Monday, January 3, 2011




§  The World Health Organization conceptual model of functioning and disability provides a useful framework for geriatric rehabilitation by taking into account the complex interactions of body functions and structures, health conditions, individual activities and participation in life situations, and environmental and personal factors.
§  A Medicare-certified inpatient rehabilitation hospital program must demonstrate that a certain percentage of patients have at least one of thirteen conditions and receive 3 hours of therapy per day.
§  Since rehabilitation treatments require active patient participation and long-term self-management, the patient and family are core members of the rehabilitation team.
§  Factors that influence recovery after a hip fracture include prior mobility and functional status, comorbid conditions, cognitive status, and social support.
§  Optimal rehabilitation outcomes depend on comprehensive assessment of the patient, coordinated interdisciplinary team management, multifaceted interventions, and access to appropriate and high-quality care.


Rehabilitation is a critical component of geriatric health care because disabling conditions in the elderly population are common. Although these conditions drastically influence quality of life, they often improve with treatment. Chronic disease almost always underlies disability in older adults; for example, stroke occurs most often in people with other vascular diseases, and hip fractures occur most often in people with osteoporosis and gait disorders. Worsening disability also occurs in progressive chronic diseases like osteoarthritis, Parkinson’s disease, or amyotrophic lateral sclerosis or in the context of deconditioning from inactivity during acute illness. To provide the best functional recovery possible, those providing geriatric rehabilitation must
§  use systematic approaches to assess the causes of disability,
§  be familiar with the advantages and disadvantages of all potential sites of care,
§  understand the role of multidisciplinary teams and care plans,
§  adapt care to comorbidities and disabilities, and
§  be familiar with the basic requirements for rehabilitation of common geriatric conditions.
This chapter is designed to provide an overview of these key issues.



Rehabilitation services are offered in both inpatient and community-based sites. Inpatient care may be provided in rehabilitation centers (freestanding hospitals or units attached to acute hospitals) or nursing facilities (Medicare skilled nursing facilities). Outpatient rehabilitation services can be provided in hospital-based or independent clinics, in day hospital settings, or in the home. The patient’s eligibility, the particular services provided, and costs vary across sites of care. The balance of advantages and disadvantages for the individual patient are important factors for the clinician to consider in recommending a site or sites of rehabilitation care.

Sites of Care: Coverage and Services

A Medicare-certified inpatient rehabilitation hospital program must demonstrate that a certain percentage of their patients have at least one of thirteen conditions, and that at least a certain percentage of patients receive 3 hours of therapy per day. Patients must be seen by a physician on a daily basis, have 24-hour rehabilitation nursing care, and be managed by a interdisciplinary team of skilled nurses and therapists. Medicare prospective reimbursement is now based on case-mix groups using the Functional Independence Measure (FIM).

Sites of Care and Outcomes

The effect of site of care on rehabilitation outcomes is not well established. A study of outcomes among persons with stroke and hip fracture examined rates of discharge to home and recovery of function that were based on use of inpatient or nursing rehabilitation services. When controlling for case-mix differences, the researchers found that stroke but not hip fracture patients were more likely to be discharged home and to recover activities of daily living (ADLs) if treated in an inpatient rehabilitation setting. Nursing homes with high volumes of Medicare patients were found to influence stroke outcomes more than traditional nursing homes. Overall, there were no differences in outcomes for hip fracture patients by site of care. In another study, stroke patients treated under managed care were found to be more likely to receive rehabilitation in skilled nursing facilities than in inpatient rehabilitation hospitals. Patients in fee-for-service setting improved more in ADLs during the treatment phase, but there were no differences in ADLs between groups 1 year later. At 1 year, the patients in managed care were 2.4 times more likely to reside in nursing homes. On the other hand, a recent observational cohort study of the effect of rehabilitation site on recovery from stroke suggests that rehabilitation at inpatient facilities, in comparison with skilled nursing facilities, produces more rapid recovery and higher proportions of patients who achieve independence as measured by the Functional Independence Measure, even after accounting for baseline differences in patient populations between the sites of care.


Numerous health professionals are required to meet the rehabilitation needs of older adults. Coordinating this care is the function of the interdisciplinary care team; team members must be able to define roles, share tasks, and communicate within and outside the team. Team building and improving team function are important issues for geriatric rehabilitation service providers. All health professionals who work with older adults should have a basic understanding of the roles and functions of various team members. The primary goal of multidisciplinary team management is to ensure that patients receive comprehensive assessments and interventions for the disabling illness and associated comorbid conditions, as well as for the specific impairments and environmental factors that may affect activities and participation. The team must establish common goals and a cohesive treatment plan.


