principles of griatric Montagnini_Rehabilitation.ppt

Objectives

To understand the significance of disability in geriatric patients

To learn the basic steps of patient assessment for rehabilitation

To be familiar with the advantages and disadvantages of the various sites of rehabilitative care

To know common rehabilitation techniques (exercise, assistive devices, therapeutic modalities)

To learn the basic steps of rehabilitation programs for common geriatric conditions (stroke, amputation, hip fracture, Parkinson’s disease, osteoarthritis and deconditioning)

1. Geriatric RehabilitationGeriatric Rehabilitation
Marcos Montagnini, M.D.Marcos Montagnini, M.D.
Division of Geriatrics/GerontologyDivision of Geriatrics/Gerontology
Medical College of WisconsinMedical College of Wisconsin

2. ObjectivesObjectives

To understand the significance of disability in geriatric To understand the significance of disability in geriatric
patientspatients

To learn the basic steps of patient assessment for To learn the basic steps of patient assessment for
rehabilitationrehabilitation

To be familiar with the advantages and disadvantages of To be familiar with the advantages and disadvantages of
the various sites of rehabilitative carethe various sites of rehabilitative care

To know common rehabilitation techniques (exercise, To know common rehabilitation techniques (exercise,
assistive devices, therapeutic modalities)assistive devices, therapeutic modalities)

To learn the basic steps of rehabilitation programs for To learn the basic steps of rehabilitation programs for
common geriatric conditions (stroke, amputation, hip common geriatric conditions (stroke, amputation, hip
fracture, Parkinson’s disease, osteoarthritis and fracture, Parkinson’s disease, osteoarthritis and
deconditioning)deconditioning)

3. DisabilityDisability

Restriction or lack of ability to perform an Restriction or lack of ability to perform an
activity in a normal manner.activity in a normal manner.

4. Disability in Geriatric PatientsDisability in Geriatric Patients

Common problemCommon problem

Increases with ageIncreases with age

By the year 2020, 13.6 million older people will have moderate to By the year 2020, 13.6 million older people will have moderate to
severe disabilitysevere disability

Higher prevalence in older women Higher prevalence in older women

Increases caregiver needs and the need for for institutionalizationIncreases caregiver needs and the need for for institutionalization

Impairs quality of life and contributes to depressionImpairs quality of life and contributes to depression

Increases health care needs and costs ( $170 billion per year)Increases health care needs and costs ( $170 billion per year)
Manton KG. J Gerontol 1998Manton KG. J Gerontol 1998

5. Disability in Geriatric PatientsDisability in Geriatric Patients

Related to multiple factors:Related to multiple factors:
•DisabilityDisability
•HospitalizationHospitalization
•Health behaviorsHealth behaviors
•Demographic characteristicsDemographic characteristics
•Several diseasesSeveral diseases

6. Causes of DisabilityCauses of Disability
•Knee osteoarthritisKnee osteoarthritis
•Hip fractureHip fracture
•DiabetesDiabetes
•StrokeStroke
•Heart disease (CAD, CHF)Heart disease (CAD, CHF)
•Peripheral Vascular DiseasePeripheral Vascular Disease
•COPDCOPD
•Visual impairmentVisual impairment
•Depression Depression
•Cognitive impairmentCognitive impairment
•CancerCancer

7. Disability among persons aged 85 and olderDisability among persons aged 85 and older

ConditionCondition % %

DementiaDementia 19.43 19.43

ArthritisArthritis 6.75 6.75

Peripheral Vascular DiseasePeripheral Vascular Disease 14.88 14.88

Cerebrovascular DiseaseCerebrovascular Disease 12.86 12.86

Hip and other fracturesHip and other fractures 8.81 8.81

Ischemic heart diseaseIschemic heart disease 1.88 1.88

HypertensionHypertension 1.38 1.38

DiabetesDiabetes 1.01 1.01

CancerCancer 0.91 0.91

Emphysema and bronchitisEmphysema and bronchitis 0.26 0.26

8. Goals of Rehabilitation in GeriatricsGoals of Rehabilitation in Geriatrics
To eliminate or reduce disabilityTo eliminate or reduce disability
by optimizing patients’ functional status and by optimizing patients’ functional status and
physical independencephysical independence
To improve quality of lifeTo improve quality of life
To decrease painTo decrease pain

9. Planning RehabilitationPlanning Rehabilitation

Multidisciplinary approachMultidisciplinary approach

Comprehensive medical, functional, and Comprehensive medical, functional, and
psychosocial assessments psychosocial assessments

Identification of current disability Identification of current disability

Identification of previous level of Identification of previous level of
functioningfunctioning

Planning rehabilitative therapies and Planning rehabilitative therapies and
assistive adaptationsassistive adaptations

