Overview of Geriatric Rehabilitation_ Program Components and Settings for Rehabilitation

7/15/2014 Overview of geriatric rehabilitation: Program components and settings for rehabilitation

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Official reprint from UpToDate www.uptodate.com ©2014 UpToDate

AuthorsHelen Hoenig, MD, MPHPatrick M. Kortebein, MD

Section EditorKenneth E Schmader, MD

Deputy EditorH Nancy Sokol, MD

Overview of geriatric rehabilitation: Program components and settings for rehabilitation

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Jun 2014. | This topic last updated: Oct 11, 2012.

INTRODUCTION — The primary purpose of rehabilitation is to enable people to function at the highest possible level

despite physical impairment. Rehabilitation includes a vast array of interventions provided by a diverse group of providers

across the entire continuum of care. While rehabilitation may be provided to all age groups, the fastest growing population

of persons requiring rehabilitation services is adults over 65 years of age. This is because of the aging of the US and

worldwide population [1,2].

Improvements in both medical and rehabilitative care have helped to reduce prevalence of old age disability [3], but it

comes with a substantive price in demands for both medical and rehabilitation care [4]. Moreover, there is concern that

improvements in health and disability gained over the last several decades may not impact the generation just entering

retirement. The increasing numbers in this population, and the apparent increases in disability related to musculoskeletal

disorders (as well as depression, diabetes, and neurological disorders) affecting mobility-related activities in particular, will

likely further drive needs for rehabilitation [5].

Making good use of rehabilitation resources is facilitated by an appreciation for how disability occurs and the mechanisms

by which rehabilitation is effective. This knowledge leads to understanding of which specific rehabilitation services might

best be provided, where to provide them, and by whom. This topic will review aspects of geriatric rehabilitation related to

types of involved providers, interventions, and settings. Indications for rehabilitation and patient assessment are addressed

separately.

CONCEPTUAL MODELS FOR DISABILITY — There are two major conceptual models for understanding disability and

where rehabilitation services can be most effective:

The International Classification of Function, Disability, and Health (ICF), developed by the World Health Organization

[6], and

A model variably known as the “Environmental Press,” “Ecological,” or “Person-Environment Fit” model, originally

described by Lawton [7].

The World Health Organization model (ICF) — The International Classification of Function, Disability, and Health (ICF)

model (figure 1) indicates that an individual’s level of function (body function, ability to execute a task [activity], and

participate in life activities) is determined by his or her health condition(s) within the context of environmental and personal

factors. Medical and surgical interventions are directed at the underlying health conditions causing disability; rehabilitation

services target the impairment, activities, and participation levels of the disablement process, as well as personal and

environmental contextual factors that influence activity and participation.

Multiple health conditions or comorbidities, with concomitant impairments, are common in older persons and influence the

disablement process. Effective treatment of late-life disability, therefore, is typically multimodal [8]. Decline in late-life

disability from 1980 to 2010 can be attributed to the combination of advances in medical care, improved socioeconomic

factors, and innovations in mainstream and assistive technology [3,9].

The ecological model — Disability results from a mismatch between individual capacity and task demands, which in turn

are influenced by the environment and the way in which tasks are performed [7,10]. For example, walking imposes different

physical demands when performed atop Mt. Everest versus at sea level. Thus, the ecological model helps to explain how

personal and particularly environmental contextual factors described in the WHO ICF model interact with physical

limitations to result in disability [6,7]. In the ecological model, remediation of disability occurs through treatments that

either increase individual capacity or reduce task demand.

Medical treatment (eg, oxygen supplementation or medication) or surgical treatment (eg, cataract surgery, joint

replacement) have the potential to increase capacity. Rehabilitation interventions may improve capacity, reduce task

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demands, or accomplish both. Examples of such interventions follow [11,12]:

Improve capacity:

Exercise

Hearing aids, reading magnifiers

Artificial limbs

Orthotics (ie, braces, splints)

Reduce task demands:

A raised toilet seat or bath bench, which reduce the effort required to rise to a standing position

A ramp or elevator to replace stairs

Both increase capacity and reduce demand:

A cane that can enhance sensory capacity by providing proprioceptive feedback to improve balance, and it can

reduce demand, for example, by offloading body weight from the leg to the arm to relieve arthritic joints or weak

lower extremities.

TYPES OF REHABILITATION PROVIDERS — Disability has many diverse causes and often occurs through the

interaction of one or more medical conditions with both personal and environmental contextual factors. Therefore, a wide

variety of providers may be involved in treating rehabilitation.

A list of types of rehabilitation providers, the typical rehabilitation interventions used by various disciplines, and the

aspect(s) of the disablement process targeted by the provider types is provided in a table (table 1). Treatment by a provider

in a single discipline is often sufficient for patients with uncomplicated conditions or with minimal disability (eg, physical

therapy for osteoarthritis of the knee or a home safety evaluation by an occupational therapist for a patient with fear of

falling). However, for more complex or catastrophic disability, a multidisciplinary team of providers is optimal to address the

rehabilitation needs related to progressive disability and the interaction of multiple contributing conditions and contextual

factors.

Multidisciplinary care is a cornerstone of rehabilitation. The efficacy of coordinated multidisciplinary rehabilitation for a

number of conditions affecting older adults, including stroke, rheumatoid arthritis, falls, and frailty, is supported by

numerous studies [13-19]. Geriatric evaluation and treatment units provide multidisciplinary care with medical, social

service, nursing, and rehabilitation personnel (typically physical and occupational therapy) working together in a

coordinated fashion [13]. Inpatient stroke rehabilitation teams include a variety of rehabilitation personnel (eg, speech

therapy, occupational therapy, physical therapy) to target rehabilitation therapies to the specific stroke-related deficits, as

well as medical, nursing, and other staff [14]. Coordination of care may be achieved with weekly team meetings and/or

scripted protocols to facilitate care coordination.

Benefits from coordinated multidisciplinary rehabilitation accrue from systematically targeting the multiple factors that

interact to cause and exacerbate disability. For example, stroke may adversely affect visual perception, speech, and

cognition as well as cause paralysis. Members of the multidisciplinary team often have both unique and overlapping

expertise, reinforcing the interventions of each other.

INTERVENTIONS

Exercise — Physical activity is defined as bodily movement that is produced by skeletal muscle contraction and that

substantially increases energy expenditure. Exercise, a type of physical activity, is defined as a planned, structured, and

repetitive bodily movement done to improve or maintain one or more components of physical fitness (eg, muscle strength,

flexibility, balance).

Physical activity is beneficial for reducing overall morbidity and mortality in older adults (table 2) [20]. Exercise

recommendations for all individuals >65 years of age are shown in a table (table 3) and discussed separately. (See

"Physical activity and exercise in older adults".)

The physical activity recommendations intended for all older adults may need to be modified for particular medical

disorders, using specific types of exercise to correct or ameliorate identified impairments and functional limitations.

Common conditions in older adults that would necessitate exercise modification include acute cardiac conditions (eg,

cardiac rehabilitation), orthopedic and neurosurgery procedures, osteoporosis, acute/postacute stroke, or chronic

respiratory disease (eg, pulmonary rehabilitation). Physical therapists, exercise physiologists, and physicians specializing



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in rehabilitation (“physiatrists”) can help to tailor the exercise prescription to meet particular patient needs.

Certain types of exercise may be particularly beneficial for specific patient populations. As an example, resistive exercise

and power training have been found to improve function in frail older adults [21]. A systematic review found that progressive

resistance exercise (ie, weightlifting) can significantly improve muscle strength and, to a lesser extent, functional activities

such as rising from a chair and ambulation [22].

During acute hospitalization, early mobilization seems to offer particular benefit, improving outcomes in multiple patient

populations, including patients with hip fracture, acute pneumonia, or critical illness in the intensive care unit [23-25].

Assistive technology — Assistive technology and adaptive methods encompass a diverse group of interventions designed

to enable people with physical limitations to participate in a broad range of activities.

Assistive technology refers to devices that may be used to make tasks easier or safer (eg, a reacher can be used

by someone with limited upper or lower extremity range of motion to make it easier to pick something up).

Adaptive methods refers to changing the way a task is done so as to make it safer or easier (eg, a stroke patient

might don a sweater more easily by putting the sleeve on the paralyzed arm first, then on the non-paralyzed arm,

and then over the head).

Often the two methods are used together. These interventions can act at all levels of the disablement process, targeting

particular organ system impairments (eg, a prosthetic leg after an amputation), particular types of activities (eg, a cane

used when walking), or broadly enhancing access and opportunities for participation (eg, ramps allowing access to public

buildings).

Assistive technology is a particularly common way of coping with disability [26]. Assistive technology includes mobility

aids such as canes and walkers, bathroom safety devices such as raised toilet seats and grab bars, self-care devices

such as reachers and built up utensils, as well sophisticated computerized and electronic technology. Use of assistive

technology has increased substantially in recent years, far exceeding the growth and aging of the US populations [27,28].

By some reports, technological advances may account for half of the decline in disability in recent years [3]. There has

been both an increase in evidence to support its effectiveness [29-31] as well as major improvements in the technology

itself, with improved ergonomics, ease of use, and durability [32]. The internet provides a wealth of information about

diverse assistive devices. Abledata is one such resource, providing objective information on assistive technology and

rehabilitation equipment available from sources within the United States and internationally.

Mobility aids — With the aging of the population, there is increasing need for mobility aids. In the United States in

2000, among adults 65 years and older, 10 percent used canes and 4.6 percent used walkers [33]. Mobility devices may

be used for diverse types of physical limitations affecting mobility, including weakness, sensory limitations (vision or

proprioception), impaired balance, and/or limited endurance. While such devices are intended to improve mobility, activity,

foster independence, and provide some protection against falls, evidence from high-quality studies on the impact of these

devices is sparse.