In the elderly patient, comorbid diseases and conditions may interrupt or delay treatment and often require adaptations in the care plan. Many of the illnesses that can interfere with rehabilitation of the older adult are predictable in this high-risk population and are potentially preventable. A systematic approach to assessment, prevention, and management of comorbid conditions can improve the patient’s chance of receiving maximal benefit from rehabilitation services. Table 15.1 highlights common causes in older patients of delayed or interrupted rehabilitation and describes measures that can be taken to reduce their impact on rehabilitation.


The primary goals of rehabilitation treatment are restitution of function, compensation for and adaptation to functional losses, and prevention of secondary complications. Ultimately, rehabilitation should maximize the person’s potential for participation in social, leisure, or work roles. Many strategies can be used to achieve these goals. Restitution of physical function usually depends on therapeutic exercises to improve flexibility, strength, motor control, and cardiovascular endurance. Although exercise has been shown to improve strength, endurance, and balance in well-defined populations of disabled older adults, there is still uncertainty about whether these gains translate into changes in mobility, ADLs, participation, or a reduction in falls. (See also Physical Activity.) In stroke, speech and language therapy can be used to treat aphasia. Cognitive rehabilitation might improve alertness and attention. However, the research evidence is insufficient to demonstrate that speech and language therapy, or cognitive rehabilitation, improve functional deficits.


Comprehensive assessment of rehabilitation patients is necessary for appropriate clinical management and for the evaluation of outcomes. The treatment plan should be guided by the results of the initial assessment. The primary components of any assessment include patient demographics, social support, place of residence prior to illness, medical comorbidities, severity of current illness, and the patient’s prior functional status. Impairments such as deficits in range of motion and flexibility, strength, sensory functions, balance, cognition, and depression should always be assessed. In conditions such as stroke, there should be an evaluation of swallowing and language function. The patient’s functional status is assessed with standardized measures of ADLs (eg, FIM, the Barthel ADL Index), and measures of instrumental ADLs. The patient’s participation or quality of life is assessed with generic measures like the SF-36 Health Survey (available at or disease-specific measures like the Stroke Impact Scale or the Harris Hip Questionnaire.


Stroke is a major cause of mortality and morbidity in the United States, particularly among persons aged 55 years and over. Acute stroke occurs in more than 700,000 people each year, and 80% or more are likely to survive, many with residual neurologic difficulties. Stroke-related deficits are severe in approximately one third of the survivors. Many patients with mild and moderate stroke become independent in ADLs, but other more complex dimensions of health status may still be affected. As stroke survival continues to increase, the need for comprehensive stroke rehabilitation will rise. Rehabilitation programs must address a broad range of stroke-related disabilities, including those in basic ADLs, instrumental ADLs, participation, and integration into health and wellness programs.

Goals of Rehabilitation

The overall goals of rehabilitation for the elderly stroke patient include restitution of function, compensation for or adaptation to functional losses, and prevention of secondary complications. Specific objectives include:
§  preventing or recognizing and managing comorbid illness and medical complications,
§  assessing each patient comprehensively, using standardized assessments,
§  matching the patient’s needs to the program capabilities,
§  training the patient to maximize independence in ADLs and instrumental ADLs,
§  facilitating the patient’s and family’s psychosocial coping and adaptation,
§  preventing recurrent stroke and other vascular conditions such as myocardial infarction, and
§  assisting the patient in reintegrating into the community.

Approach to Management

Guidelines for rehabilitation following stroke have been updated by a team sponsored by the Department of Veterans Affairs and the Department of Defense (available at The guidelines offer algorithms for initial assessment and rehabilitation referral, followed by management in inpatient or community settings. The guidelines assess the quality of evidence for a series of recommendations. Recommendations considered to have a “good” evidence base are highlighted. Many important issues in management have not yet been assessed in clinical trials and thus do not meet standards for a “good” evidence base. Yet, management recommendations may still be considered appropriate care, since a lack of evidence should not be considered to indicate a lack of benefit. The guidelines emphasize that better clinical outcomes are achieved when patients with acute stroke are treated in a setting that provides coordinated, multidisciplinary stroke-related evaluation and services. Recent studies have confirmed that adherence to guidelines promotes better outcomes. Coordinated care reduces 1-year mortality, improves functional independence, and increases satisfaction with care. Benefits are not restricted to any particular subgroup of patients. Stroke severity should be systematically assessed, using the NIH Stroke Scale (available at


Epidemiology and Surgical Care

Each year in the United States, about 250,000 people have a hip fracture. The risk of fracture is higher in women, in nursing-home residents, and in persons with dementia. Mortality is about 5% during the initial hospitalization but nears 25% in the year following fracture. Recovery to the prior level of function occurs in about 75% of survivors, but their overall mobility will be more limited; up to half of those with recovery will still require an assistive device. About half of patients will have an initial decline requiring transient long-term care, and about 25% will still be in long-term care 1 year later.

