because the intensive therapy sessions typically occupy only 3 h/day, it is important that the techniques, exercises, and approaches learned during these sessions be reinforced when the patient returns to the ward.

EQUIPMENT

Equipment in geriatric rehabilitation should be used appropriately to provide the best benefits and safety. Patients' and caregivers' preferences are also important. Some types of equipment are very basic but often overlooked, such as eyeglasses, hearing aids, dentures, and appropriate footwear.

For patients with gait problems, canes, crutches, or walkers may be appropriate (Table 37-3). The function of a cane is to widen the base of support and improve balance. Cane height should reach approximately to the level of the greater trochanter and permit elbow flexion to ~20–30°. For relieving weight-bearing pain, it should be placed in the hand opposite the painful lower extremity. The broad-based quad cane provides more stability. Walkers offer bilateral support for balance and stability while walking. Standard walkers have no wheels and must be picked up. Front-wheel walkers require less coordination between upper and lower extremities and, therefore, are often prescribed for patients with ataxic gait and those who are unable to lift and move the standard walker (eg, frail elderly). However, they are less stable than a standard walker and harder to use on thick carpet. Wheelchairs and scooters are other assistive devices for mobility. ADL adaptive devices such as reachers, built-up feeding utensils, swivel spoons, rocker knives, walker baskets, sock aids, and specially designed clothing and shoes may be useful depending on each situation.

Environmental adaptations are usually focused on modification of bathrooms and entryways. Raised toilet seats and associated grab bars or frames make it safer and easier to use the toilet. Tub and shower seats, nonstick tub surfaces, and grab bars are useful bathing aids. The home entrance may be modified with railings, grab bars, and ramps. Wheelchair ramps should rise about 1 in. for every 12 in. in length.

DISCHARGE PLANNING

Discharge planning should begin as soon as the patient's condition is stabilized and probable functional outcome can be predicted. If the patient is a candidate for nursing home living, rehabilitation should be focused on adjusting to disability and on basic functions that will improve quality of life in the nursing home (ie, swallowing, positioning, seating). The patient will often continue to have functional improvement with rehabilitation at a nursing home. If the patient plans to return home, complete detailed information on home structure and support should be provided by the family or through a home visit. Clear, well-informed communication about care needs and rehabilitation goals among the patient, rehabilitation team, and family/caregivers is essential before any discharge and ideally should be discussed throughout the rehabilitation process.

 

Figure 37-3. FIM Instrument. Uniform Data System for Medical Rehabilitation, State University of New York at Buffalo. Used with permission.

Table 37-2. Geriatric rehabilitation team.

Team member

Role

Patient and family

Participate in setting goals, long-term disability management

Rehabilitation nurse

Patient care, case management, patient and family interaction and teaching

Social worker

Case management, assessment of family and community resources, discharge planning

Physician

Provides medical care for disability and comorbid conditions, usually team leader

Occupational therapy

Helps to improve ADLs and IADLs, assesses and applies splints and assistive device

Physical therapy

Assesses and treats mobility problems: strength, flexibility, balance, endurance, coordination, mobility aids

Speech & language pathology

Assesses and manages communication and swallowing problems

Psychologist

Assesses and manages cognitive, behavioral, and affective status

Dietitian

Evaluates nutrition status and therapeutic diets

Recreational therapy

Assesses and manages leisure preferences, adaptations and integration into therapeutic plan

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REHABILITATION FOR COMMON GERIATRIC PROBLEMS

Stroke

General Considerations

Stroke is the third leading cause of death in the United States and the leading cause of serious, long-term disability. Each year ~700,000 people experience a new or recurrent stroke. Stroke was the cause of 167,661 deaths (~1 of every 14 deaths) in the United States in 2000; 50% of stroke deaths occurred outside the hospital. There are ~4.5 million stroke survivors alive today.

Treatment

Poststroke care may be divided into 3 phases: acute care, intensive rehabilitation, and long-term care. A rehabilitative approach should be a continuing process

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started as soon as life-threatening problems are under control during acute hospitalization.

Table 37-3. Common assistive devices for mobility.