Site and cost of rehabilitationSite and cost of rehabilitation

10. Assessing a Geriatric Patient for Assessing a Geriatric Patient for
RehabilitationRehabilitation

11. Medical AssessmentMedical Assessment
Disease process and co-morbiditiesDisease process and co-morbidities
Potential for recoveryPotential for recovery
Pain and other symptomsPain and other symptoms
MedicationsMedications
Physical examPhysical exam
CardiopulmonaryCardiopulmonary
NeurologicalNeurological
MusculoskeletalMusculoskeletal
Bowel and bladder functionBowel and bladder function
Skin integritySkin integrity

12. Medical AssessmentMedical Assessment
Nutritional status Nutritional status
Swallowing functionSwallowing function
VisionVision
HearingHearing

13. Psychosocial AssessmentPsychosocial Assessment
Cognition – MMSECognition – MMSE
MotivationMotivation
Depression- GDSDepression- GDS
CommunicationCommunication
Social support, caregiverSocial support, caregiver
Place of residencyPlace of residency
FinancesFinances
Advance DirectivesAdvance Directives
Discharge planning/Home AssessmentDischarge planning/Home Assessment

14. Functional Assessment ScalesFunctional Assessment Scales

ADLs (Katz ADL scale)ADLs (Katz ADL scale)

IADLs (Lawton-Brody)IADLs (Lawton-Brody)

Function (FIM, Barthel Index)Function (FIM, Barthel Index)

Gait Gait

Balance/ FallsBalance/ Falls

EnduranceEndurance

15. Functional Independence Measure Functional Independence Measure
(FIM)(FIM)
Population – rehabilitation clientsPopulation – rehabilitation clients
Format- task performanceFormat- task performance
6 Domains: Self-care, sphincter control, mobility, 6 Domains: Self-care, sphincter control, mobility,
locomotion, communication, social cognitionlocomotion, communication, social cognition
Score: 1-7 on each measureScore: 1-7 on each measure
Maximum score: 126Maximum score: 126
Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwins FS. Andvance in functional Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwins FS. Andvance in functional
assessment of medical rehabilitation. assessment of medical rehabilitation. Topics in Geriatric RehabilitationTopics in Geriatric Rehabilitation 1986: 1 1986: 1
(3): 59-74(3): 59-74..

16. Barthel IndexBarthel Index
Developed for people with neurological or Developed for people with neurological or
musculoskeletal disabilities musculoskeletal disabilities
Format – interviewFormat – interview
10 items: bowels, bladder, grooming, toilet use, 10 items: bowels, bladder, grooming, toilet use,
feeding, transfers,feeding, transfers,
mobility, dressing, stairs, bathingmobility, dressing, stairs, bathing
Total 100 pointsTotal 100 points
Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Maryland State Maryland State
Medical Journal Medical Journal 1965: 14:61-651965: 14:61-65

17. Berg Balance ScaleBerg Balance Scale
Population – elderlyPopulation – elderly
Format – task performanceFormat – task performance
14 tasks, each item scored from 0 to 4, maximum 14 tasks, each item scored from 0 to 4, maximum
of 56 pointsof 56 points
Higher scores represent better performanceHigher scores represent better performance
Simple to administer, safe to performSimple to administer, safe to perform
Intra and inter-rater reliability are highIntra and inter-rater reliability are high
Berg KO, Williams JI, Wood-Dauphine SL, Maki BE: Measuring balance in the elderly: Berg KO, Williams JI, Wood-Dauphine SL, Maki BE: Measuring balance in the elderly:
validation of an instrumentvalidation of an instrument. Canadian Journal of Public Health. Canadian Journal of Public Health 1992: 83: suppl. 7-11. 1992: 83: suppl. 7-11.

19. Tinetti Assessment of Balance and Tinetti Assessment of Balance and
GaitGait
Population – elderlyPopulation – elderly
Format – task performanceFormat – task performance
Nine items for balanceNine items for balance
Seven items for gait, scored 0,1,or 2Seven items for gait, scored 0,1,or 2
Total 28.Total 28.
Tinetti ME. Performance-oriented assessment of mobility problems in elderly Tinetti ME. Performance-oriented assessment of mobility problems in elderly
patients. 1986. patients. 1986. JAGSJAGS 34:119-126. 34:119-126.

