Rehabilitation of Older Adult Patients with Arthritis

by Shari M. Ling, M.D.

• Assistive Devices
• The Physician’s Role
• Rehabilitation Settings
• Medical Issues for the Rehabilitation Patient
• Rehabilitation Resources
• Selected References

Assistive Devices

• Assistive Devices to Enhance Mobility
• Available Self-Care Devices

A variety of devices are available to assist with mobility and self-care. Devices are designed to compensate for functional deficits but should be fitted for each patient’s individual needs. These devices should therefore be prescribed in consultation with an interdisciplinary team. The cost of some aids are covered by Medicare or other insurance policies but must be either ordered or prescribed by a physician. Devices prescribed for nursing home residents are provided by the nursing home. Self-care devices may be purchased upon discharge from an in-patient rehabilitation program or after returning home. Standard wheel chairs may be rented (reimbursable 80%) or purchased. Rental is preferable since repairs are covered by the rental agency. Custom-fitted wheelchairs are expensive and must be fitted to each patient’s needs. A physician’s prescription or order is required for insurance reimbursement, and should be written in such a way that therapists have some latitude to adjust a device to the patient’s needs.

Assistive Devices to Enhance Mobility

Mobility Devices	Objective	Advantages	Disadvantages	Reim- bursement
Wheelchairs -standard -power	mobility for those who are unable to ambulate or have poor endurance	standard: easy transport; patient remains active power: allows quadriplegics & patients with poor lower extremity function to remain independent	standard: energy expenditure; power: requires intact vision & reason; expense; high maintenance; less portable	Medicare 80%Other Plans: vary 80-100%
Walkers -standard -rolling -hemi -platform	stability and support	standard: greatest stability rolling: easier to lift; more normal gait pattern; better balance hemi: larger base of support; stability for patients with 1 functional arm platform: allows for weight bearing by humerus	standard: difficult to maneuver; impossible on stairs; changes normal gait speed/pattern rolling: less stable, less control, requires an even/smooth surface hemi: does not fit on stairs	All walking aids covered by Medicare 80%
Canes -large-based -small-based -single-point	weight redistribution, compensate for visual & proprioceptive losses	varying degrees of stability and support		All walking aid covered by Medicare 80%
Crutches -Axillary -Canadian(forearm)	improve balance, redistribute weight	axillary: can achieve less than full weight bearing; more support than a cane Canadian: allows hand use & reaching	axillary: plexus injury; less stables than a walker; requires good standing balance & upper extremity strength Canadian: less stable; same as axillary	All walking aid covered by Medicare 80%

Available Self-Care Devices

As with mobility devices, rehabilitation team members should be used as resources to identify and specify the devices that are best suited to each patient’s needs. This list provides a small sample of devices. Self-care devices vary in cost and as a whole are not reimbursable.

Self-Care	Devices	Cost
Dressing	Sock aide Reacher	$10.00 $22.00
Bathing	Bath seat Long handle sponge Tub grab bar	$35.00-$50.00 $3.25 $59.00
Meal Preparation	Cutting Board Jar Opener	$33.00 $12.50
Toileting*	Commode Raised toilet seat	$110.00-$165.00 $28.00-$40.00

The Physician’s Role

• Physical Therapy
• Occupational Therapy
• Speech and Language Pathology
• Recreational Therapy
• Vocational Rehabilitation
• Social Worker
• Psychologist
• Nurse & Physician’s Assistant
• Physiatrist
• Problem Specific Programs

Physical Therapy

• Goal:To maximize safe and independent mobility
• Objectives: Build strength & endurance, improve balance, & coordination, improve lower extremity joint range of motion & function, improve transfers and ambulation. Improve safety awareness. Management of orthotic/prosthetic and assistive devices. Selection of appropriate wheel chair seating.
• Modalities: Superficial heat or cold, deep heat, electrical stimulation, and massage to reduce pain and spasm and to promote stretching; hydrotherapy for wound care
• Home environment: modifications to improve safety and a barrier free accessibility

Occupational therapy

• Goal: To maximize safe and independent self-care
• Objectives: Build upper extremity strength, fine motor skills, coordination & dexterity. Improve upper extremity joint range of motion, maximize visual-perceptual & cognitive skills. Maximize home and financial management; promote safety awareness.
• Techniques: Encourage clothing & footwear modifications for ease of use. Use of appropriate assistive and adaptive equipment to compensate for self-care deficits (built-up handles, long-handled reacher, etc.). Design and management of upper extremity orthotics to stabilize and protect painful or weak joints or to facilitate holding and using utensils. Energy conservation techniques for efficient self-care and ambulation.
• Home environment: Modifications to improve self-care (ADLs, IADLs)

