THIS ARTICAL CONSISTS OF THE FOLLOWING ASPECTS
- KEY POINTS
- CONCEPTUAL MODEL FOR GERIATRIC REHABILITATION
- SITES OF REHABILITATION CARE
- TEAMS AND ROLES
- IMPACT OF COMORBID CONDITIONS
- REHABILITATION APPROACHES AND INTERVENTIONS
- COMPREHENSIVE ASSESSMENT
- HIP FRACTURE
- TOTAL HIP AND KNEE ARTHROPLASTY
- MOBILITY AIDS, ORTHOTICS, ADAPTIVE METHODS, AND ENVIRONMENTAL MODIFICATIONS
- ANNOTATED REFERENCES
§ 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.
Geriatric rehabilitation services can be organized around a conceptual model of disability in order to assess the status and needs of the patient, match treatments with specific conditions, and evaluate rehabilitation outcomes. The recently revised World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF) provides a useful framework. See the WHO Web site (available at http://www3.who.int/icf/beginners/bg.pdf) for an ICF guide and a discussion of the ICF model of disability (Figure 15.1). The ICF has two main domains: “Health Condition” and “Contextual Factors.” Disability and functioning are viewed as outcomes of interactions between health conditions (diseases, disorders, injuries) and contextual factors, which range from a person’s most immediate environment, like furniture in the room, to the more general environment, like access to public transportation. Personal factors include a person’s age, race, gender, educational background, personality, fitness, and life style.
In the WHO model, interventions can be designed to modify a person’s impairments, limitations in activities, and restrictions in participation. For example, a treatment plan may be developed to improve a person’s strength (impairment level), but the significance of this intervention is due to its effect on his or her physical mobility (activity) and ultimately the person’s ability to return to social or physical roles (participation). The effects of gains in strength and physical mobility on participation could be modified by the person’s motivation or social support. For example, if a man improves in strength and balance but his family and friends continue to “do everything for him” and do not encourage independent function, he may remain dependent. The physical environment is another powerful modifier. Even the person who achieves improved function cannot regain prior work or household roles if physical barriers to access in the community are not removed or adapted by such means as ramps or modified bathrooms. In summary, the interaction of disease and disability is particularly complex in older adults. The ICF model is useful for structuring comprehensive rehabilitation care for older patients.
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).
The Medicare-approved skilled nursing facility must provide 24-hour nursing care. Dietary, pharmaceutical, dental, and medical social services are also available. Physicians must supervise patient care and can visit the patient infrequently, but they must be available 24 hours a day on an emergency basis. Therapy services are available, but multidisciplinary coordination may not occur. In this setting, maintenance of function without progress may be the goal of care. Reimbursement is based on prospective payment according to the resource utilization groups (RUG III) classification, which is based on the Minimum Data Set (MDS 2).
Medicare provides home-health benefits to patients who require intermittent or part-time skilled nursing care and therapy services and who are homebound, defined flexibly to include individuals who “occasionally leave the home.” These services must be prescribed and recertified every 60 days by a physician. There is no prior hospitalization requirement or limit on the number of visits a person may receive. Medicare provides care in 60-day episodes. As long as patients continue to remain eligible for home-health services, they may receive an unlimited number of medically necessary episodes of care. Home-health services provide skilled nursing and home-health aides, therapy services, medical social services, and supplies. Even though physicians must certify the patient for services, they are rarely involved in the supervision of care, and multidisciplinary coordination of care may not be available.
The escalating expenditures for Medicare’s postacute care benefits from $2.5 billion in 1986 to more than $30 billion in 1996 led to the Balanced Budget Act (BBA) of 1997, which mandated prospective payment systems rather than fee-for-service reimbursement. In skilled nursing facilities, the BBA mandated the implementation of a per diem prospective payment system covering all costs (routine, ancillary, and capital) related to the services furnished to the patients under Part A of the Medicare program. Per diem payments for each admission are case-mix adjusted by the use of a resident classification system (RUG III) that is based on data from patient assessments (the MDS 2) and relative weights developed from staff time data. Home-health care reimbursement is now under a prospective payment system. Payment rates are based on relevant data from patient assessments conducted by clinicians using the Outcome and Assessment Information Set (OASIS). The OASIS was originally developed to assess quality of care in home health. The OASIS is lengthy, encompassing sociodemographic, environmental, support system, health status, and functional status attributes; it is required for reimbursement by Medicare for home-health services. For each 60-day episode of care, national payment rates vary, depending on the intensity of care required. Home-health agencies receive less than the full 60-day episode rate if they provide only a minimal number of visits to beneficiaries.