Assistive Device

Indications

Advantages

Disadvantages

Single-point cane

To widen the base of stability and improve balance

Low cost; fits easily on stairs or other surfaces where space is limited

Point of support is anterior to the hand, not directly beneath it

Quadruped cane

As above

Provides broad-based support

Some may not be practical for use on stairs; prevents walking quickly

Walk cane (hemiwalker)

As above

Provides very broad-based support; especially useful for patients with hemiplegia

May not allow pressure to be centered over the cane; cannot be used on most stairs

Crutches

To improve balance and lateral stability and relieve weight bearing

Improves balance and lateral stability; relieves weight bearing

Requires good arm strength; awkward in small or crowded area; may damage nerve or vessel in axilliary area

Walker (pick up/standard, four-wheel, front-wheel)

To improve balance and relieve weight bearing

Affords greatest stability; improves anterior and lateral stability.
Provides sense of security
Several styles are available, depending on need

Tends to be cumbersome in confined area; eliminates normal arm swing; cannot be used safely on stairs; walkers with wheels difficult on carpeting and uneven surfaces

Wheelchair

To maximize mobility in people who cannot ambulate safely

Does not require leg strength
Able to move fast outdoors

Cumbersome in confined area; difficult to take in and out of vehicles

Candidates for intensive rehabilitation are those who are medically stable but have residual disabilities and need help with at least 2 ADLs, are able to sit up (with or without support) for 1 h, and are able to learn and participate in active rehabilitation treatments. Patients who meet these criteria and require moderate to total assistance in mobility or performing ADLs are candidates for an intense inpatient program if they are able to tolerate ≥ 3 h of therapy each day. Patients who meet these criteria but require only supervision or minimal assistance in mobility or ADLs are usually candidates for home or outpatient rehabilitation if the home environment and support are adequate or for rehabilitation in a skilled nursing facility if environment and support are not adequate at home.

Individual rehabilitation needs and goals vary greatly. There should be a comprehensive assessment using standardized assessment tools. It is important that a care plan be developed by an interdisciplinary team based on goals that have been discussed with the patient and family.

Factors determining appropriate placement include medical stability, mobility, incontinence, cognitive function, mental health issues, presence of pain, swallowing abilities, communication abilities, evidence of neglect, ability to learn, level of assistance needed for mobility and ADLs, endurance, ability to manage IADLs, amount of medical care needed, and adequacy of family support. Figure 37-4 provides an algorithm to help decision making in rehabilitation placement

Interdisciplinary rehabilitation improves functional outcome, but it is not clear which component of this approach is most important. With rehabilitation, ~10% of stroke patients recover full physical function, 40% have some mild to moderate loss of function, and another 40% have significant functional losses; 10% are likely to need institutional care. Table 37-4 lists factors affecting functional outcome after stroke.

Increasing age is strongly associated with worse functional outcome at hospital discharge and follow-up. However, age is not a significant predictor of change in FIM score, implying that age should not be a factor that influences access to intensive stroke rehabilitation. An elderly person may have more disabilities after a stroke than a younger person but will have the same degree of functional improvement after the stroke. Other factors that are weakly associated with poor functional outcome include lower educational level, poor social supports, single marital status, unemployment, history of stroke, history of coronary artery disease, and presence of diabetes mellitus. Factors that are not associated with stroke outcome include financial resources and history of hypertension, congestive heart failure, or peripheral vascular disease. The presence of the following in the first 1–4 weeks after a stroke are strongly associated with worse functional outcome at discharge: bowel and bladder incontinence, aphasia, global functional deficits, and sensory, motor, balance, visual, perceptual, and cognitive deficits. Unilateral neglect is also a negative predictor for recovery of function.

Rehabilitation interventions strongly associated with improved functional outcome are early initiation of rehabilitation services (within 72 h poststroke) and rehabilitation provided in an interdisciplinary inpatient setting.