Rehabilitation of Hip Fracture

Rehabilitation of hip fracture includes pain management, mobilization, and prevention of complications, such as delirium and thromboembolic events. The most important factors influencing recovery appear to be how soon mobilization is initiated and how frequently therapy is provided. Delay in mobilization is often driven by surgical recommendation, with proper healing of the fracture taking precedence over mobility. Partial weight bearing is difficult for many older patients to achieve; they are either up on their feet or not. Prolonged inactivity is clearly associated with poorer functional outcomes, and early weight bearing has been shown to be associated with low rates of surgical failure. Accelerated rehabilitation with rapid mobilization, coordinated planning, early discharge, and community follow-up has been associated with a 17% reduction in costs and no detriment to rates of recovery. Intensity of service clearly affects outcome, as those who receive more than once-daily physical therapy during initial rehabilitation are more likely to be discharged directly to home than those who receive physical therapy once a day or less.

Prevention of Recurrence

Persons who have had a hip fracture often have other comorbidities, such as osteoporosis and balance problems, that place them at risk for further fractures. Efforts to diagnose and treat osteoporosis, improve balance, and reduce injury risk are a key part of treatment planning during rehabilitation. (See also Osteoporosis and Osteomalacia.) The use of hip protectors has been extensively studied, with varying results. For those living in an institutional setting, there may be some benefit. For patients living in the community, hip protectors do not appear to decrease the incidence of hip fractures. As a recent study demonstrates, adherence remains a major issue. Only 38% of community-dwelling women in the study found the hip protectors to be acceptable and agreed to participate. At the end of 1 year, only about half the participants were still wearing the hip protectors daily.


Natural History

In the United States, joint arthroplasty is the most common elective surgical procedure performed; approximately 280,000 are done annually. The primary indications for joint replacement are progressive pain and mobility limitation despite conservative care. The most common diagnosis associated with the need for joint replacement is osteoarthrosis, followed by rheumatoid arthritis. The long-term results of joint replacement have generally been excellent and include significant pain relief and improved function. Continued success rates in the 90% range are seen 10 to 15 years after joint replacement. The most common reason for failure of the hip or knee replacement is loosening of the implant. Joint infection is another major concern; infection affects 0.2% to 1.1% of total hip and 1% to 2% of total knee replacements. Deep infections often necessitate removal of the implant, long-term antibiotics until there is no sign of infection, then ultimate replacement with another implant. (See also Infectious Diseases, especially the section on prosthetic device infections.)


Plain radiographs are the usual method for determining the severity of joint damage at both the hip and knee. Loss of cartilage is shown by joint-space narrowing, and often osteophyte formation is also present.


Anticoagulation to prevent thromboembolism and good pain control are the major goals during the immediate postoperative period for both hip and knee arthroplasty. (See also Perioperative Care, and anticoagulation information in the Appendix.) It is recognized that patients who have undergone a major orthopedic procedure like total hip or knee arthroplasty are at particularly high risk for both symptomatic and asymptomatic venous thromboembolism (VTE). Recent guidelines for the prevention of VTE suggest the routine use of low-molecular-weight heparin, fondaparinux, or adjusted-dose warfarin. Pain control in the initial postoperative period is often achieved with narcotics dispensed orally, intravenously, or by patient-controlled analgesia pumps. For both hip and knee arthroplasty, early mobilization is the standard of care, and weight bearing often begins on the second postoperative day. Patients at low risk can often be discharged from the acute care hospital within 5 days. For those at high risk, defined as being older than 70 years or having two or more comorbid conditions, early inpatient rehabilitation has been shown to improve functional outcomes and decrease total length of stay. Age alone should not be used as a criterion for eligibility for joint replacement, as even persons older than 80 years who are in good health with stable chronic conditions have excellent results.



More than 50,000 people undergo lower extremity amputation each year in the United States. Most of these people have systemic vascular disease, with or without diabetes mellitus. Those with diabetes often have other end-organ disease, such as blindness, end-stage renal disease, and peripheral neuropathy. Mortality in this group approaches 50% at 2 years and 70% at 5 years. For up to one fifth of patients, amputation of the contralateral extremity is needed within the first 2 years after the initial amputation. The majority of dysvascular amputees have such a burden of comorbid disease that the prosthesis is largely used for limited mobility, such as transfers and ambulation within the home.


Key factors to assess include the patient’s prior functional status, stability of comorbid conditions, cognition, and upper extremity use, as well as the condition of the stump and other lower extremity. Successful prosthetic ambulation is associated with independent prior ambulation, ability to bear weight on the contralateral leg, stable medical status, and ability to follow directions. Blindness and end-stage renal disease do not necessarily preclude rehabilitation. A systematic approach to monitoring amputee status has been incorporated into an instrument, the Prosthetic Profile of the Amputee.