There are multiple options for mobility aids, and their appropriate use is outlined below. An algorithm for selecting among

mobility aids and a table that reviews indications and the relative pros and cons of various mobility aids are provided

(algorithm 1 and table 4).

Despite availability of insurance coverage, many older adults purchase mobility aids over the counter on their own or borrow

them from friends or relatives without professional guidance, which can lead to problems using the device [34]. Mobility

aids that are not properly fit or are used incorrectly can increase the risk of falls and injury. Falls directly related to mobility

devices account for over 50,000 visits annually to emergency departments in the United States [35]. Moreover, 30 to 50

percent of wheelchair users report tips and falls [36]. It is vital to observe older patients actually using their mobility aid to

verify proper fit and correct use and to refer the patient to expert consultation with a certified Assistive Technology Provider

(ATP), physical therapist (PT), or occupational therapist (OT) if there is any question.

Canes — Canes are the most commonly used type of mobility device [37,38]. Most persons are not properly

instructed in cane use, and up to 70 percent of canes are used incorrectly or are the wrong height or design [33]. As a

result, almost 30 to 50 percent of individuals abandon use of the cane after receiving it.

Typically, canes are used to reduce the weight borne across an arthritic joint, thereby reducing pain, or to assist with

balance when the balance problem is due to impaired sensation and/or mild leg weakness. A cane can transmit

proprioceptive input to the hand and arm, which can be helpful to people with neuropathic problems or visual deficit. Canes

are lightweight and versatile, but require good hand and arm strength and provide only minimal support. Canes are most

useful when the gait problem is unilateral and/or mild.









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A variety of options are available in canes. For most patients, a simple cane with an ergonomic grip is most effective [39].

A quad cane with four tips provides a broader base of support but is clumsier to use. A cane with a pistol grip handle can

increase weight support.

The cane needs to be at the right height so as not to throw off balance and to provide proper biomechanical support, with

the handle of the cane at the level of the wrist with the arm fully extended. Most canes can be adjusted by cutting the cane

at the tip or, for adjustable canes, with the button on the side of the cane. Most canes have a rubber tip to improve traction

that should be inspected for wear and replaced when worn.

A cane should be used in the hand opposite to the affected limb to preserve a normal gait pattern and keep the body

weight over the base of support to ensure good balance.

Crutches — Like canes, crutches come with various options (eg, axillary, forearm, and platform crutches). However,

as all crutches require excellent arm strength and coordination for effective use, they are seldom used with older patients.

Improper use of crutches, especially the more common axillary crutches, can result in injury to the shoulder (eg, brachial

plexopathy and rotator cuff tendinitis). There are several different ways to use crutches (eg, swing through gait, touch-down,

etc.) and most require learning a novel gait pattern, which can be challenging in the presence of even mild cognitive

impairment.

Walkers — Walkers are the second most commonly used type of mobility aid [34,35]. Walkers generally are used

to treat bilateral gait problems or when more body-weight support or balance support is needed than a cane can provide.

Walkers come with many options in the number of wheels and type of support.

One of the most commonly used types of walker is a two-wheel or front-wheel walker. A four-point or pick-up walker is

seldom used any more, as it is harder to use and offers little additional stability [40]. Forearm supports can be attached to

a two-wheel walker to enable use by persons with weak grip or hand deformities.

Increasingly common is a four-wheel walker with brakes located on the handles like a bicycle (sometimes called a “rollator”

or “Canadian walker”). Four-wheel walkers come with and without a seat and with or without a basket. A four-wheel walker

is less stable than a two-wheel walker. It requires good hand coordination to use the brakes and is more expensive than a

two-wheel walker; but it is more maneuverable, and the seat affords an opportunity to rest at will. It is a good choice for

someone whose main problem is poor endurance from pain or shortness of breath (such patients often have the necessary

balance and hand coordination to safely use this type of walker, and the seat allows for rest breaks). A three-wheel walker

can provide similar balance support as a four-wheel walker, but it is lighter weight and more maneuverable so it is

particularly useful for patients dealing with mobility in narrow confines (eg, a trailer) [41]; however, it is does not come with

a seat or basket so it is less useful for people with limited endurance or who need to transport items while walking (eg,

shopping).

A “Merry Walker” has four wheels, a sling seat, and railings on four sides so that the patient is protected from falling yet

can propel themselves. The Merry Walker is larger than other walkers and is best used in an institutional setting with wide

doorways/hallways.

A “Knee Walker” is a relatively new wheeled mobility device. It is similar to the foot-propelled or kick scooters used by

children but with a platform on which the patient can rest their knee while walking. It is especially useful for people who

must be non-weight-bearing after surgery or injury to the foot or ankle as it is easy to use and it avoids the need for a

wheelchair or crutches.

Wheelchairs — Wheelchairs may be used when weightbearing is prohibited or in patients with significant functional

impairments (eg, bilateral leg weakness, impaired balance, and/or motor coordination too severely impaired for safe use of

a walker). The most commonly used wheelchair is a manual wheelchair with a sling seat that folds and has removable

footrests and armrests.

Many older individuals pay for wheelchairs and other assistive devices themselves [42] and may be tempted to save money

by use of non-removable foot rests or by using a second-hand wheelchair. Fixed foot rests are a fall hazard and make it

harder to get in and out of the chair and should be avoided. Borrowing a wheelchair can be problematic if the fit is not

adequate or the seat is worn, reducing comfort and increasing the risk of pressure ulcers [43].

Important aspects of wheelchair fit for all wheelchair users include seat width and height. The seat width should allow about

one inch between the thighs and the armrests, such that there is no pressure or rubbing on the lateral thighs while still

allowing good biomechanics when propelling the chair. The seat length should allow about two inches between the end of

the seat and the knees, and the foot rests are positioned so the thighs are slightly elevated or level such that the seat









provides even support to the buttocks and thighs. Patients who use their feet to propel the wheelchair (eg, stroke patients)

require a “hemi-height” wheelchair with a seat height that is lower to the ground. A seat cushion generally should be used

with a wheelchair and a specialized pressure-reducing cushion is appropriate for persons in the wheelchair full-time or who

have difficulty with limited ability to shift their weight while seated [44,45]. Specialized seating systems can be provided for

persons with truncal instability.

Shoulder pain is common in manual wheelchair users, and it is likely that elders with arthritic joints and women whose

upper extremities are weaker are at particular risk for developing shoulder problems with prolonged manual wheelchair use

[46]. Patients who develop shoulder pain with wheelchair use should be evaluated for rotator cuff tendinitis. (See

"Evaluation of the patient with shoulder complaints".)

A variety of options are available to treat shoulder pain in manual wheelchair users, including exercises to strengthen the

shoulder musculature, training on how to most efficiently propel the wheelchair, and/or providing a lightweight wheelchair

that is easier to propel or even a power wheelchair [47,48]. Ultra lightweight manual wheelchairs can be adjusted for

optimal biomechanical advantage when propelling the wheelchair, and interchangeable power assist wheels are available

that can reduce the force needed to propel the wheelchair. Wheelchairs with special adaptations to meet specialized

needs (eg, ultra lightweight, elevating leg rests, reclining backrests, power wheelchairs, etc.) may require additional

justification to ensure reimbursement [49].

Motorized wheelchairs and scooters are increasingly common and are most helpful for community mobility [50]. Even the

most compact motorized wheelchair has a larger footprint than a manual wheelchair, making it hard to maneuver in the

home. The cost-benefit trade-offs for these devices need to be considered carefully: financial costs include not only the

device, but a car lift to transport the device and an entry ramp if it is to be used in the home. There also is a risk of

accidents (collisions, tipping over); however, the risk of deconditioning appears minimal.

At least in the short term, power scooters do not appear to be overused or to cause deconditioning [51]. It appears that

most wheelchair users pick and choose locations where they use their wheelchair depending on needs, abilities, and

environmental constraints [52]. Benefits from wheelchairs relate to increased mobility and participation in activities that

would be prohibitive otherwise [53].

A systematic review of the evidence regarding the best way to obtain the optimal wheelchair found that there is only limited

evidence to determine best practices [54]. There is some evidence that expert assistance, fitting, and training is helpful for

improving wheelchair use [55-57]. For patients with complex rehabilitation and seating needs (eg, deformities, increased

muscle tone/spasticity), a multidisciplinary team can be helpful, including a rehabilitation physician (physiatrist), an

occupational therapist (OT) or physical therapist (PT) with expertise in wheelchairs, a certified rehabilitation technology

supplier, and/or a rehabilitation technician [54]. For individuals with complex needs, several components of a wheelchair

program will help to assure a good outcome: education to reduce accidents and maximize mobility; involving the individual

in the prescription process; and active follow-up to reduce accidents and make adjustments, as needed, to improve fit and

usage [54]. Expert evaluation and training is also important for patients who will use the wheelchair full-time, who are at

increased risk for pressure sores (eg, due to incontinence or inability to weight shift), for persons with postural problems, or

if a motorized wheelchair or scooter is being considered. However, even short-term and intermittent wheelchair users likely

benefit from fitting and training by an OT or PT in use of the device, with beneficial effects related to comfort and ability to

safely navigate with the wheelchair [56].

Reimbursement for mobility aids in the US — Medicare (Centers for Medicare and Medicaid [CMS]) will pay for

“durable medical equipment” (DME), including all types of mobility aids, but it is important to follow their guidelines to

ensure coverage (table 5) [58]. Medicare guidelines for Mobility Assistive Equipment (MAE) favor use of a cane or walker

over a manual wheelchair and a manual wheelchair over a power wheelchair scooter, approving the higher-level device only

if the patient has a mobility limitation that is not adequately compensated with the lower-level device [59]. Generally,

Medicare reimbursement is limited to one type of mobility aid per qualifying illness (ie, the patient isn’t provided both a

quad cane and a wheelchair for mobility needs after a stroke). Face-to-face evaluation by a physician or midlevel provider

and substantive medical justification is required by CMS for power mobility devices [60].