20. Timed “Up and Go”Timed “Up and Go”
Population – frail elderlyPopulation – frail elderly
Format – task performanceFormat – task performance
Task – Begin seated in chair, stand, walk to line 3 meters Task – Begin seated in chair, stand, walk to line 3 meters
away, turn, return and sit down again. Task is timed. Can away, turn, return and sit down again. Task is timed. Can
also rate perception of risk of fall on 5 point ordinal scale.also rate perception of risk of fall on 5 point ordinal scale.
Scoring – timeScoring – time
Predicts a patient’s ability to walk safely alone outsidePredicts a patient’s ability to walk safely alone outside
Correlates well with Berg Balance Test and Barthel IndexCorrelates well with Berg Balance Test and Barthel Index
Podsiadlo D, Richardson S. The timed “up and go”: A test of basic functional Podsiadlo D, Richardson S. The timed “up and go”: A test of basic functional
mobility for frail elderly persons. mobility for frail elderly persons. JAGSJAGS 1991: 39: 142-148. 1991: 39: 142-148.

21. EnduranceEndurance
6-Minute Walking Test6-Minute Walking Test
Population – children or adultsPopulation – children or adults
Format – task performanceFormat – task performance
Scoring – Distance covered in six minutesScoring – Distance covered in six minutes
Guyatt GH, Sullivan MJ, Thompson PJ, et al. The 6 minute walk: a new Guyatt GH, Sullivan MJ, Thompson PJ, et al. The 6 minute walk: a new
measure of exercise capacity in patients with chronic heart failure. measure of exercise capacity in patients with chronic heart failure. Can Can
Med AssocMed Assoc 1985: 132: 919-923. 1985: 132: 919-923.

22. Site of RehabilitationSite of Rehabilitation

23. Site of RehabilitationSite of Rehabilitation

Depends on:Depends on:
• the patient’s ability to participate in an intense the patient’s ability to participate in an intense
rehabilitation process.rehabilitation process.
•the progress the patient is expected to make the progress the patient is expected to make
with rehabilitation.with rehabilitation.
•potential for the patient to return to a potential for the patient to return to a
noninstitutional setting at discharge.noninstitutional setting at discharge.

24. Site of RehabilitationSite of Rehabilitation

InpatientInpatient
•Acute care hospitalAcute care hospital
•Rehabilitation hospitalRehabilitation hospital
•Skilled nursing facilitySkilled nursing facility

OutpatientOutpatient
•Hospital-based or independent clinicsHospital-based or independent clinics
•Day-hospital settingsDay-hospital settings
•HomeHome

25. Medicare coverageMedicare coverage

In- hospital setting:In- hospital setting:
•Multidisciplinary team and a coordinated plan of careMultidisciplinary team and a coordinated plan of care
•Rehabilitation physicianRehabilitation physician
•Rehabilitation nursingRehabilitation nursing
•3 hours per day of physical therapy and occupational 3 hours per day of physical therapy and occupational
therapy therapy
•Good prospect of significant functional improvementGood prospect of significant functional improvement
•Realistic and clearly articulated goals of therapyRealistic and clearly articulated goals of therapy
•Inpatient rehabilitation facilities are reimbursed by Inpatient rehabilitation facilities are reimbursed by
Medicare by the use of a prospective payment systemMedicare by the use of a prospective payment system
•Maximum length of stay is 90 days per illnessMaximum length of stay is 90 days per illness

26. Medicare coverageMedicare coverage

Skilled nursing facility:Skilled nursing facility:
•Need for skilled restorative care Need for skilled restorative care
•5 days per week of physical therapy5 days per week of physical therapy
•Not a requirement: occupational therapy, 3 hours daily of specific Not a requirement: occupational therapy, 3 hours daily of specific
rehabilitative care, the care of a rehabilitation physician, or a rehabilitative care, the care of a rehabilitation physician, or a
multidisciplinary approachmultidisciplinary approach
•Dietary, pharmaceutical, dental, medical, and social services must be Dietary, pharmaceutical, dental, medical, and social services must be
availableavailable
•Reimbursement limited to 750 minutes per weekReimbursement limited to 750 minutes per week
•Eligibility for Medicare skilled nursing benefits is restricted to persons Eligibility for Medicare skilled nursing benefits is restricted to persons
who have had a hospital stay of at least 3 days in the past 30-day who have had a hospital stay of at least 3 days in the past 30-day
period.period.

27. Medicare coverageMedicare coverage

Home-health benefitsHome-health benefits
•Provided to patients who require intermittent or part-time Provided to patients who require intermittent or part-time
skilled nursing care and therapy services and who are skilled nursing care and therapy services and who are
homeboundhomebound
•There is no prior hospitalization requirement or limit on the There is no prior hospitalization requirement or limit on the
number of visits a person may receivenumber of visits a person may receive
•Skilled nursing and home-health aids, therapeutic aids, Skilled nursing and home-health aids, therapeutic aids,
medical and social services, and suppliesmedical and social services, and supplies
•Physicians are rarely involved in the supervision of carePhysicians are rarely involved in the supervision of care
•Multidisciplinary coordination of care may not be available Multidisciplinary coordination of care may not be available
•Prospective payment systemProspective payment system

