by John C. King, MD
Geriatric Rehabilitation is becoming more and more important as advances in medicine and surgery allow for the survival of greater insults by disease or trauma leaving residual functional deficits. This, combined with the deficits in function associated with the burgeoning aging baby boomer generation will continue to expand rehabilitation needs over the next two decades.
Improvements in stroke acute care provide greater survival and minimization of functional deficits. Neverthe-less, patients often suffer significant declines in function that impede full participation in society.
Comprehensive inpatient rehabilitation programs for stroke patients have shown to be more effective than subacute skilled nursing facility (SNF) level of care for enhancing recovery of function and more rapid reintegration into society for afflicted stroke patients. Despite this, many patients still get shunted to SNF levels of care. One advancement that requires the significant support more likely to be found in inpatient rehabilitation facilities (IRF) is constraint induced therapy. For the moderately hemiplegic patient, constraining the intact and normal limb during activities of daily living has been shown to result in more rapid recovery of the impaired limb’s function than traditional therapy. However, this can
be frustrating for the patient when implemented, and therefore requires significant therapist support and encouragement to be successful.
Electroprostheses are being used to help minimize hemiplegic shoulder subluxation that otherwise can inhibit arm use and lead to painful shoulder conditions. These can be transcutaneous with surface applied electrodes or intramuscular implanted systems. Such devices can assist in functional electrical stimulation which uses the stimulation to accomplish a particular task, such as shoulder flexion. This can enhance neuromuscular reeducation
of the brain and can further facilitate recovery. Implanted electrodes in the shoulder, arm and forearm with computer assisted control have been used to provide a neuroprosthesis to permit more complex arm use than is normally available to a tetraparetic patient from spinal cord injury. Such implanted units in bilateral legs have permitted paraplegic patients to stand and walk with the assistance of a computer controller and walker. Electroprosthe-ses have even been used to permit bladder control in spinal cord patients and to facilitate male fertility in younger SCI patients.
Deep brain stimulation has been able to dramatically reduce tremors in Parkinson’s patients who nevertheless need rehabilitation to optimize their functional gains permitted by such implantations. Some qualities, such as bradykinesia, may be less responsive and continue to impair function such that training in how to best accomplish tasks no longer impeded by tremors may be needed through rehabilitation.
While advances continue in inpatient geriatric rehabilitation care, returning patients rapidly to home environments and reintegrating them back into society including the workforce, the Centers for Medicare and Medicaid Services is adding restrictions (the 75 Percent Rule) on which geriatric patients should go to IRF level of care. This trend appears to be due to cost containment concerns resulting from the growing population of aged. Whether this shift back to nursing home levels of care, where rehabilitation in the last decade has improved, will in the long run be cost beneficial
or effective for most conditions remains unknown but hopefully becomes
better studied prior to adverse policy implementations.
John Chandler King, MD is a Professor of Rehabilitation Medicine at The University of Texas Health Science Center at San Antonio and Director of the Judge Blair Reeves Rehabilitation Center at the University Health System. He is a nationally invited lecturer and author of 68 research papers and chapters on various rehabilitation topics. He is President-elect of the Association of Academic Physiatrists and serves as an Associate Editor for the American Journal of Physical Medicine and Rehabilitation.
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