Some medical supply stores and vendors employ a certified Assistive Technology Professional (ATP) especially for

provision of complex devices (eg, power wheelchairs). Medicare/CMS covers consultation with an OT or PT for fitting and

training in use of any type of durable medical equipment, including mobility aids.

The Veterans Health Administration (VHA) will also cover most types of mobility aids and without some of the restrictions

in the Medicare system (eg, more than one type of mobility aid may be provided for a particular medical problem so long as

it is medical necessary), although medical justification by a VHA medical provider is required and training in use of the



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device by a VHA rehabilitation provider is also usually required.

Typically, Medicare will pay for rental of a standard manual wheelchair, with the patient owning the wheelchair after 13

months of rental [61]. Wheelchairs for nursing home residents are provided by the institution rather than Medicare/CMS, so

it can be difficult to obtain a specialized wheelchair in that setting. Veterans own the mobility aids provided to them by the

VHA, and they do not need to be returned when they are no longer needed, although they may need to be returned to get a

new or replacement device.

Bathroom and self-care aids — A wide variety of devices and environmental modifications can be used to make self-

care tasks easier and improve safety, particularly in the bathroom. While the evidence to support the efficacy of particular

bathroom devices is limited [62], the theoretical rationale for their provision is strong. Several randomized clinical trials have

demonstrated beneficial clinical outcomes (eg, physical function, and/or balance confidence and/or reduced falls) from

home health interventions that include provision of assistive devices, environmental modifications, and home visits by

rehabilitation therapists [63-67]. Evidence suggests that simply providing home safety assessments and equipment without

involvement of a professional such as an OT is less effective [68].

Useful information on bathroom design and other types of environmental modification to enhance independence and safety

is available at the websites for the Center for Inclusive Design and Environmental Access

(www.ap.buffalo.edu/idea/home/index.asp) and the Center for Universal Design (www.design.ncsu.edu/cud/index.html).

Commonly-used bathroom equipment includes raised toilet seats, seats in the tub/shower, hand-held showers, and grab

bars.

Raised toilet seats — It is easier to rise to standing when starting from a higher level than a lower level [69], so a

raised toilet seat or tub/shower bench may be helpful to someone with weak legs, painful joints, or poor balance.

Raised toilet seats may be free standing (eg, bedside commode) or attached directly to the toilet. Tub/shower

benches also come in a variety of shapes and sizes.

Grab bars — Bars may allow patients to rise more safely by enabling use of the arms to compensate for weak legs

or limited sensation. Patients may rely on items already in their home such as a nearby sink or towel bar for this

purpose, which is fine if they are stable or securely attached to the wall, but can be dangerous if the item is

unstable. Placement of grab bars can eliminate some of the risk.

There is considerable variety in grab-bar technology [70], with options such as direct attachment to the toilet or a

raised toilet seat, swing away bars, attachment to the side of the tub, or directly to the wall itself.

For patients who need help from another person for transfers, use of a gait belt can improve safety, and hydraulic lifts are

available that can be easily used even by quite frail caregivers.

Prosthetics and orthotics — A prosthesis is an artificial device that replaces a missing body part (eg, artificial limb)

while an orthosis is an external device applied to the body to support or improve the function of that body segment/joint (eg,

ankle foot orthosis, carpal tunnel splint).

Prostheses — Prosthetic devices require detailed patient evaluation for optimal prescription. Careful consideration of

medical comorbidities and the premorbid functional status is required, particularly in older persons. Such factors may be of

lesser importance for younger patients with traumatic amputation.

Lower extremity amputations are the second most common type of amputation (with digit amputation most common), and

up to 90 percent are due to peripheral vascular disease in diabetic patients. The underlying disease that resulted in an

amputation (eg, diabetes, peripheral vascular disease) often affects the function of other organ systems and the patient’s

ability to cope with the increased work of walking required with a prosthesis. Comorbid conditions such as cognitive

impairment, arthritis, pulmonary disease, or stroke can also affect the use of a prosthesis. A systematic review noted that

the following factors were most predictive of functional walking ability after a prosthetic limb: cognition, fitness, preoperative

mobility, ability to stand on one leg, and independence in activities of daily living [71].

For some severely debilitated amputees, a manual or power wheelchair with a cosmetic leg may provide the best functional

outcome. For other amputees, functional needs may be met with a low-tech prosthesis, such as a simple knee or ankle

joint rather than a computerized knee or multiaxial ankle joint. In contrast, those with an above-knee amputation who are

likely to be able to ambulate in the community may benefit from a high-tech prosthesis with a computerized knee [72].

A multidisciplinary amputee clinic including a physiatrist, a physical therapist, and a prosthetist is the optimal resource for

determining the proper prosthesis and assuring correct fit and function. If this is not available, it is vital for the ordering

physician to work closely with a certified prosthetist and include a PT early in the process. In general, obtaining proper

prosthetic fit and function requires a skilled prosthetist. Unfortunately, there is limited research available to assist in





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determining the optimal prosthesis for an individual patient [73]. Prosthetic training is typically completed on an outpatient

basis by a physical therapist who may then work with the prosthetist to modify the prosthesis if abnormal gait patterns or

skin breakdown are noted; ideally, there are intermittent evaluations and supervision by a physiatrist skilled in amputee

rehabilitation.

Orthoses — Orthoses (ie, splints and braces) are available for virtually every joint in the body including the spine.

There are a number of prefabricated, “off the shelf” orthoses (eg, carpal tunnel splints, soft cervical collar). Custom orthoses

are generally fabricated by an orthotist although occupational therapists may also perform this function, particularly for

upper-extremity joints. Prefabricated splints and braces are most appropriate for uncomplicated conditions that don’t have

substantial deformity.

Commonly used prefabricated lower-extremity braces in the geriatric population include those for the knee (eg, knee

sleeve, knee unloader braces), ankle foot orthoses for foot drop, and heel cushions for plantar fasciitis/heel pain. There are

few randomized trials with any braces. The available evidence indicates that knee braces may reduce pain and improve

function for patients with osteoarthritis [74,75].

Knee sleeves may be used for mild to moderate severity knee osteoarthritis (OA); devices to control patellar motion

(eg, patellar cutout) may be beneficial for patellofemoral OA. Due to the limited evidence of benefit for any particular

knee sleeve, patient preference should be the deciding factor. (See "Nonpharmacologic therapy of osteoarthritis",

section on 'Braces'.)

Knee unloader braces are designed to alleviate pain by unloading the osteoarthritic medial or lateral compartment of

the knee. Medial/lateral unloader braces should be reserved for patients with more severe knee OA and are best

prescribed by an orthopedic surgeon, rehabilitation physician/physiatrist, or with input from a physical therapist.

Patients with knee instability may be prescribed a hinged knee brace that can be set to limit range of motion to a

particular arc; however, such braces should only be prescribed under the direction of a rehabilitation or orthopedic

provider as they should be used in conjunction with a rehabilitation program.

Foot drop occurs most commonly after a stroke but may also be seen with a neuropathy affecting the

fibular/peroneal nerve. Ankle foot orthoses (AFOs) maintain the foot in a neutral position during ambulation and can

improve gait speed and self-confidence in patients with foot drop [76,77].

There is fair evidence that heel cushions may be beneficial for plantar fasciitis, and pre-fabricated heel cushions

appear to be just as effective as higher-cost custom-molded foot orthoses [78,79]. (See "Plantar fasciitis", section

on 'Treatment'.)

Patients at prolonged bedrest benefit from a protective orthosis to maintain the foot in a neutral position, preventing

Achilles tendon contractures and protecting the heels from skin breakdown/pressure ulcers.

For the upper extremity, carpal tunnel functional wrist splints are effective for reducing numbness and pain [80]; over

the counter splints are as effective for treating carpal tunnel syndrome symptoms as custom fit splints [81].

However, the patient should be referred for neurological evaluation (eg, electrodiagnostic testing) and possible

surgery if there is any evidence of thenar muscle weakness or atrophy. (See "Treatment of carpal tunnel syndrome",

section on 'Treatment'.)

Osteoarthritis of the first metacarpal phalangeal joint is common and it can be effectively treated with an opponens

splint. These splints typically are hand crafted by an occupational therapist, hand therapist (PT or OT), or

prosthetist.

Environmental modification — “Environmental modification” and “universal design” describe interventions and methods

to minimize the effects of the environment in exacerbating disability and enhance “accessibility” for all persons irrespective

of their abilities. The term “universal design” highlights an overarching goal of enabling access for the widest possible

breadth of physical abilities. However, the effects of medical conditions on physical function are variable among individuals

[82]; similarly, interactions with the environment are not uniform across conditions and impairments. The

environment/person interface can be particularly important for persons with impairments affecting mobility and also for

persons with low vision.

Environmental modification may be used in isolation or in conjunction with assistive technology to enhance access and

utility of both public and private spaces for persons with disability [64]. Increasing evidence supports the influence of the

physical environment (ie, terrain, housing) on functional outcomes in older adults [83]. For example, elders who live in

neighborhoods with a mixture of residential and business facilities (ie, “mixed use”) and higher-density neighborhoods

report greater independence with Instrumental ADLs, with the effect most prominent among those with greater physical

limitations [84].



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The Americans with Disabilities Act (ADA) of 1990 directed that new public and private business construction must be

accessible, and it supports widely used guidelines for accessibility. Technical information on the ADA is available at

www.adata.org, and information on accessibility is available from the US Access Board (www.access-board.gov/the-board).