28. Site of care: Advantages and Site of care: Advantages and
DisadvantagesDisadvantages

Inpatient care: may not be appropriate for frail Inpatient care: may not be appropriate for frail
adults because of intensive rehab programadults because of intensive rehab program

Skilled nursing care: offers 24-hour care for those Skilled nursing care: offers 24-hour care for those
who cannot care for themselves or do not have a who cannot care for themselves or do not have a
caregivercaregiver

Day-hospital or outpatient clinic: transportationDay-hospital or outpatient clinic: transportation

Rehab in the home setting: patients may not Rehab in the home setting: patients may not
have the caregiving they needhave the caregiving they need

29. Rehabilitation InterventionsRehabilitation Interventions

30. Rehabilitation InterventionsRehabilitation Interventions

ExerciseExercise

Assistive devices and adaptive equipmentAssistive devices and adaptive equipment



Physical modalitiesPhysical modalities

31. ExerciseExercise
•Endurance (cardiovascular conditioning)Endurance (cardiovascular conditioning)
•Flexibility (prevention of contractures)Flexibility (prevention of contractures)
•ResistiveResistive (increase muscle strength) (increase muscle strength)

IsometricIsometric

Isotonic (weight training, thera-band, push-ups, sit-ups)Isotonic (weight training, thera-band, push-ups, sit-ups)

IsokineticIsokinetic
•Balance (falls)Balance (falls)
•Functionally-based (vestibular impairment)Functionally-based (vestibular impairment)

32. ExerciseExercise

Resistive exercises and walking program decreases Resistive exercises and walking program decreases
pain and improve function in patients with stable pain and improve function in patients with stable
osteoarthritis of the knee. (Kovar, 1992; Fisher osteoarthritis of the knee. (Kovar, 1992; Fisher
1991).1991).

Weight bearing exercises for 60 min three times Weight bearing exercises for 60 min three times
weekly has shown to stabilize bone mineral density weekly has shown to stabilize bone mineral density
and improve function in older women with and improve function in older women with
osteoporosis (Bravo, 1996).osteoporosis (Bravo, 1996).

High intensity resistance training improved muscle High intensity resistance training improved muscle
strength, size and functional mobility nursing home strength, size and functional mobility nursing home
residents up to 96 years of age (Fiatarone, 1990).residents up to 96 years of age (Fiatarone, 1990).

33. ExerciseExercise

High intensity resistant exercise training in 100 High intensity resistant exercise training in 100
nursing home patients over the age of 70 years nursing home patients over the age of 70 years
can counteract muscle weakness and physical can counteract muscle weakness and physical
frailty. (Fiatarone, 1994).frailty. (Fiatarone, 1994).

Progressive resistance training and progressive Progressive resistance training and progressive
functional training are effective in reducing fall-functional training are effective in reducing fall-
related behaviors in high-risk geriatric patients related behaviors in high-risk geriatric patients
with a history of injurious falls.with a history of injurious falls.
(Hauer et al, 2001)(Hauer et al, 2001)

34. Assistive DevicesAssistive Devices

To increase area of supportTo increase area of support

To increase balance/stabilityTo increase balance/stability

To increase sensory feedback to To increase sensory feedback to
compensate for visual and compensate for visual and
proprioceptive lossesproprioceptive losses

To decrease weight bearing on lower To decrease weight bearing on lower
extremityextremity

36. Assistive devicesAssistive devices

CanesCanes
•Support 15% to 20% of the body weightSupport 15% to 20% of the body weight
•tipstips
•handles (wood, light-weight aluminum) handles (wood, light-weight aluminum)
•length (greater trochanter to the ground, wrist length (greater trochanter to the ground, wrist
crease to the ground)crease to the ground)
•held on the patient’s unaffected sideheld on the patient’s unaffected side

37. Assistive DevicesAssistive Devices

CrutchesCrutches
•Difficulty to use for older peopleDifficulty to use for older people
•Highest energy useHighest energy use

38. Assistive DevicesAssistive Devices

Walkers: Walkers:
•Standard/pick-up walker: slow, staggering gaitStandard/pick-up walker: slow, staggering gait
•Wheeled walker: Wheeled walker:

smoother, coordinated and faster gaitsmoother, coordinated and faster gait

better for persons with cognitive impairmentbetter for persons with cognitive impairment

forearm support for patients with limited forearm support for patients with limited
had functionhad function

40. Assistive DevicesAssistive Devices

WheelchairsWheelchairs
•Manual: Manual:

physical limitation not compatible with physical limitation not compatible with
ambulationambulation

poor endurancepoor endurance

need for increased independenceneed for increased independence
•Power: Power:

severely reduced endurance severely reduced endurance

upper extremity weaknessupper extremity weakness

need for increased independenceneed for increased independence

ScootersScooters

Poor endurance and adequate sitting balancePoor endurance and adequate sitting balance