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.
The effect on outcomes of site of rehabilitation care for a more broad range of conditions has also been studied in a sample of consecutive patients enrolled from 52 hospitals in three cities with five targeted conditions (chronic obstructive pulmonary disease, heart failure, hip procedures, hip fractures, and stroke). Using case-mix adjustment models, these researchers found that patients who were discharged to nursing homes fared worst and those who were sent home with home-health or to rehabilitation hospitals did best. This type of observational study is vulnerable to bias, despite adjusting the analyses, since patient prognosis for recovery may influence discharge site; those with poor prognosis are more likely to go the nursing home, and those with better prognosis for recovery go to inpatient or home-health settings. Nevertheless, site of care may be an important factor in recovery.
The effect of prospective payment on postacute rehabilitation has been examined. Patients discharged from acute-care settings with one of five diagnoses that commonly use rehabilitation services were followed for patterns of postacute services before and after prospective payment. The transition to prospective payment appeared to result in an increase in the proportions of patients receiving no rehabilitation services, in a decrease in home-health services, and in stable or slightly increased inpatient services. This study found no consistent effects of these changes on clinical outcomes. Another study found decreases in intensity and duration of rehabilitation services in skilled facilities after prospective payment was initiated. The clinician who advocates for an appropriate site of rehabilitation care on the basis of severity of impairments, functional status, and social support might improve the outcomes of many patients.
Each site of care has advantages and disadvantages from the patient’s perspective. Inpatient care is the most intense but may not be endurable for frail elderly patients, since it requires 3 hours per day of active (and fatiguing) therapy. Skilled nursing offers 24-hour care for those who cannot care for themselves or do not have a full-time caregiver. Outpatient services have clear advantages and disadvantages. Patients often prefer to return to their own homes but may not have the care support they need. Participation in day hospital or outpatient clinic requires transportation, which can be costly and time consuming.
In summary, clinicians must be familiar with the services provided in a wide range of rehabilitation settings and with the advantages and disadvantages of each. The clinician is responsible for recommending the best match between patient needs and program services. However, under certain insurance plans, decisions about location of services may be heavily influenced by costs. More systematic evaluation of rehabilitation outcomes that is based on the structures and processes of care offered by various settings is essential if we are to have more rational use of rehabilitation programs in the future. The Centers for Medicare and Medicaid Services (CMS) is currently monitoring the quality of patient care using information from the patient assessments. A research study of preventive rehabilitation (“Prehab”) using a home-health approach in high-risk community-dwelling older adults demonstrated reduced frequency of functional decline.
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.
The patient and the family are core members of the rehabilitation team; their expectations and preferences must be integrated into the care plan. Rehabilitation, unlike many other interventions, requires active patient participation. If the patient is the leader in decision making, he or she gains a sense of control and responsibility. Patient self-management is now an essential part of the effective management of chronic disease. Chronic disease self-management incorporates self-monitoring, knowledge about disease, and personal control over prevention and management practices.
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.
Older adults with reduced mobility are at high risk for skin breakdown, which can interfere with recovery and require extensive treatment. Immobility or altered weight bearing can precipitate pressure ulcers that heal poorly. Clinicians should monitor pressure and weight-bearing areas and be prepared to modify footwear, wheelchairs, and bedding as needed. (See also Pressure Ulcers.) Since thromboembolic events are also common with reduced mobility, their prevention should be a routine part of care. (See also the discussions of thromboembolism in Respiratory Diseases and Disorders, and Perioperative Care.)