Helpful information on environmental modification and universal design pertinent to both public and private spaces can be

found at the websites for the Center for Inclusive Design and Environmental Access

(www.ap.buffalo.edu/idea/Home/index.asp) and the Center for Universal Design (www.design.ncsu.edu/cud/index.html).

Occupational therapists have particular expertise in the person-environment interface within the home environment and can

work in conjunction with architects and structural engineers to recommend the most beneficial modifications; physical

therapists are particularly helpful with mobility impairments, equipment, and methods for coping with environmental

challenges both inside and especially outside the home; low-vision specialist provide unique expertise for these same

kinds of problems in older adults coping with low vision (eg, macular degeneration).

Modalities for pain — Several therapeutic modalities are available for the treatment of pain.

Heat/Cold — Two of the most commonly used therapeutic modalities are heat and cold. Both heat and cold may

be delivered to the patient in several different ways. Mechanisms of thermal transfer include conduction (eg, hot or

cold pack), convection (eg, whirlpool bath), and conversion (eg, ultrasound, diathermy). The effect of commonly used

modalities for delivering heat and cold is at the superficial level of the body; core temperature is altered very little by

localized thermal modalities. Ultrasound, particularly low-frequency ranges, is used to heat deeper tissues (up to

several cm in depth). Heating modalities include heating pads/hydrocollator packs, heat lamps, hot tub/whirlpool,

paraffin baths (paraffin mixed in mineral oil heated to 45 to 54°C), and ultrasound (0.5 to 3.0 MHz). Heat causes

local vasodilatation and hyperemia. Cooling modalities for rehabilitation include ice cubes/packs/wraps

(recommended duration 10 to 20 minutes per session; thin damp towel between skin and ice), ice massage, and

whirlpool baths.

While both heat and cold are most frequently utilized for their pain relieving effects, other indications include muscle

relaxation for heat, and relief of swelling and edema for cold (table 6). Contraindications for thermal modalities must

be considered (table 7). Heat is generally contraindicated in patients with acute injury and application of cold is to

be avoided for patients with insensate skin or Raynaud phenomenon.

Evidence for the relative benefits of different methods to provide heat is limited and comparisons of modalities (eg,

hot pack versus diathermy) appear to show equal benefit for pain relief [85]. Although one study showed more rapid

resolution of calcific rotator cuff tendinitis with ultrasound compared to exercise alone, there was no difference

between the groups at nine months [86].

Transcutaneous electrical nerve stimulation (TENS) — TENS is primarily used for musculoskeletal pain relief.

The mechanism of action for TENS is uncertain, although it has been postulated that TENS modulates pain

perception through the gate control pain theory. Well-controlled investigations have not demonstrated significant

benefit of TENS for musculoskeletal pain disorders beyond placebo or heat alone [87,88].

Iontophoresis/Phonophoresis — These modalities utilize electric current (iontophoresis) or ultrasound energy

(phonophoresis) to force a therapeutic medication (eg, glucocorticoid) into tissues. Both are used to treat soft tissue

musculoskeletal injuries. Although evidence is limited, the few randomized controlled trials indicate that these

modalities are generally no more effective than placebo [89,90].

Other — Persons with dysphagia may be helped by special feeding techniques (eg, tucking the chin, swallowing a second

time after every bite) and/or dietary modifications (eg, use of gelatin to thicken liquids) [91]. A speech language pathologist

(speech therapist) can use radiographic and/or endoscopic studies to clarify the nature of the dysphagia and fine-tune

recommendations. Treatment of dysphagia may be directed by the speech language pathologist individually or in

collaboration with a nutritionist and/or occupational therapist.

Reimbursement (US, other than mobility aids) — The Veterans Health Administration (VHA), but not Medicare/CMS,

will pay for bathroom safety devices such as raised toilet seats, tub/shower seats, or grab bars, considering these items

not medical equipment and/or needed for “personal convenience;” however, Medicare will pay for a free-standing “bedside”

commode (table 5) [92].

Medicare/CMS will not pay for other assistive devices related to self-care (eg, specialized eating utensils), although the

VHA does provide these items. Consultation with a rehabilitation therapist (eg, OT, PT) for evaluation, fitting, and training in

use of any type of assistive devices is paid for by both Medicare and the VHA, and such consultation can help assure the

prescribed device will meet the patient’s needs and that they can use it safely [93].

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Medicare/CMS provides coverage for many prosthetic and orthotic devices, although generally the patient is responsible for

a 20 percent co-pay (table 5) [58].

Medicare will cover fabrication of a prosthetic limb and related follow-up visits with a prosthetist, as does the

Veterans Health Administration (VHA). Per Medicare guidelines, the functional level of the amputee must be

considered and specified in the prescription for the prosthetic limb.

Typically both Medicare and the VHA will pay for a splint fabricated by an orthotist or occupational therapist and

many prefabricated braces as well.

The VHA will pay for ramps and some home renovations (with a monetary cap that varies with “service connection”), and

some veterans are eligible for a “specially adapted housing” grant [94]. Medicare does not cover environmental

modifications.

REHABILITATION SETTINGS — Rehabilitation therapy services can be delivered in a wide variety of settings across the

care continuum. Settings for rehabilitation include the acute hospital (eg, critical care units, general medical or surgical

units) and postacute locations including transitional care units in hospitals, rehabilitation hospitals, nursing homes/skilled

nursing facilities, outpatient facilities, and the patient’s home. The intensity and nature of services that can be delivered

differ across the settings.

When not delivered in a dedicated rehabilitation unit, rehabilitation treatment is often limited to services by a single

discipline (eg, physical therapy [PT] or occupational therapy [OT]). Even when more than one rehabilitation service is

involved, the degree of coordination that is possible (ie, in the hospital, largely through progress notes or discharge

planning rounds) is less optimal than the coordination through in-person contact and physician-led weekly conferences that

is required in an inpatient rehabilitation facility.

Rehabilitation therapy in the acute hospital — Rehabilitation therapy in the intensive care unit (ICU) is relatively new

[25]. Early mobilization, beginning the first day of ICU hospitalization and while the patient is still on a ventilator, can

shorten length of stay and improve functional outcomes [95-97].

Rehabilitative services for patients on medical and surgical wards typically focus on mobilization and discharge planning.

Data are accruing showing the merits of early mobilization for diverse acutely-ill patient populations [23-25]. There is good

evidence showing benefit from early intensive PT/OT in the hospital for stroke patients, and for patients with a total joint

replacement or hip fracture [23,98].

For example, early intensive rehabilitative therapy for stroke patients improves functional outcomes (eg, ability to walk and

to use the toilet independently) [99]. As another example, hip fracture patients with fewer days of immobility post-

operatively (ie, mobilized to be out of bed beyond a chair) had better ability to walk at two months and lower six-month

mortality [98]. However, it is necessary to determine if a patient has the capacity, both physically and mentally, to

participate in PT or OT. Close coordination of medical care can help, for example, by reducing delirium and by ensuring

optimal pain management [23,100]. (See "Prevention and treatment of delirium and confusional states" and "Management

of postoperative pain".)

Suggestions for parameters to determine the hospitalized patient’s ability to participate in PT or OT are shown in a table,

with focus on the patient’s cognitive, hemodynamic, musculoskeletal, and pain status (table 8).

Even for patients who can’t participate in therapy, involvement of PT and OT is a necessary component of discharge

planning in any adult for whom there is concern about the ability to return home (eg, limitations in self-care or mobility are

present). This is particularly important for older adults as they are vulnerable to adverse effects from care transitions and

often require care in multiple settings over the course of illness and recovery [101].

Post-acute hospital rehabilitation — A common critical decision for inpatient providers is determining the type of setting

in which post-acute rehabilitation will be delivered. Ideally, rehabilitation during the post-acute period will help to ensure

maximal recovery for patients after an acute illness.

Post-acute rehabilitation may take place in a number of different venues with differing advantages for various types of

geriatric patients. These sites include:

Inpatient rehabilitation facilities (IRF or “acute” rehabilitation)

Long-term acute care hospitals (LTACH)

Skilled nursing facilities (SNF) with Medicare certified therapy services (sometimes referred to as “subacute” or

“transitional care” units)











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The Geriatric Evaluation and Management inpatient rehabilitation program (within the Veterans Administration)

Home health

Outpatient therapy services

Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, the level of medical and

nursing support, and reimbursement. The options and considerations when considering continued rehabilitation upon

discharge from the acute hospital setting are summarized in a table (table 9).

Multiple factors are to be considered when determining an appropriate location for post-acute rehabilitation for a particular

geriatric patient. Definitive research is lacking to guide decisions. Key factors to consider include:

Medical diagnosis

Functional abilities (pre-morbid, admission and current)

Medical stability

Cognition

Therapy tolerance and motivation

Types of therapy services needed

Psychosocial factors such as patient/family preference, geographic location

Third party reimbursement

(See "Hospital discharge", section on 'Determining the post-discharge site of care'.)

Medical diagnosis — The medical diagnosis is an important determinant of eligibility for admission to an inpatient

rehabilitation facility (IRF or acute rehabilitation hospital). Under the Centers for Medicare and Medicaid (CMS) guidelines,

60 percent of patients admitted to an IRF must have 1 of 13 medical diagnoses (table 10). These guidelines therefore

influence the availability of beds and acceptance of particular patients referred for IRF care.

Diagnoses that often warrant a higher level of post-acute care (ie, intensive rehabilitation in an IRF) include stroke, spinal

cord injury, and traumatic brain injury. General orthopedic patients (eg, patients recovering from hip fracture, ischemic

amputation, or total joint replacement) may not gain particular benefit from intensive rehabilitation, and may recover function

just as well with rehabilitation in a subacute or skilled nursing facility [102-104]; each patient should be evaluated

individually to determine their most appropriate postacute rehabilitation setting. Frailty in patients with hip fracture or

ischemic amputation may limit their ability to tolerate more intensive rehabilitation while patients with an elective total joint

replacement may have good general health and be able to rehabilitate with home health therapy followed by therapy in an

outpatient facility. In contrast, patients with traumatic amputation often have other concomitant injuries requiring intensive

rehabilitation.

