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When evaluating a disability, your health care provider will focus on understanding how the loss of function developed and progressed over time. Other vital factors in predicting whether function can be regained are how severe the loss of function is, what caused it, and the potential for recovery.

Rehabilitation can take place in many types of settings:

Rehabilitation programs within hospitals or special rehabilitation hospitals use a multidisciplinary team approach, which involves the combined efforts of many specialists. The members of the rehabilitation team focus on different parts of health and manage different rehabilitation activities. The specific team members will vary significantly depending on the specific disability and situation.

In this setting, maintaining function may be the goal of care. In contrast to the Medicare requirements for the hospital level of rehabilitation, the requirements for insurance coverage at the nursing level of rehabilitation do not include occupational therapy, a multidisciplinary approach, or the services of a rehabilitation physician. However, the requirements do specify that a person must need daily physical therapy and skilled nursing care and that continued, significant functional improvement must be documented. To be eligible for skilled nursing benefits through Medicare, the person must have had a hospital stay of at least 3 days in the past 30 days. The length of Medicare coverage for rehabilitation in nursing homes is limited.

Outpatient rehabilitation offers a wide range of services from private practitioners’ offices that offer fee-for-service care, to outpatient rehabilitation facilities that provide the same comprehensive team efforts as in hospital rehabilitation units. Generally, these outpatient units are appropriate for people with short-term illnesses, such as low back pain or minor trauma. Other services may be appropriate for people who need follow-up services after being discharged from a rehabilitation hospital or for whom an inpatient rehabilitation program is not suitable. Often, the availability of transportation is what determines whether the person can participate in an outpatient rehabilitation program.

Home-care rehabilitation programs can be an important part of follow-up care for people who have been discharged from any type of inpatient rehabilitation program. In addition, home rehabilitation services can help provide short-term or maintenance therapy. Medicare provides home-health benefits to patients who need intermittent or part-time skilled nursing care and therapy services, and who are homebound or leave the home only occasionally. Physicians must certify the person for services, but they are rarely involved in the supervision of care. There is no requirement for prior hospitalization, and there is no limit on the number of visits a person may receive but only for the time that the person needs to have a nurse come to his or her home. Home-health services provide skilled nursing and home-health aides, therapeutic services, medical and social services, and supplies.

Each site of care has advantages and disadvantages. Inpatient care is the most intense but may not be possible for frail elderly patients, because it requires 3 hours per day of active (and tiring) therapy. Skilled nursing offers 24-hour care for those who cannot care for themselves or do not have a full-time caregiver. Patients often prefer to return to their own homes for outpatient services, but the care-giving they need may not be available. Participation in a day hospital or outpatient clinic requires transportation, which can be costly and time consuming.

Several common diseases of old age usually require rehabilitation. These include stroke, hip fracture, and diseases that result in amputation being necessary (eg, severe problems with circulation).

Most stroke therapy programs take place in a rehabilitation hospital, a rehabilitation unit in an acute-care hospital, or a nursing facility. Patients with acute stroke who receive coordinated, multidisciplinary evaluation and services do better than patients who do not. The goal of physical therapy in these programs is the ability to walk safely again, usually using a cane, walker, or other assistive device. Generally, occupational therapists address problems with weakness and coordination of the arms, as well as with difficulties in thinking or perception. For people who have difficulty speaking, speech therapists develop specific treatment programs that include trying to restore speech ability and, if necessary, developing another way to communicate.

Someone who has had one stroke is at very high risk for a second stroke. The rehabilitation phase is a good time to make sure that risk factors for stroke have been evaluated and any preventive treatments are started. For example, narrowing of the arteries that go to the brain (eg, carotid arteries) and certain heart conditions can lead to stroke. If someone has one or both of these conditions, the use of aspirin or other blood thinners might be considered. Other risk factors to investigate include smoking, high blood pressure, high cholesterol levels, and diabetes.