Speech and language pathology

• Goal: Improve communication
• Objectives: Improve neurologic communication deficits; swallowing evaluation and training for dysphagia, speech training post-laryngectomy; family training
• Targeted Problems: dysphasia, dyspraxia, dysarthria, aphasia
• Devices: augmentative communication

Recreational Therapy

• Goal: Develop or enhance leisure activity skills
• Objectives: Develop structured leisure time planning, fosters socialization skills
• Modalities: Group and individual activities

Vocational Therapy

• Goal:
• Explore vocational alternatives and maximize the vocational potential for the older worker.
• Evaluation of the worker’s barriers to continue the current job, skills, attitudes, functional capacities and matches this profile to job requirements, physical and other demands, etc.
• Options include returning to the previous job, transitional work, alternative jobs, retraining and retirement.

Social Worker

• Goal:
• Maximize informal and formal supports to enable independent function. A social worker can help to rally available informal supports (family members, friends, neighbors, church members), and can help to identify formal resources available in the community (home-health aides, agencies). Provides patient & family education, support and counseling.

Psychologist

• Goal: Maximize cognitive and affective function
• Objectives: Assesses and assists with cognitive, affective and problem solving skills

Nurse & Physician’s Assistant

• Objectives: Reinforces functional tasks learned in therapy while monitoring for potential medical events; patient education in appropriate medication use, evaluation & management of bowel/bladder dysfunction; family training prior to or following discharge from the in-patient setting to the home. Important in all settings but can provide primary care in the home.

Physiatrist

• Evaluates functional needs of the patient and prescribes therapy
• provides medical and rehabilitative guidance
• monitors rehabilitative progress; adjusts/adapts therapy plans

Problem specific programs

• cardiac, pulmonary, orthopedic, oncology, brain injury

Rehabilitation Settings

Determine which setting is most beneficial to the patient.

• Acute Rehabilitation facilities – focus on rehabilitation goals, emphasize restoration of physical functioning with return to the previous living situation. Patients must be able to participate actively in physical, occupational, and speech/language therapy combined to total 3 hours each day per patient, five days/week. A physician directed multidisciplinary team of service providers (physical therapist, occupational therapists, speech therapists, physiatrists, rehabilitative nurses and social workers) delivers care.
• Subacute rehabilitation – Working to the same rehabilitation goals as acute facilities, subacute rehabilitation facilities provide more intensive therapy services (up to 3 hours of combined therapy each day, five days/week) than skilled nursing facilities. As with acute rehabilitation facilities, a multidisciplinary team of service providers provides care.
• Rehabilitative nursing homes – same goals as above. Medicare pays skilled nursing facilities ($2880 for 27.8 days) less than the cost of care provided in rehabilitation facilities ($9768 for 21.3 days). There are no time requirements for the amount of rehabilitative services required each day. Services may be provided independently by each rehabilitative service.
• Skilled nursing facilities – Can provide variable amounts of therapy.
• Home care – Therapy services are available to patients who are confined to the home as a result of medical reasons. A patient is considered to be homebound if that patient has an illness or injury which restricts the ability to leave the home except with the aid of a supportive device, special transportation, or the assistance of another person. Physical therapy provides restorative range of motion, therapeutic exercise, gait evaluation and training, use of therapeutic modalities. Speech and language pathology services are available through home-care and are considered skilled services. Occupational therapy available but must be delivered in conjunction with skilled nursing, physical therapy or Speech therapy.

Choices for Rehabilitation

	In-Patient	Nursing Home & Day Care Programs	Out-Patient	In-Home
Physician in Charge	acute hospital MD, primary physician, geriatrician, surgeon, physiatrist	primary physician, geriatrician	primary physician, geriatrician, surgeon, physiatrist	primary physician, geriatrician
Goals	restore prior function; safe return to community living;family training	restore prior function	restore prior function; family training	restore prior function; family training
Common Conditions	recovery from: orthopedic surgery, stroke; other neurologic diseases amputation; other surgery deconditioning following medical illness	deconditioning following an acute event; continuation of in-patient rehab; recovery from orthopedic surgery & stroke	musculoskeletal disorders; recovery from: orthopedic surgery, stroke/other neurologic diseases; amputation; other surgery deconditioning	deconditioning following an acute event; continuation of in-patient rehab; recovery from orthopedic surgery & stroke; home exercise instruction
Criteria	deficits in 2+ domains of function; have potential for recovery; medically able to participate 1-3 hrs/day x days/week	frail elderly who need rehabilitation and have recovery potential	not home-bound	home-bound
Services	Physiatry PT OT SLP Social work Gait evaluation Home safety & family training	Program dependent	Physiatry PT OT SLP Social work Gait evaluation Family training	PT SLP OT with PT/SLP/skilled nursing Home adaptation Home safety & family training
Payment	Medicare days 1-20 100%; days 21-100 80% 3 days week: Medicare part B Supplemental insurance	5 days/week: Medicare days 1-20 100%; days 21-100 80% 3 days week: Medicare part B Supplemental insurance	Medicare Supplemental insurance	Medicare: 3 days/week for up to 3 months of therapy. Co-payment