Incontinence is prevalent among older patients; causes include detrusor hyperactivity, obstruction, neurogenic bladder, immobility, and cognitive deficits. Indwelling catheters increase the risk of infection and are rarely appropriate. A structured approach to the assessment and treatment of bladder problems should be a basic component of any rehabilitation service. (See also Urinary Incontinence.)
The risk of pneumonia is increased by inactivity and disordered swallowing, as well as underlying lung disease. The prevention of aspiration pneumonia involves difficult tradeoffs. Routine radiologic screening for aspiration has precipitated a marked increased awareness of this problem, but the clinical relevance of modest amounts of aspiration detected radiologically is unknown. Conservative measures such as changing food consistency with liquid thickeners and cohesive food substances and lowering head position while eating may help alleviate the problem. Sometimes aspiration risk is addressed by discontinuing all oral feeding and placing an enteral feeding tube. This approach eliminates the fundamental human pleasure of eating and may not be successful, since oral secretions or refluxed gastric contents can still be aspirated. (See also Eating and Feeding Problems.) Upper gastrointestinal bleeds may occur during rehabilitation as a consequence of stress or medications and may not be preceded by typical symptoms. (See also Gastrointestinal Diseases and Disorders.)
Mental functioning is critical for rehabilitation, which requires the ability to follow commands and learn. Since older adults who have been acutely ill are at increased risk for delirium, clinicians should assess mental status and screen for easily reversible causes in their older patients. (See also Delirium.) Depression is endemic in newly disabled persons and can manifest as low motivation; formal screens for depression and early intervention are essential. (See also Depression and Other Mood Disorders.) Seizures can develop after stroke, and spasticity can develop during stroke recovery. Interventions for spasticity such as physical therapy or muscle relaxants have offered only modest benefit; some trials of botulinum toxin have suggested promising results but others have had no effect. (See also the section in stroke in Neurologic Diseases and Disorders.)
Certain comorbid conditions common in elderly patients, including diabetes mellitus, heart disease, peripheral vascular disease, musculoskeletal disorders, sensory impairments, and dementia, require ongoing adaptations in rehabilitation. Activity level is a powerful factor in glucose metabolism; diabetic patients are therefore likely to experience changes in glucose levels and medication requirements during rehabilitation. Increased caloric intake during recovery may also affect their medication needs. Therapy personnel should know how to assess diabetic control, use a glucometer, and intervene for hypoglycemia. (See also Diabetes Mellitus.) Most abnormal gaits increase the energy requirements of walking; an abnormal gait in a patient with coronary artery disease may cause coronary symptoms to worsen. Persons with poor cardiac output may have extreme exercise limitations. Medication adjustments for heart diseases may be necessary but can cause adverse effects of their own, such as orthostatic hypotension. Patients with one vascular disease often have others; peripheral vascular disease is common, often associated with insensitive or painful feet and high risk of skin breakdown. Treatment of painful peripheral neuropathy may foster increased activity and avoid pressure ulcers. Musculoskeletal status should be monitored to avoid overuse syndromes involving increased demand on vulnerable joints. For those with vision and hearing impairment, corrections must be provided and teaching approaches adapted accordingly. In patients with dementia, rehabilitation progress is still possible, but carryover may be decreased and the need for supervision and cueing increased.
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.
Therapeutic modalities such as massage, heat, cold, and ultrasound are used to decrease pain and muscle spasm. These and other pain management strategies may contribute to increased function and tolerance for further rehabilitation. There is little research evidence supporting objective benefits from modalities, but patients commonly report symptomatic relief. (See also Persistent Pain.)
Equipment for mobility, dressing and bathing assistance, orthotic and prosthetic devices, and splints all can augment or replace the function of impaired body parts and thereby reduce limitations in activities and participation. For example, an ankle orthosis can prevent foot drop and improve safety and speed of walking. A wheelchair can provide mobility for community activities.
Repeated practice of task-specific activities such as bed mobility, transfers, and walking can improve functional mobility. Upper extremity function improves with specific functional training activities, such as grasps, reaches, and fine manipulations. Balance training may improve balance and reduce the risk of falls. Older adults may benefit from retraining in instrumental ADLs, such as cooking, managing finances, or driving a car.