The goal of rehabilitation for people who have had a hip fracture is to regain as much function as possible. Rehabilitation focuses on physical therapy to strengthen the leg muscles. Stronger leg muscles can prepare the person for walking and can also help keep a hip fracture that has been fixed with pins or screws more stable. During therapy, arm muscles are also strengthened to help with use of walking aids such as walkers. In addition, arm strength and function are important for bathing and dressing, which may be affected by the leg problems. Generally, people progress from using a walker, to using a wide-based four-prong cane, to walking with a single-point cane, and hopefully eventually to walking without any aid at all, although many people still need a walking aid even a year after a fracture.

People who fracture a hip often have a tendency to all and osteoporosis (brittle bones), which puts them at increased risk of more fractures. Key parts of rehabilitation include the following:

• treating osteoporosis
• improving balance
• reducing the risk of injury

Although hip protector pads reduce the rate of hip fracture, most people find them too difficult to wear.

Seventy-five percent of all amputations are performed on people older than 65 years. About 90% of amputations involve the leg, with two-thirds of these done below the knee. Fortunately, fewer than 15% of people with amputations below the knee eventually need amputations above the knee. Approximately 75% of older adults can regain their ability to walk, with or without assistive devices, if they undergo the proper rehabilitation program before and after they receive an artificial limb (ie, prosthesis).

Ordinarily, the rehabilitation process for an amputation takes longer than that for either a stroke or hip fracture. The program begins before surgery and involves not only an evaluation of the amputation site, but also a comprehensive evaluation of both your medical condition and motivation to participate in the program. Whenever possible, management before surgery should include stabilizing any medical problems, especially heart and lung disease. Your surgeon, primary care physician, physiatrist, and you and your family should discuss your care plan after surgery as well as your conditioning and training before you get a prosthesis. This includes preparing you for the possible "phantom limb" sensation, in which you feel as if the amputated limb were still present.

The initial efforts after surgery include the following:

• taking proper care of the stump to promote healing
• beginning an exercise program to strengthen the muscles above the site of the amputation
• maintaining proper position and exercising to prevent contractures (muscle stiffening) of the knee or hip

Shrinking of the stump to accommodate the socket of a temporary prosthesis is usually done by using tight elastic cuffs or by frequent wrapping with tight elastic bandages. Usually, people are measured for a temporary prosthesis 4—8 weeks after surgery and for a permanent prosthesis 8—12 weeks after surgery.

In preparation for an amputation, the therapy program initially involves training in transfer techniques, such as from bed to wheelchair or from chair to toilet. After an amputation, you will progress to practicing weight bearing on a temporary prosthesis, first on parallel bars, and then using a walker and eventually crutches and a cane for assistance. By the time you complete the rehabilitation program, you will probably be able to walk without any assistance.

The list below provides some guidelines for the use of prostheses:

• Age alone is never a reason to avoid use of a prosthesis.
• In general, the prosthesis should be as light as possible, and the attachment should be easy to use.
• People who have a prosthesis should be able to (or receive training so they are able to) perform simple transfer movements without the prosthesis. For example, it should not be necessary to put on a prosthesis to transfer from a bed to either a wheelchair or the bathroom in the middle of the night.
• About 75% of older adults who have had an amputation can walk with a prosthesis. Many people who have had amputations below the knee can walk independently, without a cane, walker, or other assistive device.
• Often, the person’s functional ability before an amputation is one of the most reliable predictors of success in learning to use a prosthesis, both short and long term.
• If you are faced with an amputation, meeting with a person who has successfully completed a rehabilitation program and who walks independently can be very useful and motivating.
• Depression after an amputation is common. Emotional support, appropriate treatment, and involvement of family members and other caregivers are critical.

Overall, an older adult who has had one leg amputated runs a 20% risk of needing a second amputation within 2 years. Approximately 30% of people who need an amputation because of poor circulation need an amputation on the other side within 5 years. The risk is even higher for people whose poor circulation has been further worsened by diabetes. For these reasons, rehabilitation should include programs to reduce the risk of poor circulation, including programs to stop smoking, reduce cholesterol, and control glucose (sugar) levels in the blood. Programs that include endurance exercise can also improve function and reduce pain and weakness. Daily monitoring for infection and other skin problems are essential.