Most of the functional recovery occurs in the first 6 mo after a stroke; some patients continue to gain functional abilities with physical therapy and exercise after 6 mo. Treadmill aerobic exercise training may improve exercise capacity and physical function after stroke. Treadmill training improves physiological reserve by increasing the peak volume of oxygen extraction while lowering the energy cost of a hemiparetic gait and increasing the peak ambulatory workload capacity. These improvements may enhance functional mobility in chronic stroke patients. Anecdoctal evidence supports the use of speech and language pathologists for cognitive rehabilitation of selected patients. In patients who are initially aphasic, ~50% of recovery of speech occurs in the first month and then recovery continues at a slower pace for ~6 mo.

Alternative therapies such as acupuncture have been tested as adjunctive treatment in stroke patients. The effectiveness of acupuncture, however, has not been proven.

Complications

  1. DEPRESSION

Poststroke depression occurs in 12–27% of patients (Table 37-5), interfering with the ability to perform ADLs. Depression is an underrecognized but treatable condition that improves with medication or psychotherapy or a combination. Thus, this diagnosis should be actively sought and treated in patients after stroke.

  1. FALLING

Stroke patients are susceptible to falling. Fall incidence can be reduced significantly with appropriate evaluation and intervention (see Chapter 12).

  1. SPASTICITY & CONTRACTURES

Spasticity and contractures, both common after a stroke, may greatly interfere with task performance. Treatment includes aggressive and consistent range- of-motion (ROM) exercises, proper positioning, and splinting. Oral medications are generally unsuccessful, although dantrolene sodium may have some beneficial effect. Injection of neurolytic agents such as phenol has variable success. The selective local intramuscular injection

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of extremely low doses of botulinum toxin A has been found effective in reducing local muscle tone for 3–6 mo, resulting in improved function in selected patients.

 

Figure 37-4. Core algorithm for rehabilitative placement of the poststroke patient. From Johnston MV: Rehabilitative placement of poststroke patients: reliability of the clinical practice guidelines of the Agency for Health Care Policy and Research. Arch Phys Med Rehabil 2000;81:541. Used with permission.

Table 37-4. Poststroke negative outcome predictors.

Age > 65
Lower education level
Poor social supports
Nonmarried
Unemployment
History of stroke
Presence of coronary artery disease
Presence of diabetes mellitus
Bowel/bladder incontinence
Cognitive deficits
Global functional deficits

  1. POOR CAREGIVER HEALTH

Early hospital discharge with home-based rehabilitation shortens the hospital stay without compromising functional outcome compared with conventional treatment. However, caregivers of the early discharge group may have worse general mental health. Support services for families have been shown to increase social activities significantly and improve quality of life for caregivers.

Osteoarthritis

General Considerations

Osteoarthritis is the most common disabling condition in older people. The first step in evaluating the rehabilitation potential of a person with osteoarthritis is a physical examination with special attention paid to ROM (active and passive), condition of joints (inflamed, deformed, swollen, or unstable), manual muscle testing, postural or gait instability, cardiovascular fitness, and subclinical conditions that could be exacerbated by exercise. Joint pain may affect the accuracy of muscle strength testing; thus, the examiner should document whether the patient has pain during muscle contraction and should estimate strength when pain interferes with an accurate examination of strength.

Table 37-5. Rehabilitation medical complications.

Complication or condition

n

%

Urinary tract infection

569

30

Joint or soft tissue pain

300

16

Depression

235

12

Hypertension

200

10

Electrolyte abnormalities

141

7

Acute urinary retention

95

5

Pneumonia

91

5

No complications

473

25

N = 1903.
From Roth, EJ: Comorbidities in stroke: issues in clinical trials. Paper presented at the National Center for Rehabilitation Research Workshop, August 2001. Used with permission.

Treatment

A variety of therapeutic modalities may be of benefit in patients with osteoarthritis. Figure 37-5 provides steps in managing osteoarthritis. Superficial heat (hot packs, heating pads, paraffin baths, fluidotherapy, whirlpool baths, and radiant heat) is more commonly used than deep heat (ultrasonography, short wave, microwave) for osteoarthritic joints. Many patients prefer cold to heat. Trial and patient preference should direct the prescription of heat or cold for symptom relief. Heat application at least temporarily reduces pain and increases the ability to move and exercise inflamed joints. Therefore, superficial heat should be applied before exercising and early in the morning to help relieve morning stiffness. Topical ointments like capsaicin and trolamine salicylate may give symptomatic relief in osteoarthritic joints but are often poorly tolerated by elderly patients. Transcutaneous electronic nerve stimulation may be helpful for hand, wrist, and knee pain. Acupuncture has not been shown to be of benefit.