Optimal level of post-acute rehabilitation — Even within groups of patients who can benefit from intensive post-

acute inpatient rehabilitation, a variety of considerations are important when determining the optimal level of post-acute

care. The following describes some key considerations across most diagnostic groups that pertain to determining the

optimal level of post-acute rehabilitation.

Prehospital and current functional abilities — Information about functional abilities may be obtained from PT

and/or OT evaluations and from the nursing service, although a history of prehospital function is best obtained from

the patient/family directly. PT/OT consultations should be made early on during an acute hospitalization. This will

help to ensure optimal clinical outcomes and allow sufficient time for the evaluation, equipment to be obtained if

needed, and the patient trained in its use.

Therapy assessments should include an evaluation of ambulatory function and the patient’s ability to perform basic

activities of daily living (ADLs) (table 11 and table 12). At a minimum, it should be determined whether the patient is

independent or requires assistance from another person. For example, most individuals who resided in a nursing

home setting pre-hospitalization will return to a nursing home, as it is unlikely they would make sufficient functional

gains to become independent again and would be unlikely to have an independent living situation to return to after

rehabilitation. Rehabilitation for such patients would best be met in a skilled nursing facility–level setting, rather than

in an IRF or with a home health service.

Medical stability — Medical stability assists in determining both the patient’s ability to participate in therapy while

in the hospital and the type of post-acute setting needed after discharge. Inpatient rehabilitation facilities have

physicians on staff to see patients daily and treat complex rehabilitation medical problems (eg, spasticity,

autonomic dysreflexia); in contrast, a skilled nursing facility has skilled nurses on staff to monitor patients’

conditions and provide skilled nursing services with intermittent support (eg, once weekly) from medical staff who


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typically have general expertise in geriatric medicine. Thus, patients with active medical problems requiring close

physician and nursing care are best discharged to either a long-term acute care hospital (LTACH) or an inpatient

rehabilitation facility (IRF).

Cognition — Participation in therapy is dependent, at a minimum, on the ability to follow one-step commands and

to sufficiently recall so that learning is possible and therapists are not repetitively instructing the same task.

Therapeutic goals are constrained when such abilities aren’t present, with interventions limited to recommendations

for equipment, environmental modifications, and caregiver training to enhance safety with functional tasks (eg,

ambulation and bathing) and caregiver training on interventions to help maintain physical/functional abilities (eg,

range of motion exercises, proper use of splints and braces).

Therapy tolerance and motivation — While rehabilitation therapy in and of itself can help reduce depression and

restore confidence, patients must be willing to participate. The patients’ motivation may be gleaned from their

participation and motivation during therapy sessions in the acute hospital setting and their willingness to work with

nursing staff during daily care. Tolerance for the more intensive therapy program required in an IRF (three hours of

therapy per day, five days per week) also may be inferred from patient participation with PT/OT during their acute

hospitalization.

Types of needed therapy services — Patients discharged to an IRF must have a demonstrated need for at least

two therapy disciplines (ie, PT/OT/speech therapy). These services may be offered in other settings, but anticipated

use of these therapies is not a requirement for admission to other settings.

Psychosocial factors — Social support, financial resources/insurance, and personal preference (eg, facility close

to home) are important considerations in determining the best location for post-acute rehabilitation.

Reimbursement (US) — Medicare uses a “prospective payment” for rehabilitation in many postacute settings, for

which a predetermined amount is provided for particular diagnoses, with consideration for the severity of the

condition and comorbid conditions (eg, mild stroke versus severe stroke with diabetes and hypertension). Social

workers can often provide helpful information about available payment rates.

A general example of these considerations for a stroke patient are as follows: Medicare prospective payment for

intensive inpatient rehabilitation after an acute stroke (without additional comorbid conditions) is approximately 12 to

14 days. In contrast, the same stroke patient may receive up to 100 days of therapy (20 days at 100 percent

coverage and 80 days at 80 percent coverage) in a skilled nursing facility. Thus, if the patient is likely to benefit from

prolonged therapy, but at a lower intensity, a skilled nursing home for rehabilitation might be the best choice.

Prospective payment is also in place for home health services. In that setting, a stroke patient might receive three

weeks of therapy (physical therapy, occupational therapy, and/or speech therapy) up to three times per week with

another one to two weeks with less frequent visits per week. Preceding treatment in an inpatient setting does not

preclude payment for home health therapies or outpatient therapies after discharge home.

In all three of these settings (inpatient rehabilitation, skilled nursing, home health), the patient must require ‘skilled’

services to qualify for Medicare payment. For home health coverage in particular, a single visit by an occupational

therapist (eg, for a home safety and falls assessment) would not be covered. Home health aid services, in the

absence of other skilled nursing or therapy series, would also not be reimbursed. In addition, home health services

are only covered for “homebound” patients, defined as being unable to leave home except for medical care and

infrequent non-medical reasons such as to go to religious services; the ordering physician must have had a face-to-

face visit with the patient in the preceding 30 days and document this [105].

Outpatient rehabilitation services continue to be paid for by Medicare as “fee for service” but the total number of

visits for all conditions are limited (to a total of $1870/year for PT plus speech therapy with an additional $1870/year

for OT in 2012). These limits may be exceeded for some medically necessary therapies with appropriate justification

from the medical provider and/or when provided in hospital emergency rooms or outpatient departments [106,107].

There is no requirement for ‘skilled services’ by physical therapy or nursing for outpatient therapy services to be

covered.

Medicaid also covers rehabilitation services with variation from state to state. The VHA provides rehabilitation

throughout the continuum of care with either no charge for services or a modest co-pay (depending on level of

service connection and/or finances).

SUMMARY





A model from the World Health Organization describes disability as determined by an individual’s health condition(s)

within the context of environmental and personal factors; rehabilitation services target the impairment as well as

personal and environmental contextual factors that influence activity and participation. In another model, disability

results from a mismatch between individual capacity and task demands; remediation of disability occurs through

treatments that either increase individual capacity or reduce task demand. (See 'Conceptual models for disability'

above.)

Rehabilitation treatment by a provider in a single discipline is often sufficient for patients with uncomplicated

conditions or with minimal disability. For more complex or catastrophic disability (eg, stroke, amputation), a

multidisciplinary team of providers as part of inpatient rehabilitation is optimal to address the interaction of multiple

contributing conditions and contextual factors. (See 'Types of rehabilitation providers' above.)

The physical activity recommendations intended for all older adults may need to be adapted to meet particular

needs, using specific types of exercise to correct or ameliorate identified impairments and functional limitations.

Physical therapists, exercise physiologists, and physicians specializing in rehabilitation (“physiatrists”) can help to

tailor the exercise prescription to meet particular patient needs. (See 'Exercise' above.)

An increasing variety of patient assistive technology aids can improve capacity for activity and/or reduce task

demands, but they can be hazardous if not used properly. Physical and occupational therapists can provide

prescription guidance as well as fitting and training in use of these devices to enhance functional benefits and

safety. Mobility aids (canes, crutches, walkers, wheelchairs) meet different needs (table 4) and, in the US, are

variably reimbursed depending upon insurance and the patient’s qualifying illness. (See 'Mobility aids' above and

'Reimbursement for mobility aids in the US' above.)

Orthoses (ie, splints and braces) are available for virtually every joint in the body including the spine; prefabricated

splints and braces are most appropriate for uncomplicated conditions that don’t have substantial deformity. A

multidisciplinary team including a physical therapist, prosthetist, and/or physiatrist can provide guidance and fitting

as may be needed for more complex devices such as a prosthetic limb. (See 'Prosthetics and orthotics' above.)

Occupational therapists (OTs) have particular expertise on the self-care skills, person-environment interface within

the home environment, and can recommend the most beneficial assistive devices and home modifications; physical

therapists (PTs) are particularly helpful with mobility impairments and equipment, as well as exercise interventions

to treat physical impairment; speech therapists have expertise in treatment of impaired speech and swallowing; low

vision specialists provide unique expertise for older adults coping with low vision; a variety of other specialized

personnel may provide rehabilitation care in particular settings (eg, recreational therapists, rehabilitation nursing).

(See 'Environmental modification' above.)

Rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Early

mobilization, beginning the first day of ICU hospitalization and while the patient is still on a ventilator, can shorten

length of stay and improve functional outcomes. Involvement of PT and OT is a necessary component of hospital

discharge planning, particularly for older adults, in patients for whom there is concern about the ability to return

home (eg, limitations in self-care or mobility are present). The options and considerations when considering

continued rehabilitation upon discharge from the acute hospital setting are summarized in a table (table 9). (See

'Post-acute hospital rehabilitation' above.)

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56. Hoenig H, Landerman LR, Shipp KM, et al. A clinical trial of a rehabilitation expert clinician versus usual care forproviding manual wheelchairs. J Am Geriatr Soc 2005; 53:1712.

57. Best KL, Kirby RL, Smith C, MacLeod DA. Wheelchair skills training for community-based manual wheelchair users:a randomized controlled trial. Arch Phys Med Rehabil 2005; 86:2316.

58. Center for Medicare & Medicaid Services. Medicare Coverage for Durable Medical Equipment and Other Devices.Department of Health and Human Services. p. 7. Available at:http://www.medicare.gov/publications/pubs/pdf/11045.pdf (Accessed on January 28, 2012).

59. Clinical Criteria for MAE Coverage. Centers for Medicare & Medicaid Services. Available at:https://www.cms.gov/determinationprocess/downloads/id143c.pdf (Accessed on December 05, 2011).

