Rehabilitation and Rehab Sites Cristian Balcescu

Why do we need to know this? Because there is such a high incidence

of disabling conditions in the older adult population which can be
improved with rehab in many cases. The primary purpose of rehab is to
allow people to function at the highest possible level despite the
presence of physical impairment. The increasing numbers of this
elderly population will make it important for all practitioners to be
aware of the results possible with rehabilitation.
How do we start? TO understand disability and where/how rehab
services can be most effective we use on of two CONCEPTUAL MODELS
FOR DISABILITY
1. The International Classification of Function, Disability, and Health
(ICF), developed by the World Health Organization- 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.

2. 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. For example, walking imposes different physical
demands when performed atop Mt. Everest versus at sea level.

Rehabilitation and Rehab Sites Cristian Balcescu

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. In the ecological model, remediation of disability
occurs through treatments that either increase individual
capacity or reduce task demand.
Rehabilitation interventions may improve capacity, reduce task
demands, or accomplish both

Impact of comorbidities on treatment

- comborbities can obviously delay treatment, require care plan to
be modified, but the complications can many times be
prevented.
- Skin breakdown monitor patients, and modify footware,
wheelchairs, bedding PRN
- Incontinence(and dangers of it), catheters and infections
- Pneumonia increased risk with inactivity, decreased swallowing
ability, underlying lung disease
- Anemia, mental functioning, DM(need for changes in medicine
and diet with increased exercise), heart disease(extreme
limitations in mobility, potential for orthostatic hypotension with
meds)
Who is involved?
- 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

Rehabilitation and Rehab Sites Cristian Balcescu

studies. 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. Inpatient
stroke rehabilitation teams include a variety of rehabilitation
personnel (eg, speech therapy, occupational therapy, physical
therapy) to target rehabilitation therapies to the specific strokerelated deficits, as well as medical, nursing, and other staff.
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.

Rehabilitation and Rehab Sites Cristian Balcescu

Where can patients be treated?

- effect of sites of care on rehab outcomes is not well established.
However, each has advantages and disadvantage
- Inpatient is most intense, but may not be endurable for frail older
patients as it requires 3hrs daily activity. SNFs are good for those
needing round the clock care without a round the clock caregiver
at home. Outpatient allows pts to return home, but the support
system may not be as strong and this requires transportation
which can be costly and time consuming.

Rehabilitation and Rehab Sites Cristian Balcescu

-

We should try to match individual patients to the care they need,

but sometimes decision is driven by cost

What can we do? Interventions

Each condition has different approaches that have been studied to
varying degress and work better for particular conditions(stroke,
postTHA, post TKA, etc)
Exercise

Rehabilitation and Rehab Sites Cristian Balcescu

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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)
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]

Cognitive rehab- may improve alertness and attention.

Language therapy post CVA aphasia
OT- repetition of tastk specific activities such as bed transfers,
grasping, reaching, retraining in IADLs
Research has not shown that speech, languance cognitive rehab
improve functional deficits.
Assistive devices:

Rehabilitation and Rehab Sites Cristian Balcescu

Example:
Post THA
- 5% mosrtality during initial hospitalization, 25% at 1 year, up to
half will continue to need assistive devices, 25% will need lng
term care 1 year later, 1.2 need some transient long term care
- early repair within 24-72 hours has been shown to reduce 1 year
mortality and complications of pressure ulcers, delirium.

Rehabilitation and Rehab Sites Cristian Balcescu

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Rehab focuses on pain management, mobilizations, prevention of

complications(PE, delirium). Most important factors are early
mobilization, and frequency of therapy(>once daily better
outcomes than once a day or less)
Anticoagulation min 10d up to 30+ day course. ASA, LMW
heparin at a usual high-risk dose, fondaparinux, a vitamin K
antagonist (target INR 2.5, range: 2.0 to 3.0), or rivaroxaban.
Prevention of future fractures osteoporosis, home safety risks,
balance training