During rehabilitation, potential barriers to regaining or maintaining function are identified and removed. Medical evaluation is often ongoing throughout rehabilitation, so that significant illness and disability can be treated or prevented. Factors that have an important influence on the outcome of rehabilitation include the following:

Older adults who have had a stroke or suffered a hip fracture are at increased risk of blood clots that are painful and could travel to the lungs (pulmonary embolus). Generally, people are treated with blood thinners during rehabilitation to prevent blood clots from forming.

Most physical therapy programs do not require a high level of physical activity. In fact, it may come as a surprise that occupational therapy puts more stress on the heart and lungs than physical therapy does. This is because exercising the arms increases blood pressure and pulse rate more than exercising the legs. Therapy activities for people with heart disease are generally adjusted, especially if these activities cause chest pain, shortness of breath, light-headedness, or fatigue. Blood pressure and pulse rate are checked often. Sometimes, additional tests are needed to evaluate cardiac risk.

Arthritis that is already present may get worse during rehabilitation. This is because therapy usually involves progressive weight bearing, which can stress the joints. Some people may develop an inflammation or bursitis around the shoulder or hip joints. Some of this is due to the increased physical activity in their rehabilitation program. Treatment is generally the same as for arthritis.

Lung function should be checked again in people who have lung disease or who become short of breath while participating in a physical or occupational therapy program. Sometimes the amount of oxygen in the blood is measured during the therapy sessions. It may be possible to include a lung rehabilitation program within the person’s primary rehabilitation program. Usually, lung rehabilitation programs work on breathing techniques, pacing activities, and learning exercises and relaxation methods to help in activities of daily living.

Rehabilitation techniques are not limited just to programs for specific conditions, such as stroke or hip fracture. They are also used when people have difficulty performing various activities of daily living, such as transferring from wheelchair to bed or toilet, eating, bathing, and dressing.

Walking problems are most common when there is a problem with the muscles, joints, or nervous system. Various assistive devices for walking, such as canes, walkers, orthotics (eg, braces), and prostheses, are designed to improve balance and support while standing or walking.

Canes are the simplest aids for walking but provide the least amount of support and balance. They can support up to 25% of body weight. Their best use is for people whose ability to walk is limited by weakness or pain on only one side.

A walker has four broadly spaced posts that surround the person using it. Walkers can support up to 50% of body weight, so they may be useful for people who have a lot of weakness or problems on both sides.

If you are considering using a walker, your home situation needs to be evaluated carefully. If you functioned well with a walker in a rehabilitation unit, you may find new challenges at home, including thresholds, throw rugs, narrow passages, and short stair treads.

Orthotics are another type of device used for rehabilitation. They can be applied to the arms, legs, and spine. Orthotics are braces that are designed to modify the support and functional characteristics of the musculoskeletal system. The goals of these braces include the following:

• relieving pain by limiting motion or weight bearing
• protecting weak, painful, or healing body parts
• reducing weight on that body part(s)
• preventing and correcting deformity
• improving function

Common reasons for using an orthosis on your legs include weakness, deformity, increased muscle tone (spasticity), ankle or knee instability, or pain on weight bearing (which sometimes occurs after surgery or with inflammatory arthritis). However, orthoses are not appropriate for everyone who has a leg problem. For example, a lower-leg orthosis may aggravate rather than improve your walking if you have poor balance, strength, or coordination. In addition, a poorly fitting device, underlying skin disease, poor circulation, or swelling all increase the chances of skin sores. The principles that apply to the use of orthoses for the arms are similar to those that apply for the legs.

Rigid braces can be valuable for people who do not have enough stability in their spine. However, the areas where the brace presses on the body must be watched carefully so that sores do not develop. Similarly, people with neck problems (eg, muscle strain, a narrowing of the spinal canal, or arthritis) can sometimes benefit from using a cervical collar. These collars are often made of soft foam or molded plastic. Regardless of material, they all provide a similar amount of support to the neck, spine, and muscles. However, neck collars and spinal supports should be used very cautiously. The following important principles should be kept in mind when using spinal supports:

• These devices should be used for only a very short time to avoid psychological dependency.
• The prolonged use of neck collars may actually weaken and eventually wither or shrink (atrophy) your neck muscles.