60. Power Wheelchair Coverage Overview. Centers for Medicare & Medicaid. Available at:http://www.cms.gov/MLNProducts/downloads/PowerWheelchair.pdf (Accessed on December 05, 2011).

61. Chapter 20: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). In: Medicare ClaimsProcessing Manual. Available at: https://www.cms.gov/manuals/downloads/clm104c20.pdf (Accessed on December
























05, 2011).

62. Gill TM, Han L, Allore HG. Bath aids and the subsequent development of bathing disability in community-living olderpersons. J Am Geriatr Soc 2007; 55:1757.

63. Mann WC, Ottenbacher KJ, Fraas L, et al. Effectiveness of assistive technology and environmental interventions inmaintaining independence and reducing home care costs for the frail elderly. A randomized controlled trial. Arch FamMed 1999; 8:210.

64. Sanford JA, Griffiths PC, Richardson P, et al. The effects of in-home rehabilitation on task self-efficacy in mobility-impaired adults: A randomized clinical trial. J Am Geriatr Soc 2006; 54:1641.

65. Gitlin LN, Winter L, Dennis MP, et al. A randomized trial of a multicomponent home intervention to reduce functionaldifficulties in older adults. J Am Geriatr Soc 2006; 54:809.

66. Wahl HW, Fänge A, Oswald F, et al. The home environment and disability-related outcomes in aging individuals:what is the empirical evidence? Gerontologist 2009; 49:355.

67. Petersson I, Lilja M, Hammel J, Kottorp A. Impact of home modification services on ability in everyday life for peopleageing with disabilities. J Rehabil Med 2008; 40:253.

68. Pighills AC, Torgerson DJ, Sheldon TA, et al. Environmental assessment and modification to prevent falls in olderpeople. J Am Geriatr Soc 2011; 59:26.

69. Alexander NB, Koester DJ, Grunawalt JA. Chair design affects how older adults rise from a chair. J Am Geriatr Soc1996; 44:356.

70. Sanford JA, Arch M, Megrew MB. An evaluation of grab bars to meet the needs of elderly people. Assist Technol1995; 7:36.

71. Sansam K, Neumann V, O'Connor R, Bhakta B. Predicting walking ability following lower limb amputation: asystematic review of the literature. J Rehabil Med 2009; 41:593.

72. Highsmith MJ, Kahle JT, Bongiorni DR, et al. Safety, energy efficiency, and cost efficacy of the C-Leg fortransfemoral amputees: A review of the literature. Prosthet Orthot Int 2010; 34:362.

73. Cumming JC, Barr S, Howe TE. Prosthetic rehabilitation for older dysvascular people following a unilateraltransfemoral amputation. Cochrane Database Syst Rev 2006; :CD005260.

74. Brouwer RW, Jakma TS, Verhagen AP, et al. Braces and orthoses for treating osteoarthritis of the knee. CochraneDatabase Syst Rev 2005; :CD004020.

75. Rannou F, Poiraudeau S, Beaudreuil J. Role of bracing in the management of knee osteoarthritis. Curr OpinRheumatol 2010; 22:218.

76. de Wit DC, Buurke JH, Nijlant JM, et al. The effect of an ankle-foot orthosis on walking ability in chronic strokepatients: a randomized controlled trial. Clin Rehabil 2004; 18:550.

77. Nolan KJ, Savalia KK, Lequerica AH, Elovic EP. Objective assessment of functional ambulation in adults withhemiplegia using ankle foot orthotics after stroke. PM R 2009; 1:524.

78. Baldassin V, Gomes CR, Beraldo PS. Effectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Arch Phys Med Rehabil 2009; 90:701.

79. Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. CochraneDatabase Syst Rev 2008; :CD006801.

80. Burke DT, Burke MM, Stewart GW, Cambré A. Splinting for carpal tunnel syndrome: in search of the optimal angle.Arch Phys Med Rehabil 1994; 75:1241.

81. Tijhuis GJ, Vliet Vlieland TP, Zwinderman AH, Hazes JM. A comparison of the Futuro wrist orthosis with a syntheticThermoLyn orthosis: utility and clinical effectiveness. Arthritis Care Res 1998; 11:217.

82. Fried LP, Bandeen-Roche K, Kasper JD, Guralnik JM. Association of comorbidity with disability in older women: theWomen's Health and Aging Study. J Clin Epidemiol 1999; 52:27.

83. Zeng Y, Gu D, Purser J, et al. Associations of environmental factors with elderly health and mortality in China. Am JPublic Health 2010; 100:298.

84. Clarke P, George LK. The role of the built environment in the disablement process. Am J Public Health 2005;95:1933.

85. Atamaz FC, Durmaz B, Baydar M, et al. Comparison of the efficacy of transcutaneous electrical nerve stimulation,interferential currents, and shortwave diathermy in knee osteoarthritis: a double-blind, randomized, controlled,multicenter study. Arch Phys Med Rehabil 2012; 93:748.

86. Ebenbichler GR, Erdogmus CB, Resch KL, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl JMed 1999; 340:1533.

87. Mulvey MR, Bagnall AM, Johnson MI, Marchant PR. Transcutaneous electrical nerve stimulation (TENS) for phantompain and stump pain following amputation in adults. Cochrane Database Syst Rev 2010; :CD007264.

88. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo






























for chronic low-back pain. Cochrane Database Syst Rev 2008; :CD003008.

89. Kroeling P, Gross A, Goldsmith CH, et al. Electrotherapy for neck pain. Cochrane Database Syst Rev 2009;:CD004251.

90. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. ClinOrthop Relat Res 2008; 466:1539.

91. Robbins J, Gensler G, Hind J, et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: arandomized trial. Ann Intern Med 2008; 148:509.

92. Centers for Medicare & Medicaid Services. Durable Medical Equipment (DME) Center. Department of Health andHuman Services. Available at: https://www.cms.gov/center/dme.asp (Accessed on December 19, 2011).

93. Chamberlain MA, Thornley G, Wright V. Evaluation of aids and equipment for bath and toilet. Rheumatol Rehabil1978; 17:187.

94. Home Modification Programs. United States Department of Veterans Affairs. Available at:www.vba.va.gov/VBA/benefits/factsheets/homeloans/homemods.doc (Accessed on February 02, 2012).

95. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acuterespiratory failure. Crit Care Med 2008; 36:2238.

96. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanicallyventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373:1874.

97. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acuterespiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010; 91:536.

98. Siu AL, Penrod JD, Boockvar KS, et al. Early ambulation after hip fracture: effects on function and mortality. ArchIntern Med 2006; 166:766.

99. Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: is earlier and moreaggressive therapy better? Arch Phys Med Rehabil 2005; 86:S101.

100. Duncan PW, Zorowitz R, Bates B, et al. Management of Adult Stroke Rehabilitation Care: a clinical practiceguideline. Stroke 2005; 36:e100.

101. Jenq G, Tinetti ME. The journey across the health care (dis)continuum for vulnerable patients: policies, pitfalls, andpossibilities. JAMA 2012; 307:2157.

102. Dejong G, Horn SD, Smout RJ, et al. Joint replacement rehabilitation outcomes on discharge from skilled nursingfacilities and inpatient rehabilitation facilities. Arch Phys Med Rehabil 2009; 90:1284.

103. DeJong G, Tian W, Smout RJ, et al. Long-term outcomes of joint replacement rehabilitation patients discharged fromskilled nursing and inpatient rehabilitation facilities. Arch Phys Med Rehabil 2009; 90:1306.

104. Bachmann S, Finger C, Huss A, et al. Inpatient rehabilitation specifically designed for geriatric patients: systematicreview and meta-analysis of randomised controlled trials. BMJ 2010; 340:c1718.

105. Centers for Medicare & Medicaid Services. Medicare and Home Health Care. Department of Health and HumanServices. Available at: http://www.medicare.gov/publications/pubs/pdf/10969.pdf (Accessed on January 28, 2012).

106. Medicare Limits on Therapy Services. Centers for Medicare & Medicaid Services. Available at:http://www.medicare.gov/publications/pubs/pdf/10988.pdf (Accessed on February 06, 2012).

107. Will Medicare pay for outpatient physical, occupational or speech therapy? MedicareInteractive.org 2011. Availableat: http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&slide_id=353 (Accessed onSeptember 11, 2012).

Topic 16852 Version 6.0


















GRAPHICS

International classification of functioning, disability,

and health (ICF) model

Towards a Common Language for Functioning, Disability, and Health: ICF -

The International Classification of Functioning, Disability and Health. World

Health Organization, Geneva, Switzerland, 2002. Copyright © 2002. Available

at: http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf.

(Accessed September 11, 2012.)

Graphic 86412 Version 1.0

http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf



Primary roles and functions of members of the multidisciplinary

rehabilitation team

DisciplineEvaluation and treatment

methods

Targeted aspect of the

disablement process

Assistive Technology

Provider (ATP*)

Determine need for assistive

technology and optimal technology

to best meet needs

Activities

Participation

Dietician Assess nutritional status

Alter diet to maximize nutrition

Health condition

Hand therapist Exercise

Physical modalities (heat,

ultrasound, etc.)