Contextual factors, both environmental and personal, should be addressed to minimize restrictions on a person’s activities and participation. For example, motivation may be addressed by collaborative goal setting, patient and family education, detection and management of depression, and use of support groups. Environmental modifications such as grab bars and raised toilet seats in the bathroom or curb cutouts on public streets can promote independent functioning.
To maintain function and enhance health status after rehabilitation, patients and families should assume responsibility for long-term self-management. Rehabilitation goals include a prevention program for worsening disability, including reintegration into social programs such as senior center programs, and health and wellness programs.
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 http://www.sf-36.org) 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
, 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. United States
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.
Rehabilitation for older adults with stroke is complex because of the heterogeneity of causes, symptoms, severity, and recovery. Stroke patients present with varying symptoms, depending on the site and size of the brain lesions. The most common type of neurologic deficit is hemiparesis, but other deficits may include sensory impairment, aphasia, dysarthria, cognitive impairment, motor incoordination, hemianopsia, visual-perceptual deficits, depression, dysphagia, and bowel and bladder incontinence. The degree of initial recovery and the time needed to reach maximal recovery is affected by the number of deficits. For example, individuals who have hemiparesis, hemianopsia, and sensory deficits are less likely to ambulate independently and require longer to regain skills than do those with hemiparesis only.
Stroke patients usually experience some degree of recovery. This recovery is most dramatic in the first 30 days but may continue more gradually for months. In the Framingham study, improvement in motor function and self-care was found to slow 3 months after stroke but to continue at a reduced pace throughout the first year. Language and visual-spatial function was recovered over 12 months, but cognitive function improved only during the first 3 months.
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 http://www.oqp.med.va.gov/cpg/STR/STR_base.htm). 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 http://www.strokecenter.org/trials/scales/nihss.html).
In general, therapy should be started early, but later supplementary interventions may also be beneficial. For persons who have completed acute poststroke rehabilitation, a structured, supervised, progressive therapeutic program in the home has been shown to produce gains in endurance, balance, and walking capacity, but no change in motor control. The benefits of this program are probably due to the aggressive intervention on deconditioning and mobility. There is less evidence to support specific therapeutic interventions for stroke.
There are several philosophical approaches to physical rehabilitation following stroke. Neurophysiologic approaches based on the theories of Bobath and Brunnstrom and on proprioceptive neuromuscular facilitation traditionally are used to restore motor control. These approaches consider the patient to be the recipient of therapy and the therapist to be the decision maker in charge of problem solving. There is no convincing evidence that any one specific technique is superior to another. New therapeutic interventions for restitution of motor function are in development. Constraint-induced movement therapy discourages the use of the unaffected extremity and encourages active use of the hemiparetic extremity, with a goal of improved motor recovery. Results in patients with chronic stroke impairment suggest potential gains beyond usual therapy. A large randomized clinical trial of constraint-induced therapy is now under way. Treadmill walking with partial body weight support using a harness connected to an overhead system may improve gait velocity, balance, and motor recovery. Speech and language therapy are often provided for stroke patients with aphasia. However, there is no universally accepted treatment. Although a recent Cochrane report states that the evidence does not support a finding of either clear effect or lack of effect, the Veterans Affairs guidelines support “good” evidence for follow-up evaluation and treatment by the speech language professional for long-term residual communication difficulties. The guidelines also support “good” evidence for cognitive retraining for attention or visual-spatial perceptual deficits and compensatory training for short-term memory deficits. The same guidelines find “good” evidence for medication treatment for depression and emotional lability. Spasticity can develop gradually after stroke and can inhibit function and interfere with hygiene. Most interventions have been disappointing, but investigational trials of botulinum toxin type AOL injection for hand spasticity have been encouraging.
The patient who has had a stroke is at high risk for recurrence: up to 7% to 10% annually. The rehabilitation phase is an appropriate time to ensure that assessment and treatment for stroke prevention has occurred. Assessments for significant carotid stenosis and for atrial fibrillation should be completed. Indications for carotid endarterectomy and anticoagulation with warfarin should be reviewed. Antiplatelet medications such as aspirin alone or in combination with dipyridamole or clopidogrel should be considered in many patients. Treatment with angiotensin-converting enzyme inhibitorsOL and statinsOL has also demonstrated reductions in risk of stroke. Other risk factors to be targeted include hypertension control and smoking.