Wheelchairs are an easy and frequently used (if not overused) way for older adults to move about. Several factors are important in use of a wheelchair, whether it is used during the rehabilitation process or on a long-term basis.

Powered or motorized wheelchairs are generally reserved for people who have not been able to get around well enough using a manual wheelchair. Generally, these people suffer from increasing disability as a result of a progressive disease, and they should be working with both a physiatrist and a physical therapist. Powered wheelchairs are made in three-wheeled and four-wheeled versions. They vary substantially in quality, adjustability, and durability, but all are quite expensive.

Transferring means moving or shifting from one surface to another, and it can begin while sitting, standing, or lying down. If you are not able to transfer alone, you may need the help of another person or an adaptive device (Figure: Aids to Help in Changing Position and Getting In and Out of Bed). Being able to transfer safely requires a combination of physical and perceptual abilities, proper equipment, and training to learn techniques that are appropriate for your specific needs. In general, to transfer safely and comfortably, you must be able to stay balanced while sitting. To transfer while standing, you must also be able to stand evenly without assistance, have lower-leg stability, and have a reasonable degree of strength in your upper arms.

A bed-to-wheelchair transfer can begin from a sitting position. You should lock the brakes on both sides of your wheelchair, grab onto the side rails of the bed to come to a sitting position, and then sit down in the wheelchair while holding the front arm of the chair with your unaffected arm (if you have weakness or paralysis on one side). This type of transfer is also known as a stand-pivot transfer. Early in the course of therapy, or if you cannot stand, a board can be used to bridge the space between the bed and the wheelchair.

A wheelchair-to-toilet transfer is similar to the bed-to-wheelchair transfer. You must also be able to manage clothing and undergarments. Special adaptive equipment can be used to help make these transfers easier and safer (Figure: Bathroom Aids). For example, toilet seats should be approximately 20" from the floor. If necessary, raised toilet seats can be attached to the standard height toilet bowl. Handrails can be attached to the wall (if it is close enough) or freestanding. Handrails should be placed on the side of the toilet that corresponds to your unaffected side if you have weakness or paralysis on one side, or on both sides of the toilet if you have weakness on both sides.

A transfer in and out of the bathtub (Figure: Bathroom Aids) must be considered carefully because it is a potentially dangerous procedure. Unlike most transfers, which normally are made from your strongest side, a tub transfer usually makes use of your weaker side. Again, adaptive equipment can help. A tub transfer bench bridges the tub side and allows you to have one leg in the tub and one leg outside the tub, so you can move safely along the bench to the tub. A person with weakness or paralysis on one side may first move the affected leg into the tub and then the unaffected leg.

Assistive devices can be used to help people who have difficulty performing activities of daily living such as feeding, bathing, and dressing. An evaluation by an occupational therapist is helpful to make sure that the assistive device is the best one for the circumstances. Several important principles need to be considered:

• A person must be physically and mentally capable of using the device effectively.
• People are more likely to use aids that are not conspicuous, complicated, cumbersome, or cosmetically ugly.
• A person with perceptual problems (eg, poor vision) may have difficulty using a device effectively.
• Assistive devices may be expensive, and they are usually not covered by insurance or other payers.
• An evaluation of a person’s home or other living situation may be needed to determine the best assistive devices to improve function and ensure safety.

Older adults with weakness, deformity, or lack of coordination of the arms, or with limited range of arm motion frequently find assistive devices for eating very helpful. A rocker knife and fork, for example, may allow a person with paralysis on one side to cut and pick up food with one hand (Figure: Eating Aids). Similar assistive devices can be used for spoons, bowls, and plates. Eating utensils can also be modified for people who have limited motion or poor grasp. For example, silverware handles can be enlarged with foam padding or other materials. A cuff that straps around the hand to hold eating utensils in place can help a person who has a weak hand.