41. Orthotics and ProstheticsOrthotics and Prosthetics

Exoskeletons designed to assist, resist, align and Exoskeletons designed to assist, resist, align and
stimulate functionstimulate function
•SplintsSplints
•BracesBraces
•Shoe insertsShoe inserts
•AFO (ankle-foot orthotic device)AFO (ankle-foot orthotic device)

43. Adaptations & Home ModificationsAdaptations & Home Modifications

Designed to maximize independence:Designed to maximize independence:
•hooks and loops instead of buttons, longer hooks and loops instead of buttons, longer
socks, long-handled shoehorn, elastic socks, long-handled shoehorn, elastic
shoelaces, special utensilsshoelaces, special utensils
•Grab bars, raised toilet seatsGrab bars, raised toilet seats
•Sliding board for transfersSliding board for transfers

46. Physical ModalitiesPhysical Modalities

HeatHeat

ColdCold

Transcutaneous Electrical Nerve Transcutaneous Electrical Nerve
Stimulation (TENS)Stimulation (TENS)

47. Therapeutic modalitiesTherapeutic modalities

HeatHeat
•Superficial heatSuperficial heat

Hot packs Hot packs

Paraffin bathParaffin bath

HydrotherapyHydrotherapy

Radiant heatRadiant heat

LaserLaser
•Deep heatDeep heat

MicrowavesMicrowaves

Short wavesShort waves

UltrasoundUltrasound

48. General Indications for Therapeutic General Indications for Therapeutic
HeatHeat

Musculoskeletal pain/OAMusculoskeletal pain/OA

BursitisBursitis

TenosynovitisTenosynovitis

Muscle spasmMuscle spasm

ContractureContracture

FibromialgiaFibromialgia

49. Heat - ContraindicationsHeat - Contraindications

Acute inflammation, trauma, or hemorrhageAcute inflammation, trauma, or hemorrhage

Bleeding disordersBleeding disorders

InsensitivityInsensitivity

Inability to communicate or respond to painInability to communicate or respond to pain

MalignancyMalignancy

EdemaEdema

Atrophic skin/ scar tissueAtrophic skin/ scar tissue

50. ColdCold

Ice packsIce packs

Cooling sprays/gelsCooling sprays/gels

General IndicationsGeneral Indications
•Acute musculoskeletal traumaAcute musculoskeletal trauma
•PainPain
•Muscle spasmMuscle spasm
•SpasticitySpasticity

51. Cold - ContraindicationsCold - Contraindications

IschemiaIschemia

Cold intoleranceCold intolerance

Raynaud’s phenomenon and diseaseRaynaud’s phenomenon and disease

Severe cold pressure responsesSevere cold pressure responses

Cold allergyCold allergy

InsensitivityInsensitivity

52. TENSTENS

Musculoskeletal painMusculoskeletal pain

53. Rehabilitation of Specific Rehabilitation of Specific
ConditionsConditions

StrokeStroke

AmputationAmputation

Hip fractureHip fracture

Parkinson’s diseaseParkinson’s disease

OsteoarthritisOsteoarthritis

DeconditioningDeconditioning

54. StrokeStroke

Stroke occurs in more than 700,000 persons each Stroke occurs in more than 700,000 persons each
yearyear

About 2/3 of all stroke patient are over age 65About 2/3 of all stroke patient are over age 65

Third leading cause of death for persons aged 65 Third leading cause of death for persons aged 65
and olderand older

Major cause of neurological-related disability in Major cause of neurological-related disability in
elderly personselderly persons

More than 80% of them are likely to surviveMore than 80% of them are likely to survive

Deficits are severe in one third of the survivors Deficits are severe in one third of the survivors
and mild or moderate in the other two thirdsand mild or moderate in the other two thirds

55. Causes of strokeCauses of stroke
CauseCause % %
Large vessel occlusion/infarctionLarge vessel occlusion/infarction 3232
EmbolismEmbolism 32 32
Small vessel occlusion, lacunarSmall vessel occlusion, lacunar 1818
Intracerebral hemorrhageIntracerebral hemorrhage 1111
Subarachnoid hemorrhageSubarachnoid hemorrhage 7 7

56. Common impairments caused by Common impairments caused by
strokestroke
ImpairmentImpairment Acute (%)Acute (%) Chronic (%)Chronic (%)
Motor weaknessMotor weakness 9090 5050
Right hemiparesisRight hemiparesis4545 2020
Left hemiparesisLeft hemiparesis3535 2525
Bilateral hemiparesis Bilateral hemiparesis 1010 5 5
Sensory deficitsSensory deficits 5050 2525
DysarthriaDysarthria 5050 2020
AphasiaAphasia 3535 2020
Cognitive deficitsCognitive deficits 3535 3030
Visuoperceptual deficitsVisuoperceptual deficits 3030 3030
DepressionDepression 3030 3030
Bladder incontinenceBladder incontinence3030 1010
DysphagiaDysphagia 3030 1010
HemianopsiaHemianopsia 2525 1010