In summary, the evidence for specific interventions for stroke rehabilitation is weak. The collective benefits of well-organized multidisciplinary care, including secondary prevention, are well established. (See also the section on cerebrovascular diseases in Neurologic Diseases and Disorders).
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.
For medically stable patients, surgical repair is recommended 24 to 72 hours after the fracture. This early repair has been associated with a reduction in 1-year mortality as well as with lower incidence of complications like pressure ulcers and delirium. However, delay of surgery is warranted to allow a medically unstable patient to improve sufficiently to tolerate the procedure. The surgical approach is determined by the location of the fracture, the presence or absence of displacement, and the prefracture mobility. One third of hip fractures occur at the femoral neck, and the other two thirds are intertrochanteric, occurring lateral to the femoral neck. Prefracture mobility is used as a guide to determine the goal of surgical treatment and to allow the risks and benefits of each surgical procedure to be considered.
Femoral neck fractures without any displacement can be surgically corrected with simple screws. However, femoral neck fractures with any degree of displacement are at increased risk for nonunion or avascular necrosis and therefore are usually treated with a prosthetic femoral head (hemiarthroplasty). Patients with significant underlying boney acetabular disease and a displaced femoral neck fracture may benefit from complete hip arthroplasty. Patients are usually allowed to bear weight immediately after repair of a femoral neck fracture, no matter which technique has been used.
For intertrochanteric fractures, the treatment of choice is open reduction and internal fixation with a compression screw or similar device. Provided there is little or no displacement, immediate weight bearing is usually allowed. However, displaced or comminuted intertrochanteric fractures commonly remain unstable, even after surgical fixation. Therefore, full weight bearing is often not allowed for up to 6 weeks or until the stability of the fracture is assured. Factors that influence recovery should be assessed, including prior mobility and functional status, comorbid conditions, cognitive status, and social support. Other information includes type of injury and repair as well as pain status. Mobility performance can be systematically assessed with numerous instruments, including one developed specifically for hip fracture (Harris Hip Questionnaire).
See also Perioperative Care.
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.
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.
To decrease the risk of dislocation after total hip arthroplasty, patients are taught to avoid motions such as deep squats and crossing their legs. To prevent excessive hip flexion, a raised toilet seat is recommended for the first few months after surgery. Rehabilitation focuses on strengthening especially the abductors, which are weakened by the surgical approach, as well as on progressive range-of-motion and gait training. Recently, orthopedic surgeons have been examining the use of a minimal incision, less than 10 centimeters, for total hip arthroplasty. This approach may lead to quicker recovery and return to function but is still being studied.
After total knee replacement, recovery of range of motion is the key to return of function and is often aided by the use of a continuous passive motion machine (CPM). Its use has been shown to decrease the need for postoperative manipulation and, combined with physical therapy, has increased active range of motion and shortened length of stay. Surgeons have also applied the concept of minimal incisions to the total knee replacement operation and with significantly more success. This operation, in the hands of an experienced surgeon, has been shown to decrease blood loss and length of stay. Postoperative swelling is common and interferes with regaining motion. However, thigh-high compression stockings, the CPM, and possibly cryotherapy can be used to manage swelling.
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.
Postoperative rehabilitation includes efforts at early mobilization, prevention of contractures, wound healing, and shaping of the stump. Poor wound healing delays rehabilitation in about 25% of cases. Prostheses vary in weight, socket type, style of foot, and suspensions. The older amputee benefits from a prosthesis that is lightweight, stable, and easy to use. Prosthetic rehabilitation involves progressive ambulation, teaching about prosthesis and stump care, and monitoring for stump injury.