There is consistent evidence that exercise training does not exacerbate pain or disease progression and is effective in decreasing pain and improving function. Promoting physical exercise should be an integral component in the management of osteoarthritis. Absolute contraindications to exercise are uncontrolled arrhythmias, third-degree heart block, recent electrocardiographic changes, unstable angina, acute myocardial infarction, and acute congestive heart failure. Relative contraindications are cardiomyopathy, valvular heart disease, poorly controlled blood pressure, and uncontrolled metabolic disease. Exercise stress testing should be considered in patients with significant cardiovascular risk factors and may help to establish an individual's initial aerobic exercise program.

To develop the best program for each patient, the physician must understand which functional problems are most important to the patient, help prioritize them, and then work with the patient to set specific short- and long-term goals. This will determine which exercise program to prescribe and will increase the likelihood of patient compliance.

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Flexibility exercises decrease stiffness, increase joint mobility, and prevent soft tissue contractures. These are often done during a warm-up period or in conjunction with resistance or aerobic activities. Patients should begin with 1 stretching exercise per muscle group at least 3 times/week, and then the number of repetitions per muscle group can be gradually increased to 4–10 repetitions. Table 37-7 shows general recommendations for static stretching exercises.

Strength training is an essential part of rehabilitation for people with osteoarthritis. Resistance training can reverse many age-related physiological changes and can enhance function by improving the strength of muscles that support the affected joints. Table 37-8 shows general principles for strength training in patients with osteoarthritis.

Isometric exercise is a better option if the joint is inflamed or unstable. This exercise can improve muscle strength and static endurance. Patients should contract the muscles targeted for strengthening, initially at ~30% of maximal effort and gradually increasing to 75% of the maximal voluntary contraction. The contraction should be held for no longer than 6 s. Initially, 1 contraction per muscle group should be performed, and the number of repetitions should be gradually increased to 8–10 as tolerated. At first, contractions should be performed at muscle lengths tolerable to the patient. As joint instability and pain decrease, the patient should gradually shift to dynamic (isotonic) training.

When joint damage is severe enough to cause contractures, more aggressive treatments may be beneficial, including arthroplasty, serial casting, serial casting combined with traction, and manipulation under anesthesia.

The main indication for arthroplasty is pain relief. Conservative (ie, nonsurgical) treatment should be exhausted before considering arthroplasty because joint replacement has limited longevity (~10–20 years).

After an uneventful hip or knee arthroplasty, patients are usually encouraged to sit up in a chair on postoperative day 1 and begin walking on day 2. By day 3, patients are usually switched to oral analgesics and started on intensive physiotherapy. By day 5, patients generally can be discharged from the hospital to either home or a rehabilitation facility depending on their condition. Six weeks after surgery, patients are usually ambulatory without the use of an assistive device. After 3 mo, most patients are able to return to their previous activities (eg, golfing, walking, swimming, cycling). One of the greatest challenges after knee arthroplasty is ensuring the return of flexion and extension of the knee. Vigorous passive exercises should be started immediately postoperatively. Most knee prostheses are now cemented, allowing full weight bearing in the immediate postoperative period. Therefore, partial weight bearing is necessary only when there is grafting or repair of tendon or muscle. The use of continuous passive motion machines immediately after surgery is controversial. ROM exercises, followed by muscle strengthening, are required for 6 weeks to 3 mo after total knee arthroplasty.