57. Complications in acute strokeComplications in acute stroke
Complication Complication Frequency (%)Frequency (%)
MedicalMedical
Pneumonia, pulmonary aspirationPneumonia, pulmonary aspiration 4040
Urinary tract infectionUrinary tract infection 4040
DepressionDepression 3030
Musculoskeletal pain, RSDMusculoskeletal pain, RSD 3030
Falls Falls 2525
Malnutrition Malnutrition 1616
Venous thromboembolismVenous thromboembolism 6 6
Pressure ulcerPressure ulcer 3 3
NeurologicalNeurological
Toxic or metabolic encephalopathyToxic or metabolic encephalopathy 1010
Stroke progressionStroke progression 5 5
SeizureSeizure 4 4

58. RecoveryRecovery

Most motor recovery occur in the first 3 Most motor recovery occur in the first 3
monthsmonths

Cognitive function improves mainly in the Cognitive function improves mainly in the
first 3 months first 3 months

Language function and visual-spatial Language function and visual-spatial
functions recover in the first 12 monthsfunctions recover in the first 12 months

59. Predictors of outcomePredictors of outcome

Older ageOlder age

Urinary and bowel incontinenceUrinary and bowel incontinence

Visuospatial deficitsVisuospatial deficits

History of previous strokesHistory of previous strokes

Speech impairmentSpeech impairment

Cognitive impairmentCognitive impairment

Depression Depression

Coronary artery disease Coronary artery disease

Presence of a supportive caregiverPresence of a supportive caregiver
Jongbloed 1986, Fullerton 1988, Kotila 1984, Meins 2003, Bagg 1998Jongbloed 1986, Fullerton 1988, Kotila 1984, Meins 2003, Bagg 1998

60. Predictors of outcomePredictors of outcome

Sitting balanceSitting balance

Bowel and bladder controlBowel and bladder control

Motor strength measured one week Motor strength measured one week
after stroke predicted overall after stroke predicted overall
functional outcomefunctional outcome
Lowen 1990Lowen 1990

61. Predictors of outcome – Site of Predictors of outcome – Site of
rehabilitationrehabilitation
•Organized stroke unit care is associated with Organized stroke unit care is associated with
lower mortality, dependency, and lower mortality, dependency, and
institutionalizations without an increased use institutionalizations without an increased use
of resources (19 trials with 3249 patients)of resources (19 trials with 3249 patients)
•Benefit has been shown to be sustained for 5 Benefit has been shown to be sustained for 5
years after treatmentyears after treatment
•Stroke Unit Trialists’ Collaboration. BMJ 1997Stroke Unit Trialists’ Collaboration. BMJ 1997
•Indredavik et al. Stroke unit treatment: long-term effects. Stroke Indredavik et al. Stroke unit treatment: long-term effects. Stroke
1997.1997.

62. Steps of RehabilitationSteps of Rehabilitation

Acute phase:Acute phase:
•Early mobilizationEarly mobilization
•Position changesPosition changes
•Range of motion exercisesRange of motion exercises
•Prevention of complicationsPrevention of complications

63. Steps of RehabilitationSteps of Rehabilitation
•Mat exercises: rolling from side to side, sitting up, Mat exercises: rolling from side to side, sitting up,
transferring from the mat to wheelchairtransferring from the mat to wheelchair
•Sitting balance Sitting balance
•Gait and standing balance: sit-to-stand Gait and standing balance: sit-to-stand
repetitions, balance and weight shifting using repetitions, balance and weight shifting using
parallel barsparallel bars
•Ambulation with assistive devicesAmbulation with assistive devices

64. Steps of RehabilitationSteps of Rehabilitation

OrthoticsOrthotics
•Shoulder support ( wheelchair lap board, pillow support, Shoulder support ( wheelchair lap board, pillow support,
sling)sling)
•AFOAFO

Swallow evaluation Swallow evaluation
•Severe dysphagia: gastrostomy tube is superior to Severe dysphagia: gastrostomy tube is superior to
nasogastric tube feeding (Norton 1996, BMJ)nasogastric tube feeding (Norton 1996, BMJ)

Speech therapySpeech therapy

Bladder and bowel managementBladder and bowel management

DepressionDepression

Cognitive statusCognitive status

Home environment modificationsHome environment modifications

Stroke Rehabilitation Guidelines (JAGS 1997)Stroke Rehabilitation Guidelines (JAGS 1997)

