Rehabilitation aims to facilitate recovery from loss of function and reduce pain. Loss of function may be due to fracture, amputation, stroke or another neurologic disorder, traumatic brain injury, sports injury, and/or musculoskeletal impairments from conditions such as arthritis, spinal cord injury, cardiac or pulmonary impairment, chronic pain, or prolonged deconditioning (eg, after some disorders and surgical procedures). Rehabilitation may involve
Psychologic counseling
Social services
Pharmacological management (eg, oral medications or injections for spasticity management to muscles and nerves)
Pain management (eg, pharmacologic management, other modalities)
For some patients, the goal is complete recovery with full, unrestricted function; for others, it is recovery of the ability to do as many activities of daily living (ADLs) as possible. Results of rehabilitation depend on the nature of the loss and the patient’s motivation. Progress may be slow for patients who are older, have severe injury, or have poor overall health and for patients who lack muscle strength. Lack of motivation, coexisting mood disturbances, lack of social support, and socioeconomic factors can also contribute to slower progress.
Rehabilitation may begin in an acute care hospital. Rehabilitation hospitals or units usually provide the most extensive and intensive care; they should be considered for patients who have good potential for recovery and can participate in and tolerate aggressive therapy (generally, ≥ 3 hours/day). Many nursing homes have less intensive programs (generally, 1 to 3 hours/day, up to 5 days/week) that last longer and thus are better suited to patients less able to tolerate therapy (eg, frail or older patients). Less varied and less frequent rehabilitation programs may be offered in outpatient settings or at home and are appropriate for many patients. However, outpatient rehabilitation can be relatively intensive (several hours/day up to 5 days/week). In-home physical therapy services may be indicated for stable patients with severe impairments who are unable to attend treatment sessions at a facility because of location or lack of transportation. In-home therapy is often used after knee replacements, in patients with ambulatory dysfunction after a fall, or if a patient is homebound due to chronic illness.
An interdisciplinary approach is best because disability can lead to various problems (eg, depression, lack of motivation to regain lost function, financial problems). Thus, patients may require psychologic intervention and help from social workers or mental health professionals. Also, family members may need help learning how to adjust to the patient’s disability and how to help the patient.
Referral
To initiate formal rehabilitation therapy, a physician must write a referral/prescription to a physiatrist, therapist, or rehabilitation center. The referral/prescription should state the diagnosis and goal of therapy. The diagnosis may be specific (eg, after left-sided stroke, residual right-sided deficits in upper and lower extremities) or functional (eg, generalized weakness due to bed rest). Goals should be as specific as possible (eg, training to use a prosthetic limb, maximizing general muscle strength and overall endurance). Although vague instructions (eg, physical therapy to evaluate and treat) are sometimes accepted, they are not in the patient's best interests and may be rejected with a request for more specific instructions. Physicians unfamiliar with writing referrals for rehabilitation can consult a physiatrist. Relevant precautions, such as heart rate limits for patients with cardiopulmonary disease, weight-bearing restrictions for patients with fractures or poor bone density, or specific modifications for patients at risk for falls, may help guide the therapists' treatment plans.
Goals of therapy
Initial evaluation sets goals for restoring mobility and functions needed to do ADLs, which include caring for self (eg, grooming, bathing, dressing, feeding, toileting), cooking, cleaning, shopping, managing medications, managing finances, using the telephone, and traveling. The referring physician and rehabilitation team determine which activities are achievable and which are essential for the patient’s independence. Once ADL function is maximized, goals that can help improve quality of life are added.
Patients improve at different rates. Some courses of therapy last only a few weeks; others last longer. Some patients who have completed initial therapy need additional therapy.
Patient and caregiver issues
Patient and caregiver education is an important part of the rehabilitation process, particularly when the patient is discharged into the community. Patients are taught how to maintain newly regained functions and how to reduce the risk of accidents (eg, falls, cuts, burns) and secondary disabilities. Family members are taught how to help the patient be as independent as possible, so that they do not overprotect the patient (leading to decreased functional status and increased dependence) or neglect the patient’s primary needs (leading to feelings of rejection, which may cause depression or interfere with physical functioning).
Emotional support from family members, caregivers, and friends is essential. It may take many forms. Spiritual support and counseling by peers or by religious advisors can be indispensable for some patients.
Geriatric Rehabilitation
Disorders requiring rehabilitation (eg, stroke, myocardial infarction, hip fracture, limb amputation) are common among older patients. Older adults are also more likely to have become deconditioned before the acute problem that necessitates rehabilitation.
Older people, even if cognitively impaired, can benefit from rehabilitation. Age alone is not a reason to postpone or deny rehabilitation. However, older people may recover more slowly because of a reduced ability to adapt to a changing environment, including
Physical inactivity
Lack of endurance
Decreased muscle strength, joint mobility, coordination, or agility
Impaired balance
Programs designed specifically for older patients are preferable because older patients often have different goals and need different types of care than do younger patients. In age-segregated programs, older patients are less likely to compare their progress with that of younger patients and to become discouraged, and the social work aspects of postdischarge care can be more readily integrated. Some programs are designed for specific clinical situations (eg, recovery from hip fracture surgery); patients with similar conditions can work together toward common goals by encouraging each other and reinforcing the rehabilitation training.