Two important issues in rehabilitation after arthroplasty are adequate pain control and prevention of deep vein thrombosis (DVT). Good pain control facilitates early mobilization and rehabilitation, resulting in a shorter convalescence period. Without prophylaxis, prevalence of DVT at 7–14 days after total hip or knee replacement is ~50–60%, with proximal DVT rates of ~15–25%. In 2001, the American College of Chest Physicians recommended either low-molecular-weight heparin (LMWH) or adjusted-dose warfarin as a first-line therapy for prevention of venous thromboembolism in hip and knee replacement surgery. Elastic stockings or intermittent pneumatic compression can be used as an adjuvant prophylaxis for hip replacement surgery; and intermittent pneumatic compression can be used as an alternative prophylaxis option for knee replacement surgery (Table 37-6).

Table 37-6. DVT prophylaxis in arthroplasty.

1. Hip replacement
Primary:SC LMWH or adjusted-dose warfarin (1A)
Alternative:adjusted-dose heparin therapy (2A)
Adjuvant:elastic stocking or intermittent pneumatic
compression (2C)

2. Knee replacement
Primary:SCLMWHor adjusted-dose warfarin (1A)
Alternative: intermittent pneumatic compression (1B)

3. Hip fracture surgery
Primary: SCLMWH or adjusted-dose warfarin (1B)
Alternative: low-dose unfractionated heparin (2B)

Note:

1. Optimal duration is uncertain but at least 7-10 days is recommended.

2. Extended out-of-hospital LMWH prophylaxis (beyond 7–10 days) is recommended for at least high-risk patients (2A)

1A, clear risk vs. benefit, randomized trials without important limitations; strong recommendation, can apply to most patients in most circumstances without reservation; 1B, clear risk vs. benefit, randomized trials with important limitations, strong recommendation, likely to apply to most patients; 2A, unclear risk vs. benefit, randomized trials without important limitations, intermediate-strength recommendation; 2B, unclear risk vs. benefit, randomized trials with important limitation, weak recommendation; 2C, unclear risk vs. benefit, observation studies, very weak recommendation.
Adapted from the Sixth ACCP Consensus Conference on Antithrombotic Therapy:DVT prophylaxis in arthroplasty. Chest 2001;119:132S. Used with permission.

Table 37-7. Static stretching exercise: general recommendations.

Exercise daily when pain and stiffness are minimal (ie, before bedtime).
Exercises can be preceded by a warm shower or by application of superficial moist heat.
Relax before beginning stretching exercise.
Perform movements slowly and extend the range of motion that is both comfortable and produces a slight subjective sensation of resistance. Breathe during each stretch.
Hold this terminal stretch position for 10–30 s before slowly returning the joint or muscle group to the resting length.
Modify the stretching exercises to avoid pain or when the joint is inflamed (decrease the extent if joint range of motion or duration of holding the static position).

Adapted from Exercise Prescription for Older Adult With Osteoarthritis Pain: Consensus Practice Recommendations. J Am Geriatr Soc 2001;49:808. Used with permission.

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ISOTONIC TRAINING

Isotonic muscle contractions are used to perform ADLs. Isotonic training has positive effects on energy metabolism, insulin action, bone density, and functional status. Osteoarthritic patients without instability or acute symptoms in the affected joint tolerate this form of exercise very well. It should include 8–10 exercises involving major muscle groups, starting at a low level so that the patient learns the exercises and does not get injured and gradually increasing both the intensity and number of repetitions. Patients should begin at 1 set of 4–6 repetitions and should avoid muscle fatigue. The training should be a maximum of 2 days/week. The amount of resistance used for training is increased 5–10%/week.

Table 37-8. Principles of strength training in osteoarthritic patients.

Specific exercises should be selected on the basis of the patient's joint stability and degree of pain and inflammation.
Muscles should not be exercised to fatigue.
Exercise resistance must be submaximal.
Inflamed joints should be isometrically strengthened and involved in only a few repetitions; movements should not be resisted.
Joint pain lasting 1 h after exercise and joint swelling indicate excessive activity.

Adapted from Exercise Prescription for Older Adult with Osteoarthritis Pain: Consensus Practice Recommendations. J Am Geriatr Soc 2001;49:808. Used with permission.

Hip Fracture

General Considerations

Hip fractures are a major cause of disability in older adults. Rehabilitation may help to reduce the disability of hip fracture.