65. Hip FracturesHip Fractures

More than 250,000/year in the USMore than 250,000/year in the US

By age 90, 32% of women and 17% of men will By age 90, 32% of women and 17% of men will
have sustained a hip fracturehave sustained a hip fracture

Risk factors: Risk factors:
•older ageolder age
•WomenWomen
•OsteoporosisOsteoporosis
•Dementia Dementia
•Nursing home residentsNursing home residents

Mortality rate:Mortality rate:
• 5% during the initial hospitalization 5% during the initial hospitalization
• 14% to 29% during the first year14% to 29% during the first year

66. Types of Hip fracturesTypes of Hip fractures

Two thirds – interthrochantericTwo thirds – interthrochanteric

One third – femoral neckOne third – femoral neck

Displaced and non-displacedDisplaced and non-displaced

67. Surgical treatmentSurgical treatment

Displaced femoral neck fracture: Displaced femoral neck fracture:
prosthetic femoral headprosthetic femoral head

Nonsdisplaced femoral neck: internal Nonsdisplaced femoral neck: internal
fixation with pins and nailsfixation with pins and nails

Interthrocantheric: open reduction and Interthrocantheric: open reduction and
internal fixation with screws and a femoral internal fixation with screws and a femoral
plateplate

68. Conservative treatmentConservative treatment

Conservative management: Conservative management:
•high-risk operative candidates high-risk operative candidates
•patients with severe dementiapatients with severe dementia
•persons who did not ambulate before the hip persons who did not ambulate before the hip
fracturefracture

69. RehabilitationRehabilitation

Early mobilization and high Early mobilization and high
frequency physical therapy and frequency physical therapy and
occupational therapyoccupational therapy

Early weight bearing Early weight bearing

Pain managementPain management

Prevention of complicationsPrevention of complications

Functional adaptationFunctional adaptation

70. Steps of RehabilitationSteps of Rehabilitation

Hip precautions: no flexion more than 90 degrees, no Hip precautions: no flexion more than 90 degrees, no
internal rotation, no abduction past midlineinternal rotation, no abduction past midline

Quadriceps isometric exercises, gentle flexion and Quadriceps isometric exercises, gentle flexion and
extension, parallel bars (2extension, parallel bars (2
ndnd
– 3 – 3
rdrd
day), use of walker or day), use of walker or
canecane

Strengthening Hip extensorsStrengthening Hip extensors

Stair training (2Stair training (2
ndnd
week) going up with uninvolved leg and week) going up with uninvolved leg and
coming down with the involved legcoming down with the involved leg

Gait assistive devicesGait assistive devices

71. Hip fracturesHip fractures

Better rehabilitation outcomes: Better rehabilitation outcomes:
•Intact cognitive status Intact cognitive status
•Younger ageYounger age
•Independence in ADL’sIndependence in ADL’s
•Social supportSocial support
•High frequency PT/OTHigh frequency PT/OT

72. AmputationAmputation

50,000-60,000 amputations in the USA each year50,000-60,000 amputations in the USA each year

Three quarters of amputations occur in people Three quarters of amputations occur in people
over age 65over age 65

PVD (65%) and diabetes are the most common PVD (65%) and diabetes are the most common
causescauses

20 – 50 % risk of losing the contra-lateral leg to 20 – 50 % risk of losing the contra-lateral leg to
vascular disease over 4 years.vascular disease over 4 years.

Two-year survival: 50 - 60%Two-year survival: 50 - 60%

Five-year survival: 30 – 40%Five-year survival: 30 – 40%

Highest mortality: unable to walk prior to Highest mortality: unable to walk prior to
surgery, hemiplegia from a prior stroke, surgery, hemiplegia from a prior stroke,
contralateral amputation, severe CAD or COPD, contralateral amputation, severe CAD or COPD,
age over 80y, visual impairment, dialysisage over 80y, visual impairment, dialysis

73. Amputation Amputation

Preservation of the knee is important Preservation of the knee is important
because of lower energy demands for because of lower energy demands for
ambulation and improved gait.ambulation and improved gait.

Energy costs for prosthetic ambulation:Energy costs for prosthetic ambulation:
•Unilateral transtibial amputation: 40 – 60%Unilateral transtibial amputation: 40 – 60%
•Unilateral transfemoral amputation: 90 – Unilateral transfemoral amputation: 90 –
120%120%
•Bilateral transtibial amputation: 60 – 100%Bilateral transtibial amputation: 60 – 100%
•Bilateral transfemoral: Bilateral transfemoral: > > 200%200%

74. Prosthetic ambulation Prosthetic ambulation

Contra- indications:Contra- indications:
•Poor cognitionPoor cognition
•Severe neurological impairment (stroke, Severe neurological impairment (stroke,
Parkinson’s)Parkinson’s)
•Severe cardiopulmonary diseaseSevere cardiopulmonary disease
•Knee or hip contracturesKnee or hip contractures