Last, phantom limb pain is common after amputation, with an estimated incidence of 60% to 80%, and pain management influences progress with rehabilitation. Treatment remains difficult, and clear evidence-based guidelines are lacking. As tricyclic antidepressantsOL and sodium channel blockersOL, like carbamazepineOL, are generally effective for neuropathic pain, they are often used for phantom pain despite the lack of well-controlled trials. A number of other medication regimens, using such agents as opiatesOL and anesthetic blocksOL, have also had success in small trials. Two recent trials of memantine showed no benefit in the treatment of phantom limb pain.
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.
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.
Crutches can support full body weight but are seldom recommended for older persons. Problems with crutches include the large amount of arm strength required, the risk of brachial plexus injury, and the necessity to use an unnatural gait pattern.
A walker is prescribed when a cane does not offer sufficient stability. A walker can completely support one lower extremity but cannot support full body weight. Walker types include pick-up and wheeled walkers. The pick-up walker is lifted and moved forward by the patient, who then advances before lifting the walker again; the result is a slow, staggering gait. It requires strength to repeatedly pick up the walker and cognitive ability to learn the necessary coordination. A wheeled walker allows for a smoother, coordinated, and faster gait and takes advantage of overlearned gait patterns. It is more likely to be correctly used by persons with cognitive impairment. The most commonly used type is the two-wheeled walker, which brakes automatically with increased downward pressure. Four-wheeled walkers are rarely used because they are less stable and more difficult to control, although they are occasionally useful for persons with Parkinson’s disease. Three-wheeled walkers may offer some advantages in ease of turning but are not yet in common use. The Merry Walker Ambulation Device has a seat and bars all the way around. It is the same size as a wheelchair and is best reserved for those with severe balance problems. It is also useful for severely demented patients.
Patients who cannot safely use or are unable to ambulate with an assistive device will require a wheelchair. A wheelchair must be fitted according to the patient’s body build, weight, disability, and prognosis. Incorrect fit may result in poor posture, joint deformity, reduced mobility, pressure ulcers, circulatory compromise, and discomfort. For the elderly patient with only one functional arm, the wheelchair may be lowered to allow for foot propulsion. Patients with lower extremity amputations may have the wheels set posteriorly to compensate for a change in the center of gravity. Motorized wheelchairs may be used by mentally alert persons with bilateral upper extremity weakness or severe cardiopulmonary disease who lack the endurance to push a wheelchair. Motorized scooters offer less trunk support than motorized wheelchairs but are more acceptable to some people. Motorized scooters and wheelchairs increase patients’ mobility but increase their risk of deconditioning, as they might otherwise push a wheelchair or ambulate. The use of a wheelchair commonly requires home modifications, including ramps and widened doorways. Cars may need to be adapted with lifts.
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).
Adaptations to facilitate dressing may be necessary for patients with problems such as frequent soiling or diminished flexibility, coordination, and endurance. Their clothing should be easy to clean, and tops should fit easily over the head or fasten in the front and allow for freedom of movement. Fastening clothes is commonly a problem for elderly persons. Hooks and loops or Velcro are usually easier to use than buttons, and they may be sewn on to replace buttons and zippers. When buttons are necessary, button hooks with customized grips may be used, or the buttons can be sewn on with elastic thread, which may eliminate the need to manipulate the buttons. Donning shoes and socks is particularly difficult for elderly persons with decreased agility. Longer, looser socks (eg, tubular socks) are easier to don. For patients who find that reaching the feet to put on shoes is a problem, a long-handled shoehorn may be useful. Elastic shoelaces eliminate the need for tying and untying.
Environmental modifications can have a major impact on the elderly person’s ability to function independently or with minimal assistance at home. A variety of assistive devices, such as reachers, special utensils, and adapted telephones, can reduce the difficulty of performing daily tasks and have a significant impact on a person’s quality of life.
The bathroom is a common place for falls. Any older person with impaired balance or lower extremity weakness should have bars installed near the toilet and tub or shower. Raised toilet seats and bathtub benches are available to assist those with lower extremity weakness. These are also useful for persons with arthritis of the hips or knees because they reduce biomechanical stress on the joint. Long-handled bath brushes, hand-held shower, and “soap on a rope” may be helpful for persons with upper extremity impairment.
■ 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.