Treatment

The typical postoperative course of hip fracture is as follows:

  • By 1 week postsurgery: ROM exercises, weight-bearing locomotion as tolerated, pivot transfers, isotonic ankle exercises, and isotonic gluteal exercises.
  • By 4–6 weeks postsurgery (endosteal and bridging calluses have formed): active ROM exercise around hip and knee, and active resistive exercise as tolerated.
  • By 8–12 weeks postsurgery: weight-bearing transfers and ambulation and weaning from assistive devices. Generally, skilled rehabilitation therapy is no longer needed.

A common pattern of functional recovery occurs after hip fracture. That is, recuperation occurs at different rates and plateaus at different times (eg, independence with upper extremity-related ADLs plateaus at 4.3 mo; recovery of cognitive function plateaus at 4.4 mo; and walking speed plateaus at 10.8 mo). Table 37-9 summarizes predictors of a poor rehabilitation outcome.

Although people with dementia have more problems in the immediate postoperative period, those with mild to moderate dementia (eg, Mini-Mental State Exam score 12–17) are often able to return to a community-living situation after an acute rehabilitation program.

Physicians can help facilitate a better outcome by being familiar with the principles guiding choice of operation and prosthesis and the main complications associated with each as well as with appropriate instruction for early weight bearing and movement precautions to prevent dislocation. Appropriate use of opioid analgesics, DVT prevention, good bowel and bladder care, and early recognition of delirium are essential for optimal results.

Deconditioning

Deconditioning is generally a result of prolonged limited mobility. The reason for the limitation of mobility can be physical (eg, pain, imbalance, reduced ROM),

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psychological (eg, fear of falls, depression), or environmental (restraint, neglect) or a result of lifestyle choices. Normal age-related changes, such as sarcopenia, make older adults more vulnerable to a deconditioned state and prolong the recovery process. Those with a high baseline level of function take longer to become deconditioned. However, significant deconditioning may occur in as few as 3 days of immobilization. The primary manifestations of deconditioning are reduced muscle strength, especially in the antigravity and large muscles, reduced joint flexibility, contracture, fatigue, resting tachycardia or abnormally high heart rate with submaximal exercise, and orthostatic intolerance.

 

Figure 37-5. Steps in managing osteoarthritis in the older patient. From American Geriatrics Society Panel on Exercise and Osteoarthritis: Exercise prescription for older adults with osteoarthritis pain: consensus practice recommendations. J Am Geriatr Soc 2001;49:808. Used with permission

The treatment of deconditioning includes providing adequate sensory and intellectual stimulation, regaining an upright posture, improving joint ROM with active or passive exercise, and increasing strength and coordination with a combination of isometric, isotonic, and functional activities. Four to 8 weeks of resistance exercise can increase strength and improve functional activity in debilitated elderly who need help with 1 or more ADLs. As a generalization, for every day of bed rest,

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2–3 days are needed for recovery. To prevent deconditioning, bed rest is generally avoided.

Table 37-9. Post-hip fracture surgery: negative outcome predictors.

Poor mobility on day 2 postsurgery (requires maximal assistance to transfer or moderate assistance to ambulate or ambulates < 2 m)
Old age (> 75)
Use of gait aid before fracture
Poor mental status (modified Pfeiffer SPMSQ score < 4)
Nursing home residence
Poor grip and ankle dorsiflexion strength
Significant number of comorbidities
Limited number of leisure activities, poor coping skills, and unmarried status
Hip pain, poor self-rated health, and previous employment in a prestigious occupation

SPMSQ, Short Portable Mental Status Questionnaire.

Falls & Instability

Each year ~30% of community-dwelling people older than 65 and 50% of those older than 80 fall. Falls are the leading cause of accidental death in the elderly. Those who survive a fall may have significant morbidity. Although the majority of falls do not result in injury, falls are associated with significant expense and health care use. Besides physical injury, falls also cause psychological and social consequences, such as fear of falling, anxiety, and admission to long-term care institutions.