75. Prosthetic ambulationProsthetic ambulation

Poor outcomes for prosthetic rehabilitation:Poor outcomes for prosthetic rehabilitation:
•Low serum albumin, elevated BUN, and Low serum albumin, elevated BUN, and
elevated glucoseelevated glucose
•DialysisDialysis
Weiss GN. J Am Geriatr Soc 1990;38:877-83Weiss GN. J Am Geriatr Soc 1990;38:877-83
Cutson TM. J Am Geriatr Soc 1991;39:A34Cutson TM. J Am Geriatr Soc 1991;39:A34

76. Steps of rehabilitationSteps of rehabilitation

Upper body strengthening, quadriceps, hip Upper body strengthening, quadriceps, hip
extensorsextensors

Active and passive ROM exercises to Active and passive ROM exercises to
prevent hip and knee contracturesprevent hip and knee contractures

Wound healingWound healing

Stump careStump care

77. Steps of rehabilitationSteps of rehabilitation

Transfers with and without the prosthesis Transfers with and without the prosthesis
immediately post-opimmediately post-op

Sitting and single-limb balanceSitting and single-limb balance

Wheelchair trainingWheelchair training

Permanent prosthesis - 6 to 8 weeksPermanent prosthesis - 6 to 8 weeks

78. Independent ambulation following Independent ambulation following
amputationamputation

Unilateral below knee : 80%Unilateral below knee : 80%

Bilateral below knee: 50%Bilateral below knee: 50%

Unilateral above knee: Unilateral above knee: < 50%< 50%

79. Parkinson’s diseaseParkinson’s disease

Parkinson’s Disease patients benefit from PT Parkinson’s Disease patients benefit from PT
added to their standard medicationadded to their standard medication

Interventions: PT exercises, OT, Speech TherapyInterventions: PT exercises, OT, Speech Therapy

Improvements in:Improvements in:
•Neurological symptoms (tremor, bradykinesia, Neurological symptoms (tremor, bradykinesia,
rigidity) rigidity)
•Walking abilityWalking ability
•ADLsADLs
•Quality of LifeQuality of Life

Goede 2001. The Effects of Physical Therapy in Parkinson’s Goede 2001. The Effects of Physical Therapy in Parkinson’s
Disease: A Research Synthesis. Arch Phys Med Rehabil 2001Disease: A Research Synthesis. Arch Phys Med Rehabil 2001

80. Parkinson’s DiseaseParkinson’s Disease

Gait assistive devices (avoid cane; use front Gait assistive devices (avoid cane; use front
wheeled walkers)wheeled walkers)

Home modificationsHome modifications

81. OsteoarthritisOsteoarthritis

Pain reliefPain relief

Exercises to increase muscle strength (knee Exercises to increase muscle strength (knee
arthritis)arthritis)

Exercises to maintain joint flexibility (hip Exercises to maintain joint flexibility (hip
arthritis)arthritis)

Assistive devicesAssistive devices

Weight reductionWeight reduction

Joint replacement- untreatable painJoint replacement- untreatable pain

82. DeconditioningDeconditioning

Occurs with a decrease in activity level (bed rest, Occurs with a decrease in activity level (bed rest,
hospitalization)hospitalization)

Leads to several physiological changes:Leads to several physiological changes:

Cardiovascular: Cardiovascular:
•increased heart rate, increased heart rate,
•decreased stroke volumedecreased stroke volume
•orthostatic hypotensionorthostatic hypotension

Pulmonary: Pulmonary:
•increased respiratory rate, decreased tidal volume, increased respiratory rate, decreased tidal volume,
minute volume and maximal breathing capacity; minute volume and maximal breathing capacity;
atelectasis, oxygen desaturationatelectasis, oxygen desaturation

83. DeconditioningDeconditioning

Metabolic changes: Metabolic changes:
•bone demineralization, calciuria, stone bone demineralization, calciuria, stone
formation, glucose intoleranceformation, glucose intolerance

ConstipationConstipation

DepressionDepression

Muscle atrophy, loss of muscle strength, joint Muscle atrophy, loss of muscle strength, joint
contracturescontractures

84. DeconditioningDeconditioning

Prevention: out-of-bed activities, bed and chair Prevention: out-of-bed activities, bed and chair
exercises, walk to diagnostic procedures, regular exercises, walk to diagnostic procedures, regular
exercise after dischargeexercise after discharge

Reconditioning exercise programs:Reconditioning exercise programs:
•Resistive exercisesResistive exercises
•FlexibilityFlexibility
•Endurance exercisesEndurance exercises

Rehab goals: prevention of contractures, enhance Rehab goals: prevention of contractures, enhance
strength, gait stability, velocitystrength, gait stability, velocity