Fabrication of splints

Impairment (upper extremity)

Medical provider Assess health conditions

Treat health conditions

(medications, surgery)

Health condition

Nursing Assessment of physical condition

Wound care and medication

management

Evaluate self-care skills

Evaluate family and home care

factors

Self-care training

Patient and family education

Health condition

Impairment

Activities

Contextual factors (especially

social)

Occupational therapist Evaluate self-care skills and other

activities of daily living

Home safety evaluation

Self-care skills training

Recommendations for assistive

technology

Fabrication of splints

Treatment of upper extremity

deficits

Impairment (upper extremity)

Activities

Participation

Contextual factors (especially

environment)

Physical therapist Assessment of range of motion and

strength

Assessment of gait and mobility

Exercise training

Treatment with physical modalities

(heat, cold, ultrasound, massage,

electrical stimulation)

Impairment (lower extremity, back,

shoulder)

Activities (mobility)

•

Δ



Prosthetist Fabricate prosthetic limbs and

other prosthetic devices (eg,

prosthetic eye)

Impairment

Psychologist/psychiatrist Assessment of mental and

emotional function

Treatment of mental/emotional

disorder (medication, counseling)

Health condition

Impairment (psychological)

Context (personal)

Recreation therapist Assess leisure skills and interests

Involve patients in recreational

activities to maintain social roles

Participation

Speech/language

therapist

Assessment of all aspects of

communication

Assessment of swallowing

disorders

Treatment of communications

deficits

Recommendations for alterations of

diet and positioning to treat

dysphagia

Impairment

Participation

Social worker Evaluation of family and home care

factors

Assessment of psychosocial factors

Counseling

Liaison with the community

Participation

Context (social)

* Successful completion of a certifying exam offered by the Rehabilitation Engineering and Assistive

Technology Society of North America.

• Occupational or physical therapist who has complete additional training and passed a national

certification exam in hand therapy.

Δ Depending on the settings, the medical provider may be a physician such as a physical medicine and

rehabilitation specialist ("physiatrist"), neurologist, orthopedic surgeon, or geriatrician and/or mid-level

practitioners such as nurse practitioner or physician assistant.




Benefits of regular physical activity

Reduces the risk of dying prematurely

Reduces the risk of dying from heart disease

Reduces the risk of stroke

Reduces the risk of developing diabetes

Reduces the risk of developing high blood pressure

Helps reduce blood pressure in people who already have high blood pressure

Reduces the risk of developing colon cancer

Reduces feelings of depression and anxiety

Helps control weight

Helps build and maintain healthy bones, muscles and joints

Helps older adults become stronger and better able to move about without falling

Promotes psychological well-being




Physical activity counseling for older adults: An evidence-based quick guide

Recommendations:

Aerobic:

≥30 min or three bouts of ≥10 min/day

≥5 days/week

Moderate intensity = 5 to 6 on a 10-point scale (where 0 = sitting, 5 to 6 = "can talk," and 10 =

all-out effort)

In addition to routine ADL's

Strength:

8 to 10 exercises (major muscle groups), 10 to 15 repetitions

≥2 nonconsecutive days/week

Moderate to high intensity = 5 to 8 on a 10-point scale (where 5 to 6 = "can talk" and 7 to 8 =

SOB)

Flexibility/balance:

≥10 min ≥2 days/week

Flexibility to maintain/improve range of motion (ie, stretching of major muscle/tendon groups,

yoga)

Balance exercises for those at risk for falls (ie, tai chi, individualized balanced exercises)

Prevention:

Create a single physical activity plan that integrates preventive and therapeutic treatment of

chronic conditions

Sample endurance (walking) and strength plan

Weeks Walking Strength

Weeks 1 to 2:

Introduction and

acclimatization

Walk 10 min

Three days/week

Intensity level = 5 to 6 on

a 10-point scale

4 to 5 exercises for major muscle groups

using weight bearing calisthenics, elastic

bands, free weights or weight machines

One set of 10 to 15 repetitions on 2

nonconsecutive days/week

Intensity level = 5 to 8 on a 10-point scale

Weeks 2 to 6:

Begin

progression

First increase to five

days/week

Gradually increase time to

either 20 min or two

bouts of 10 min/day

Gradually add 4 to 5 exercises, totaling 8 to

10 major muscle group exercises

One set of 10 to 15 repetitions on two

nonconsecutive days/week

Intensity level = 5 to 8 on a 10-point scale

Weeks 6+:

Continued

progression and

exercise routine

refining

Progress time to meet

guideline of at least 30

min, in at least 10 min

bouts

Five or more days/week

Add a third nonconsecutive day/week

Increase resistance by 2 to 10 percent

depending on patient's progress and

comfort level

Emphasize pain free exercising

Recognize your role for PA advocacy

Tips for physical activity counseling:

If patient is: Planned approach:

[1]

[2]



Not ready to

change

Educate on benefits of exercise

Ready to change Develop a specific physical activity plan

Active Support continued activity

Assess current physical activity (type, frequency, duration, intensity)

Advise benefits relative to medical history

Tailor realistic plan (consider chronic illness, current physical activity level, functional limits, and

preferred activities)

Specify what to do where and when

Look for barriers and strategize solutions

Encourage social support: who and how

Confirm patient is "very sure" of physical activity success

Chart plan and give written physical activity Rx to patient

In follow-up, revise physical activity plan to enhance progress

Reinforce positive behavior and activity documentation

Reaffirm that more physical activity enhances benefits

For more resources and handouts see:

American College of Sports Medicine. Exercise is Medicine website. Available at:

www.exerciseismedicine.org/resources.htm. (Accessed December 17, 2011).

Veterans Health Administration Research and Development. Project LIFE Modules: Changing the

PACE for Seniors. US Department of Veterans Affairs. Available at:

www.research.va.gov/resources/pubs/LIFE-modules.cfm. (Accessed December 17, 2011).

National Center for Health Promotion and Disease Prevention (NCP). MOVE! Handouts. US

Department of Veterans Affairs. Available at: www.move.va.gov/handouts.asp. (Accessed

December 17, 2011).

ADL: activites of daily living; SOB: short of breath.

References:

1. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for

adults from the American College of Sports Medicine and the American Heart Association. Circulation

2007; 116:1081.

2. Morey MC. Celebrating 20 years of excellence in exercise for the older veteran. Federal Practitioner 2007;

24:38.


http://www.exerciseismedicine.org/resources.htm

http://www.research.va.gov/resources/pubs/LIFE-modules.cfm

http://www.move.va.gov/handouts.asp



Determining which gait aid to prescribe for issues of endurance, balance,

or weight-bearing



When more than one gait aid is listed in a box, they are listed in order of increasing support.

Comorbid conditions would influence which gait aid to chose when more than one option is



available and/or would influence use of a more supportive device (eg, some with a little impairment

in endurance plus a little impairment in balance might require a wheelchair for community mobility

but be able to use a walker at home).

COPD: chronic obstructive pulmondary disease; HF: heart failure.




Attributes for selection of particular mobility aids

Body

weight

supported

Unilateral/bilateral

support

Balance

required

Coordination

needed

Arm

strength

needed

Cane Minimal (10

to 15

percent)

Unilateral Good Good Good

Two-wheel walker Moderate

(15 to 30

percent)

Bilateral Moderate Moderate Moderate

Four-wheel walker Moderate

(15 to 30

percent)

Bilateral Good Good Moderate

Crutches, swing-

through motion

Full (100

percent)

Unilateral Good Good Excellent

Crutches,

alternating motion

Partial (30 to

50 percent)

Bilateral Good Good Good

Manual wheelchair Full (100

percent)

Bilateral Minimal Minimal-

moderate*

Minimal-

good*

Power

wheelchair/scooter

Full (100

percent)

Bilateral Minimal-

moderate

Moderate Minimal

* Amount of coordination and arm strength for manual wheelchair depends on if it is self-propelled or

propelled by another person.

• Good sitting balance is required for a scooter but may not be required for a power wheelchair.


•



Medicare coverage of durable medical equipment and prosthetic and

orthotic items

What Medicare covers What the patient pays

Durable medical equipment

Air fluidized beds The patient pays 20 percent of the Medicare-

approved amount after paying Medicare Part B

deductible for the year. Medicare pays the other

80 percent. The Medicare-approved amount is

the lower of the actual charge for the item or the

fee Medicare sets for the item. However, the

amount the patient pays may vary because

Medicare pays for different kinds of durable

medical equipment in different ways. Some

equipment may be able to be rented or

purchased.

Blood glucose monitors

Bone growth (or osteogenesis) stimulators

Canes (except white canes for the blind)

Bedside commode

Crutches

Home oxygen equipment and supplies

Hospital beds

Infusion pumps and some medicines used in

them

Lymphedema pumps/pneumatic compression

devices

Nebulizers and some medicines used in them

Patient lifts

Scooters and power wheelchairs

Traction equipment

Transcutaneous electronic nerve stimulators

(TENS)

Ventilators or respiratory assist devices

Walkers

Wheelchairs (manual and power)

Prosthetic and orthotic items

Arm, leg, back, and neck braces Patient pays 20 percent of the Medicare-

approved amount after paying Medicare Part B

deductible for the year. Medicare pays the other

80 percent.