The most common risk factors for falls are muscle weakness, history of falls, gait deficit, use of an assistive device, visual deficit, arthritis, depression, cognitive impairment, and age > 80. (The evaluation of falls is reviewed in Chapter 12.)

Because a fall is usually the result of many interacting factors, interventions must address each factor. Interventions are usually a combination of gait training and appropriate use of assistive devices; review and modification of medications; exercise and balance training; treatment of postural hypotension; modification of environmental hazards; and treatment of cardiovascular disorders, including arrhythmias. An interdisciplinary approach has proven most effective in fall rehabilitation and prevention. Although exercise has proven benefits for patients with falls, questions still remain regarding optimal type, duration, and intensity. Exercise programs may be more effective in frail elderly people than younger, more fit people. Tai chi ch'uan has been shown to be helpful in some studies. Home assessment, to ensure elimination of environmental risk factors, should also be considered for patients at high risk for falls.

Amputation

General Considerations

There are > 100,000 new amputees yearly in the United States, many of whom are elderly people with peripheral vascular diseases. Because of advances in vascular surgery and technology, the number of above-knee amputations has decreased; more people now have below-knee amputations. This is important because below-knee amputations greatly reduce energy cost for ambulation and reduce psychological morbidity, both of which are important to successful rehabilitation.

Treatment

If possible, the patient should be evaluated preoperatively to outline the likely rehabilitation plan and to start measures to improve muscle strength (especially in hip extensors and the upper body) and prevent contractures. Because the emotional effect of limb loss is significant, patients and families need a supportive environment where they can acknowledge and express their feelings.

Bed exercise should be started on the first postoperative day. The patient should get out of bed and begin balance training within 3–4 days. A temporary prosthesis or walking aid can be used by the end of the first week. The permanent prosthesis is usually fitted ~6–8 weeks after surgery when the limb stump has resolved and healed. Patients are taught how to take care of the stump with massage and wrapping to reduce edema and how to inspect it for evidence of infection and pressure. The quality of interface between the limb remnant and the prosthesis is the single most critical factor for successful use of the prosthesis. The prosthesis socket (the portion that fits snugly over the limb remnant) determines the patient's comfort and ability to control the artificial limb. Advances in prosthetic technology have led to prostheses that are comfortable and easy to use. Some have dynamic response, shock-absorbing mechanisms, and micro-processor-controlled movement, which allow the person to perform most of the usual ADLs. Factors associated with poor success include increased age, cerebrovascular disease, and dementia. Patient factors that predict a good rehabilitation outcome are independence before amputation, ability to bear weight on the contralateral side, medical stability, and ability to follow instructions.

Phantom sensations in the amputated limb are often felt by amputees, but pain occurs only in a minority.

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Sometimes neuromas at the amputation sites are problematic and require injection with a steroid-anesthetic mixture or excision. Socket fit may change with weight alterations. Falls and fear of falling are pervasive among amputees and need to be addressed adequately.

REFERENCES

General Principles

American Geriatrics Society: Geriatric Rehabilitation. American Geriatrics Society, 1993.

Dittmar SS, Gresham GE: Functional Assessment and Outcome Measures for the Rehabilitation Health Professional. Aspen, 1997.

Manton KG, Gu X: Change in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proc Natl Acad Sci USA 2001;98: 6354. [PMID: 11344275]

Schoeni RF et al: Persistent, consistent, widespread, and robust? Another look at recent trends in old-age disability. J Gerontol 2001;56B:S206. [PMID: 11445613]

Waidmann TA, Liu K: Disability trends among elderly persons and implications for the future. J Gerontol 2000;55B:S298. [PMID: 10985301]

Stroke Rehabilitation

Anderson C et al: Home or hospital for stroke rehabilitation? Results of a randomized controlled trial: I. Health outcomes at 6months. Stroke 2000;31:1024. [PMID: 10797161]

Bagg S et al: Effect of age on functional outcomes after stroke rehabilitation. Stroke 2002;33:179. [PMID: 11779908]

Cherney LR et al: Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect. Arch Phys Med Rehabil 2001;82:322. [PMID: 11245753]

Cifu DX, Flax HJ: Factors affecting functional outcome after stroke. Paper presented at the National Center for Medical Rehabilitation Research Workshop, August 2001.