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Medical Issues for the Rehabilitation Patient

• Pain
• Thromobembolic Phenomena
• Urinary Retention or Incontinence
• Constipation
• Orthostatic Hypotension
• Cardiovascular Deconditioning

Pain

• Investigate the cause (new fracture? Flare of arthritis? Infection?)
• Investigate contributing factors (depression, anxiety)

• Solutions
• provide medications with adequate timing, dose, interval

• Oral Options
• Short acting simple analgesics
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
• Short acting narcotic analgesics
• Long acting narcotic analgesics
• Gabapentin, carbamezapine
• Nortriptyline

• Parenteral Options
• narcotic analgesics
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
• Transcutaneous (fentanyl)

Thromboembolic Phenomena

• Pharmacologic options
• low molecular weight heparin (LMWH)
• low dose unfractionated heparin (LDUH)
• Warfarin
• Aspirin

• Nonpharmacologic options
• foot pumps
• intermittent pneumatic compression
• graded compression elastic stockings

Surgery	Best	Also good
Total knee arthroplasty	Low Molecular Weight Heparin	Intermittent Pneumatic Compression with Low Molecular Weight Heparin
Total hip arthroplasty	Low Molecular Weight Heparin, warfarin	Add Intermittent Pneumatic Compressions
Hip fracture repair	Low Molecular Weight Heparin, Low Dose Unfractionated Heparin	Warfarin

Urinary Retention or Incontinence

• identify the cause, exclude urinary tract incontinence, medication induced?, functional?, retention?
• Solutions
• minimize medications
• toileting schedule
• check post-void scans with intermittent catheterization for volumes > 200 cc
• exclude UTI

Constipation

• Frequent event following orthopedic surgery

• Prophylaxis
• fiber supplements
• mobilization
• hydration
• Solutions
• sorbitol
• lactulose
• hydration
• review and remove meds (narcotics, anti-cholinergics)

Orthostatic Hypotension

• Frequent in patients with cardiovascular disease
• predictor of mortality
• risk for falls
• Solutions
• lower extremity wraps
• abdominal binder
• progressive seating schedule in a reclining wheel chair
• careful medication review
• blood pressure monitoring with therapy
• tilt table

Cardiovascular Deconditioning (angina; congestive heart failure) and hypoxemia (COPD)

• Solutions
• Appropriate medical management
• Small meals and limited activity for 30-60 minutes following meals to avoid post-prandial hypotension
• Blood pressure & oxygen monitoring with therapy
• Supplemental oxygen
• Maintain hematocrit
• Hypo- or hyperglycemia in diabetic patients:
• Solutions
• Regular meals
• Snacks on hand
• Frequent glycemic monitoring
• Skin Breakdown:
• Solutions
• Proper nutrition & hydration
• Small meals and limited activity for 30-60 minutes following meals to avoid post-prandial hypotension
• Avoidance of incontinence
• Frequent repositioning
• Proper skin care

Rehabilitation Resources

The Terrace Rehabilitation Unit of the Johns Hopkins Geriatric Center Deb Youngquist, Program Manager	(410) 550-0757
Johns Hopkins Home Care	(410) 288-8100 or 8111
American Physical Therapy Association	1-800-999-2782; (703) 684-2782
American Occupational Therapy Association	1-800-426-2547
National Library of Congress Referral Center	(202) 287-5670
National Rehabilitation Association	(703) 836-0850
National Rehabilitation Information Center 8455 Colesville Road, Suite 935 Silver Spring, Maryland 20910-3319 naric@capaccess.org	1-800-346-2742; (301) 588-9284
National Clearing House of Rehabilitation Training Materials	1-800-223-5219
National Institute on Disability and Rehabilitation Research Office of Special Education and Rehabilitative Services US Department of Education 400 Maryland Avenue Washington, DC 20202
National Institute on Human Resources and Aging	1-800-647-8233
Rehabilitation Services Administration	1-800-346-2742; (202) 205-8926
US Dept of Education, Rehab Services Admin (RSA)
National Rehabilitation Information Center for Disability Resources & NARIC Info

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