Rehabilitation aims to facilitate recovery from loss of function. Loss may be due to fracture, amputation, stroke or another neurologic disorder, arthritis, cardiac impairment, or prolonged deconditioning (eg, after some disorders and surgical procedures). Rehabilitation may involve physical, occupational, and speech therapy; psychologic counseling; and social services. 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 elderly patients and for patients who lack muscle strength or motivation.
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 h/day). Many nursing homes have less intensive programs (generally, 1 to 3 h/day, up to 5 days/wk) and thus are better suited to patients less able to tolerate therapy (eg, frail or elderly 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/wk).
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 practitioners. Also, family members may need help learning how to adjust to the patient's disability and how to help the patient.
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 patients' best interests and may be rejected with a request for more specific instructions. Physicians unfamiliar with writing referrals for rehabilitation can consult a physiatrist.
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 drugs, 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 family education is an important part of the rehabilitation process, particularly when the patient is discharged into the community. Often, the nurse is the team member primarily responsible for this education. 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 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.
Disorders requiring rehabilitation (eg, stroke, MI, hip fracture, limb amputation) are common among the elderly. The elderly are also more likely to have become deconditioned before the acute problem that necessitates rehabilitation.
The elderly, even if cognitively impaired, can benefit from rehabilitation. Age alone is not a reason to postpone or deny rehabilitation. However, the elderly may recover slowly because of a reduced ability to adapt to a changing environment, including
Programs designed specifically for the elderly are preferable because the elderly often have different goals, require less intensive rehabilitation, and need different types of care than do younger patients. In age-segregated programs, elderly 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.
Last full review/revision February 2009 by Mathew H. M. Lee, MD; Alex Moroz, MD, FACP