Easy ways of preparing food are often helpful. Foods that do not need to be cut, chopped, or mixed are generally recommended, along with packages and containers that are easy to open. A board with a rough surface, a rubber mat, or sponges can be used to hold food steady. Using blenders, coffee pots, crock pots, microwave ovens, and electric skillets all reduce the need to use the stove or oven. All small kitchen appliances should be on a stable work surface at a comfortable height. Pizza cutters can sometimes replace knives. Oversized bowls, plate guards, and soup dishes with high rims can be used to avoid spills for people who make extra movements or have tremors. For people who have lost some manual dexterity, electric can openers and jar openers can be extremely helpful.

Many bathing and grooming aids are available to help people who have limited motion or grasping ability, weakness, or difficulty with coordination. These include the following:

• raised toilet seats
• tub transfer benches
• long-handled bath sponges
• "soap-on-a-rope"
• wash mitts
• a hand-held shower hose attached to the faucet
• a bath mat secured to the tub surface with safety-tread tape
• combs and brushes with foam-padded enlarged handles

In addition, a wall mirror can be tilted downward to permit better visibility from a wheelchair.

Assistive devices are also available to help with dressing (Figure: Dressing Aids). These include the following:

• buttonhooks or zipper pulls
• hook and loop (Velcro^®) attachments, which are excellent substitutes for buttons or shoelaces
• dressing sticks, which allow users to dress while sitting (users can hook or pull the cuff or sleeve of a shirt or pant leg into position)
• devices for putting on socks, which allow users who cannot reach their feet to pull up socks or stockings themselves
• other slip-on dressing aids

For people who have limited motion of the arms or shoulders, various reaching aids (Figure: Reaching Aids) can help in pulling hats off a shelf or in picking items up off the floor.

People who are undergoing either restorative or maintenance rehabilitation may benefit from electrical stimulation and thermal approaches. These techniques are used to increase circulation, stimulate muscles, and ease pain.

Two kinds of electrical stimulation are generally available:

• functional electrical stimulation
• transcutaneous electrical nerve stimulation (TENS)

In functional electrical stimulation, an electrical current is used to produce a muscle contraction. This prevents muscles that have not been used for a while from withering and shrinking (atrophy). It also increases the range of muscle motion and strength, helps increase the voluntary function of a previously paralyzed muscle, and decreases muscle tone that is too great or spastic. For older adults who have severe weakness of the upper arms, functional electrical stimulation can help prevent a shoulder dislocation, which can lead to a "frozen" shoulder. Electrical stimulation has also been used to improve the strength of pelvic muscles in older women who suffer from certain forms of incontinence.

TENS involves the direct electrical stimulation of the spinal cord. It improves muscle strength and mass, and it may relieve pain. It has been used to treat pain associated with rheumatoid arthritis, poor circulation, and nerve diseases, possibly reducing the amount of pain medicine that is needed. TENS has also been used to treat older adults who have shingles (herpes zoster), to reduce muscle tone that is too great or spastic after a stroke, and to relieve the nerve pain sometimes associated with diabetes or poor circulation. While TENS is sometimes used for chronic low back pain, it has not been proved to work.

Various thermal approaches are used primarily to treat pain, reduce inflammation, and increase muscle tone. Heat can be applied either superficially with a hot pack, or more deeply using ultrasound or diathermy. Heat can help muscles relax, relieve pain, help with tissue healing, and prepare stiff joints and tight muscles for exercise. Hot packs can be applied to most body surfaces. They may reduce muscle spasm in older adults who have arthritis involving the neck, muscular low back pain, or muscle contractions. Baths of liquid paraffin are used most often to apply heat to the hands or feet and may be particularly helpful to reduce hand stiffness and pain in people who have arthritis.

Ultrasound is a deep-heating technique that can increase temperatures deep in the tissues. This can relieve joint tightness, loosen scar tissue, and reduce pain and muscle spasm. It has been used to treat bursitis, tendonitis, and low back pain.

Hydrotherapy in the form of a whirlpool or other pool therapy may also be helpful. It has been used to treat arthritis and joint injuries or replacements. It has also been used to relieve pain, support wound healing, and help with various neurologic disorders.

Cold treatments or cold packs are commonly used to treat sudden muscle or bone injuries. They can sometimes reduce pain and muscle spasms, especially those caused by brain injury.