Rehabilitation for Amputation

Rehabilitation starts in the preoperative stage, when the patient begins with strength and flexibility exercises and receives teaching about the recovery process. Amputation surgery generally aims to preserve the knee, since the below-the-knee amputee has a much lower energy requirement of walking than does the above-the-knee amputee. This decision must be weighed against risks of poor wound healing with more distal amputation.


Assistive devices, orthotics, adaptive methods, and environmental modifications are effective for elderly patients with disabilities and handicaps. It is important to identify the underlying causes of disability before prescribing a device or modification, because medical or surgical treatment for individual diseases and impairments may be more effective or may enhance the usefulness of these approaches.

Mobility Aids

Canes typically support 15% to 20% of the body weight and are to be used in the hand contralateral to the affected knee or hip. The tips, handles, materials, and lengths of canes vary. As the number of tips increases, the degree of support also increases, but the cane becomes heavier and more awkward to use. The cane tip is fitted with a 5-cm diameter rubber tip with a concentric ring to prevent slipping. The handle of the cane may be curved or have a pistol grip; the pistol grip offers more support but is less aesthetically pleasing to some people. Canes can be made of a variety of materials, but most are made of wood or lightweight aluminum. The length of the cane is important for stability. Some canes are adjustable, but wooden canes must be cut to size. One of three methods may be used to evaluate the proper cane length: measuring the distance from the distal wrist crease to the ground when the patient is standing erect, measuring the distance from the greater trochanter to the ground, or measuring the distance between the ground 15 cm in front of and to the side of the tip of the shoe and the elbow flexed at 30 degrees.

Orthotics, Adaptive Methods, and Environmental Modifications

Orthotics are exoskeletons designed to assist, resist, align, and stimulate function. Orthotics are named by the use of letters for each joint that the device involves in its structure. Thus, an AFO is an ankle and foot orthotic device used to support weak calf or pretibial muscles (eg, for a stroke patient with lower extremity weakness).

Annotated References

         Gill TM, Baker DI, Gottschalk M, et al. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med. 2002; 347(14):1068–1074.
This is a randomized controlled trial of a restorative program called “Prehab” in 188 community-dwelling frail persons aged 75 or older. The Prehab program lasted up to 6 months and focused on physical therapy for mobility, balance, muscle strength, and transfers. The control group received education. The Prehab group was found to have less functional decline than the control group. Prehab was also found to have a beneficial effect among those with moderate but not severe frailty.
         Gillespie WJ. Extracts from “clinical evidence”: hip fracture. BMJ. 2001; 322(7292):968–975.
The author presents commonly asked questions, such as “What are the effects of specific surgical interventions in the treatment of hip fractures?” and provides answers based on evidence from randomized controlled trials. The benefits, harms, and a summary statement are given for each possible answer to the question. The topics that are included range from surgical management to common postoperative complications and rehabilitation after the fracture repair.
         Hesse S, Werner C, von Frankenberg S, et al. Treadmill training with partial body weight support after stroke. Phys Med Rehabil Clin N Am. 2003;14 (1 Suppl):S111–S123.
This is a review of treadmill therapy with partial body weight support as an intervention for gait impairment after stroke. Chronic and acute patients have been studied. It was found that gait becomes more symmetric and efficient after treadmill training. Multicenter trials are under way.
         Hoenig H, Duncan PW, Horner RD, et al. Structure, process, and outcomes in stroke rehabilitation. Med Care. 2002;40(11):1036–1047.
This prospective cohort study of 128 acute stroke patients in 11 Veterans Affairs medical centers examined the effect of the structure of stroke care on process of care that was based on Agency for Health Care Policy and Research (AHCPR) guidelines and outcome measured by Functional Independence Measure (FIM) motor score 6 months after discharge. Structural features such as systemic organization, staff expertise, and technological sophistication were found to predict adherence with guidelines. Guideline adherence was found to predict 6-month FIM scores.
         Nikolajsen L, Jensen TS. Phantom limb pain. Br J Anaesth. 2001;87(1):107–116.
This review article presents the available literature on incidence and types of pain seen in persons after amputation. Possible mechanisms of phantom pain and other factors that influence phantom pain are described. Treatment options and timing for these options, either before or after the amputation, are presented.
         Wells JL, Seabrook JA, Stolee P, et al. State of the art in geriatric rehabilitation: part II: clinical challenges. Arch Phys Med Rehab. 2003;84(6):898–903.
The authors present a review of the common clinical problems seen in geriatric rehabilitation, including rehabilitation for hip fracture and stroke. Information is provided, in a strength-of-evidence framework, about trials involving comorbidity and adverse outcomes, early rehabilitation after repair, and use of specialized orthopedic rehabilitation units.
Stephanie A. Studenski, MD, MPH
Cynthia J. Brown, MD, PT
Pamela W. Duncan, PhD

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