Artificial limbs and eyes

Breast prostheses (including a surgical

brassiere) after a mastectomy

Ostomy supplies for people who have had a

colostomy, ileostomy, or urinary ostomy (per

physician order)

Prosthetic devices needed to replace an

internal body part or function (eg, Foley

urinary catheter)

Therapeutic shoes or inserts for people with

diabetes who have severe diabetic foot

disease (prescribed by the doctor treating the

diabetes or a podiatrist, and provided by

doctor or other qualified individual such as a

podiatrist)

Adapted from: Medicare Coverage for Durable Medical Equipment and Other Devices. Medicare Website. Available

at: http://www.medicare.gov/publications/pubs/pdf/11045.pdf (Accessed January 28, 2012).


http://www.medicare.gov/publications/pubs/pdf/11045.pdf



Indications for heat and cold therapeutic modalities

Heat Cold

Analgesia Analgesia

Muscle relaxation Muscle relaxation (eg, spasticity)

Assist with connective tissue extensibility (ie,

joint contracture, musculotendinous stretching)

Edema/hemorrhage resolution (eg, initial 24 to

48 hours after acute musculoskeletal trauma)

Hyperemia/acceleration of metabolic processes

(eg, tenosynovitis, bursitis)

Reduction of metabolic processes

Hematoma resolution

Adapted with permission from: DeLisa's Physcial Medicine and Rehabilitation: Principles and Practice, 5th

edition, Frontera WR (Ed), Lippincott Williams & Wilkins, 2010. Copyright © 2010 Lippincott Williams & Wilkins.

www.lww.com.


http://www.lww.com/



Contraindications for heat and cold therapeutic modalities

Heat Cold

Acute injury/trauma/hemorrhage Ischemia

Insensate skin Insensate skin

Ischemia Inability to communicate/respond to pain

Edema Impaired thermal regulation

Inability to communicate/respond to pain Raynaud's phenomenon

Impaired thermal regulation Pronounced cold pressor response

Malignancy

Cardiac disorders (eg, decompensated heart

failure)

Adapted with permission from: DeLisa's Physcial Medicine and Rehabilitation: Principles and Practice, 5th

edition, Frontera WR (Ed), Lippincott Williams & Wilkins, 2010. Copyright © 2010 Lippincott Williams & Wilkins.

www.lww.com.


http://www.lww.com/



Criteria to identify patients able to participate in occupational

therapy/physical therapy treatment in the acute hospital setting

Health

characteristicCriteria

Cognition Able to follow one-step commands

Oriented to person

Remember one of three items

Hemodynamic Mean arterial pressure 65 to 110 mm Hg (resting systolic blood pressure 85 to

160 mm Hg, and <200 mm Hg with exertion)

Heart rate 40 to 130 beats per min

Respiratory rate 5 to 40 breaths per min

Oxygen saturation ≥88 percent, with or without supplemental O and at rest

or with activity

Change in vital signs with activity <20 percent

Hematocrit >25 percent

No unstable angina (eg, change in ECG with activity)

Musculoskeletal

stability

Fracture/open wounds require explicit physician guidance with regards to

physical activity (eg, weight-bearing status, orthoses/braces, etc.)

Pain No acute exacerbation of pain during OT/PT

OT: occupational therapy; PT: physical therapy; ECG: electrocardiogram.


2



Characteristics of US postacute care settings where rehabilitation may be

provided

Rehabilitation

site

Facility

characteristics

Medical

coverage

Therapy

servicesNursing Insurance

Inpatient

rehabilitation (acute)

Multidisciplinary

team patient care

conferences

required within

four days of

admission and

weekly thereafter

Physician

available 24

hours/day, 7

days/week;

active medical

problem(s)

requiring

physician

supervision

with visit five

or more

days/week

PT, OT,

and

speech

therapy

available.

Patients

must need

two or

more

therapy

services

and must

receive

therapy

three or

more

hours per

day, five

days per

week.

24-hour

care

Medicare

Part A: days

1 to 20: 100

percent;

days 21 to

100: 80

percent plus

co-payment;

>100 days:

no coverage

Skilled nursing facility

(subacute/transitional

care unit)

Physician

supervised;

physician

evaluation

within two

weeks of

admission and

every 30

days;

physician

available in

emergencies

PT and OT

available;

typically

one or

more

session

per day

24-hour

care

Same as

inpatient

rehabilitation

Long-term acute care

hospital (LTACH)

Physician

available 24

hours/day;

active/ongoing

medical

condition

requiring

physician-level

care (eg,

ventilator

dependent)

PT and OT

available

24-hour

care

Same as

inpatient

rehabilitation

Home

therapy/nursing

Physician

referral and

recertification

every 60 days

PT, OT,

and

speech

therapy

available

Home

health

nursing

Typically one

to three

visits per

week by

OT/PT for

one to three

weeks, one

visit per



week with

RN, daily

home health

aid

Outpatient (hospital

or free-standing

clinic)

Physician

referral and

recertification

every 30 days

PT, OT,

and

speech

therapy

available

N/A May be

limitations in

number of

visits per

year

OT: occupational therapy; PT: physical therapy.

Adapted from: Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed, Pacala JT, Sullivan

GM (Eds), American Geriatrics Society, New York, 2010.




Medicare qualifying medical conditions for intensive rehabilitation facility

Stroke

Spinal cord injury

Congenital deformity

Amputation

Major multiple trauma

Femur fracture (hip fracture)

Brain injury

Neurological disorders (including multiple sclerosis, muscular dystrophy, Parkinson disease)

Burns

Active polyarticular rheumatoid/psoriatic arthritis and seronegative arthritides, with qualifiers

Systemic vasculitides with joint inflammation, with qualifiers

Severe or advanced osteoarthritis involving two or more major weight-bearing joints, with qualifiers

Hip or knee joint replacement, or both, with qualifiers

Source: CMS Manual System. Pub. 100-04, Medicare Claims Processing, Transmittal 347. Department of Health

and Human Services, Centers for Medicare and Medicaid Services 2005. Available

at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R347CP.pdf (Accessed

September 11, 2012).


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R347CP.pdf



Katz index of independence in activities of daily living

Activities Independence Dependence

Points (1 or 0)

Points (1)

NO supervision, direction, or personal

assistance

Points (0)

WITH supervision, direction,

personal assistance or total care

Bathing (1 point) Bathes self completely or

needs help in bathing only a single part

of the body such as the back, genital

area or disabled extremity.

(0 points) Needs help with bathing

more than one part of the body,

getting in or out of the tub or

shower. Requires total bathing.

POINTS:_____

Dressing (1 point) Gets clothes from closets and

drawers and puts on clothes and outer

garments complete with fasteners. May

have help tying shoes.

(0 points) Needs help with dressing

self or needs to be completely

dressed.POINTS:_____

Toileting (1 point) Goes to toilet, gets on and

off, arranges clothes, cleans genital

area without help.

(0 points) Needs help transferring

to the toilet, cleaning self or uses

bedpan or commode.POINTS:_____

Transferring (1 point) Moves in and out of bed or

chair unassisted. Mechanical

transferring aides are acceptable.

(0 points) Needs help in moving

from bed to chair or requires a

complete transfer.POINTS:_____

Continence (1 point) Exercises complete self

control over urination and defecation.

(0 points) Is partially or totally

incontinent of bowel or bladder.POINTS:_____

Feeding (1 point) Gets food from plate into

mouth without help. Preparation of food

may be done by another person.

(0 points) Needs partial or total

help with feeding or requires

parenteral feeding.POINTS:_____

Total points:_____

6 points: high (patient independent).

0 points: low (patient very dependent).

Reproduced with permission from: Katz S, Down TD, Cash HR, Grotz RC. Progress in the development of the

index of ADL. Gerontologist 1970, 10:20. Copyright © 1970 Oxford University Press.




The Lawton instrumental activities of daily living scale

Activities Points

Ability to use telephone

1. Operates telephone on

own initiative; looks up

and dials numbers

1

2. Dials a few well-known

numbers

1

3. Answers telephone,

but does not dial

1

4. Does not use

telephone at all

0

Shopping

1. Takes care of all

shopping needs

independently

1

2. Shops independently

for small purchases

0

3. Needs to be

accompanied on any

shopping trip

0

4. Completely unable to

shop

0

Food preparation

1. Plans, prepares, and

serves adequate meals

independently

1

2. Prepares adequate

meals if supplied with

ingredients

0

3. Heats and serves

prepared meals or

prepares meals but does

not maintain adequate

diet

0

4. Needs to have meals

prepared and served

0

Housekeeping

1. Maintains house alone

with occasion assistance

(heavy work)

1

2. Performs light daily

tasks such as

dishwashing, bed making

1

3. Performs light daily

tasks, but cannot

maintain acceptable level

of cleanliness

1

Activities Points

Laundry

1. Does personal laundry completely 1

2. Launders small items, rinses socks,

stockings, etc.

1

3. All laundry must be done by others 0

Mode of transportation

1. Travels independently on public

transportation or drives own car

1

2. Arranges own travel via taxi, but does

not otherwise use public transportation

1

3. Travels on public transportation when

assisted or accompanied by another

1

4. Travel limited to taxi or automobile with

assistance of another

0

5. Does not travel at all 0

Responsibility for own medications

1. Is responsible for taking medication in

correct dosages at correct time

1

2. Takes responsibility if medication is

prepared in advance in separate dosages

0

3. Is not capable of dispensing own

medication

0

Ability to handle finances

1. Manages financial matters independently

(budgets, writes checks, pays rent and bills,

goes to bank); collects and keeps track of

income

1

2. Manages day-to-day purchases, but

needs help with banking, major purchases,

etc.

1

3. Incapable of handling money 0



4. Needs help with all

home maintenance tasks

1

5. Does not participate in

any housekeeping tasks

0

Scoring: For each category, circle the item description that most closely resembles the client's

highest functional level (either 0 or 1).

A summary score ranges from 0 (dependent, requires significant assistance to live in the community)

to 8 (independent, no assistance required to maintain self in community).

Reproduced with permission from: Lawton MP, Brody EM. Assessment of older people: Self-maintaining and

instrumental activities of daily living. Gerontologist 1969, 9:179. Copyright © 1969 Oxford University Press.




Disclosures: Helen Hoenig, MD, MPH Nothing to disclose. Patrick M. Kortebein, MD Employment: Novartis PharmaceuticalsCorporation (myoanabolic agent). Kenneth E Schmader, MD Grant/Research/Clinical Trial Support: Merck [Herpes Zoster (Zostervaccine)]. H Nancy Sokol, MD Employee of UpToDate, Inc.

Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are addressed by vettingthrough a multi-level review process, and through requirements for references to be provided to support the content. Appropriatelyreferenced content is required of all authors and must conform to UpToDate standards of evidence.

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Disclosures

http://www.uptodate.com/home/conflict-interest-policy

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