Cifu DX, Stewart DG: Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions. Arch Phys Med Rehabil 1999;80:S35. [PMID: 10326901]

Mant J et al: Family support for stroke: a randomized controlled trial. Lancet 2000;356:808. [PMID: 11022928]

Silver KH: Chronic stroke: therapeutic intervention. Paper presented at the National Center for Medical Rehabilitation Research Workshop, August 2001.

Teasell R et al: The incidence and consequences of falls in stroke patients during inpatient rehabilitation: factors associated with high risk. Arch Phys Med Rehabil 2002;83:329. [PMID: 11887112]

Arthoplasty Rehabilitation

Brady OH et al: Rheumatology: 10. Joint replacement of the hip and kneewhen to refer and what to expect. Can Med Assoc J 2000;63:1285. [PMID: 11107466]

Chen B et al: Continuous passive motion after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil 2000; 79:421. [PMID: 11157647]

Geerts WH et al: Prevention of venous thromboembolism. Chest 2001;119:132S. [PMID: 11157647]

Hip Fracture Rehabilitation

Fox KM et al: Intertrochanteric versus femoral neck hip fractures: differential characteristics, treatment, and sequelae. J Gerontol 1999;54A:M635. [PMID: 10647970]

Haentjens P et al: The economic cost of hip fractures among elderly women. A one-year, prospective, observational cohortstudy with matched-pair analysis. Belgian Hip Fracture Study Group. J Bone Joint Surg Am 2001;83:493. [PMID: 11315777]

Magaziner J et al: Recovery from hip fracture in eight areas of function. J Gerontol 2000;55A:M498. [PMID: 10995047]

Overend TJ et al: Determination of prefracture physical function in community-dwelling people who fracture their hip. J Gerontol 2000;55A:M698. [PMID: 11078101]

Osteoarthritis Rehabilitation

American Geriatrics Society Panel on Exercise and Osteoarthritis: Exercise prescription for older adults with osteoarthritis pain: consensus practice recommendation. A supplement to the AGS clinical practice guidelines on the management of chronic pain in older adult. J Am Geriatr Soc 2001;49:808. [PMID: 11480416]

Gill TM et al: Role of exercise stress testing and safety monitoring for older person starting an exercise program. JAMA 2000; 284:342. [PMID: 10891966]

Prevalence of arthritisUnited States, 1997. MMWR Morb Mortal Wkly Rep 2001;50:334. [PMID: 11465902]

Deconditioning Rehabilitation

Meuleman JR et al: Exercise training in the debilitated aged: strength and functional outcome. Arch Phys Med Rehabil 2000;81:312. [PMID: 10724076]

Falls Rehabilitation

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Fall Prevention: Guideline for the prevention of falls in older persons. JAm Geriatr Soc 2001;49:664. [PMID: 11380764]

Close J et al: Prevention of falls in the elderly trial (PROFET): a randomized controlled trial. Lancet 1999;353:93. [PMID: 10023893]

Cumming RG et al: Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol 2000;55A:M299. [PMID: 10819321]

Robertson MC et al: Effectiveness and economic evaluation of anurse delivered home exercise programme to prevent falls: 1. Randomised controlled trial. Br Med J 2001;322:1. [PMID: 11264206]

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Rubenstein LZ et al: Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men. JGerontol 2000;55A:M317. [PMID: 10843351]

Wong AM et al: Coordination exercise and postural stability in elderly people: effect of Tai Chi Chuan. Arch Phys Med Rehabil 2001;82:608. [PMID: 11346836]

Amputee Rehabilitation

Fletcher DD et al: Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil 2001;82:776. [PMID: 11387582]

Marks LJ, Michael JW: Science, medicine, and the future: Artificial limbs. BMJ 2001;323:732. [PMID: 11576982]

Miller WC et al: The prevalence and risk factors of falling and fear of falling among lower extremity amputees. Arch Phys Med Rehabil 2001;82:1031. [PMID: 11494181]