Rehabilitation of the Orthopedic Surgical Patient

Introduction

Acute rehabilitation tries to restore the premorbid physical and mental functioning of patients as much as possible by increasing muscle strength and patient endurance, improving muscular coordination and control, and providing adaptive equipment when necessary. Choosing the appropriate setting for provision of the needed services requires a working knowledge of the different levels of care available for rehabilitation services—acute inpatient rehabilitation, subacute rehabilitation, outpatient rehabilitation, and home health services. Determinants of the appropriate level of care include the functional limitations of the patient, the need for medical monitoring, social support, cognitive functioning, nursing needs, therapeutic disciplines required, and ability to tolerate three hours of therapy a day.

The Centers for Medicaid and Medicare Services recently instituted a prospective payment system for acute inpatient rehabilitation facilities. For Medicare approved facilities, a certain percentage of all admitted patients must have 1 of 13 diagnoses: stroke, brain injury, burns, SCI, neurological disorders, major multiple trauma, congenital abnormalities, inflammatory polyarthritis with impairments of ambulation and ADLs that have not responded to less intensive therapies, amputations, hip fractures, bilateral joint replacements, and unilateral joint replacements in individuals > 80 years old or the morbidly obese. Rehabilitation centers must provide, and patients admitted to the acute rehabilitation center must require, interdisciplinary, team-based care, 24-hour rehabilitation nursing, daily physician assessment, and three hours of therapy daily. The interdisciplinary team in acute rehabilitation facilities consists of a physician leader, registered nurse (RN) with rehabilitation certification or expertise, physical therapy, occupational therapy, speech therapy, therapeutic recreation, social work, nutrition, neuropsychology, and often psychology, an orthotist, prosthetist, and a chaplain. Patients receive therapy five to seven days a week (Table 66-1).

Table 66-1 Criteria for Admission to Acute Rehabilitation

Preadmission assessment must include:
- Prior level of function
- Expected level of improvement
- Expected length of time to accomplish improvement
- Risk for clinical complications (ie, decubitus ulcer, UTI, etc.)
- Condition that caused need for rehabilitation (etiologic diagnosis, ie, stroke)
- The impairments necessitating rehabilitation (diagnosis, ie, hemiparesis, dysphagia)
- Combination of treatments needed (wound care, bowel/bladder training, antibiotics, therapies)
- Expected duration of rehabilitation
- Anticipated discharge destination (must be to community, SNF is not an acceptable discharge destination)
- Any anticipated post acute rehabilitation therapies needed (ie, HH, outpatient therapy)
Acute inpatient rehabilitation is deemed reasonable and necessary if:
- Multiple therapy disciplines are needed (PT, OT, and or ST) and PT/OT referral from the index hospital
- Intensive level of rehabilitation provided (three hours per day and at least five days a week)
- Ability to participate in intensive therapy and make reasonable improvement demonstrated
- MD supervision provided on a daily basis
- Interdisciplinary team approach utilized
- Insurance approval required prior to transfer

Long-term acute care (LTAC) facilities may also provide daily therapies using speech (ST), physical (PT), and occupational therapy (OT) but these facilities are best suited for patients whose medical needs, such as ventilatory support, telemetry, wound care, long-term IV antibiotics, and administration of chemotherapy, preclude their participation in rehabilitation at an intensive level. By providing highly concentrated medical and nursing services that exceed the level of medical care that can be delivered at a skilled nursing facility, LTAC is considered hospital-level care. The LTAC rehabilitation goals resemble that of the acute inpatient rehabilitation with the goal of establishing and maintaining medical stability. The length of hospitalization typically lasts longer, around 25 days. If they meet criteria, patients may be admitted to acute rehabilitation following a LTAC stay (Table 66-2).

Table 66-2 Alternative Options to Acute Rehabilitation

	Services	Eligibility	Emphasis
Subacute rehabilitation	Requires assistance with wound care, IV medications, and PT, OT, and ST; up to 2 hours of therapy each day; seen by a physician weekly or monthly; in general, 1:1 sitters must not be required for 24 hours prior to transfer; requires a 3-day hospital stay for Medicare to approve; some facilities may provide hospice care for patients with life expectancy of less than 6 months	Patients who do not require, or who cannot tolerate the more aggressive pace of acute rehabilitation yet require supervision and/or support for ADLs not available in the community	Up to 2 hours of therapy a day up to 5 days a week
Home care	PT, OT, and ST in the home setting; hospice care including nursing care, pain control, spiritual or emotional counseling, symptom management	Patients who are homebound or who require assistance to get out of the home	Safe mobility and performance of activities of daily living (ADLs) in the home, generally 1 to 2 times a week over a period of a few weeks
Outpatient therapy (Some offer more comprehensive and intensive day programs similar in intensity to inpatient acute rehabilitation therapy).	PT/OT/ST/TR/SW and nursing as well as orthotists, prosthetists, and neuropsychology services	Patients who need and can tolerate more aggressive therapy and who can be safely cared for at home	Therapy 4 to 5 hours per day, 5 days a week

At either type of facility, rehabilitation or LTAC, the rehabilitation professionals simultaneously provide care for cancer, cardiovascular, musculoskeletal, neurologic, pulmonary, organ transplantation, postoperative and trauma complication, and other medical comorbid conditions (Table 66-3).

Table 66-3 Acute Rehabilitation Providers

Provider	Methods of Evaluation and Treatment
Physical therapy	Assess muscle strength, joint range of motion, gait, and mobility Provide exercise training to improve strength, ROM, endurance, balance Employ physical modalities (heat, ultrasound, electrical stimulation, massage) to treat lower body deficits
Occupational therapy	Assess joint strength and range of motion Assess self-care skills (grooming, bathing, eating, toileting) Assess ability to perform ADLs (food preparation, household activities) Provide self-care, ADL training, assistive devices Assess home safety (such as assessing which bathroom aids such as grab bars, raised toilet seat, and shower chairs would most benefit the patient) Provide physical modalities (heat, ultrasound, e-stim, massage) to treat upper extremity deficits Fabricate splints
Speech therapy	Treat dysphagia, recommend diet consistencies to accommodate impairments of swallow Assess speech, comprehension, cognition, and treat communication deficits
Recreation therapist	Assess leisure skills and interests Increase social interaction, which may include horticultural, music, and dance therapies Facilitate community reentry Can also facilitate some vocational activities
Rehabilitation nurse	Evaluate self-care needs Evaluate family/caretaker and home factors Provide self-care training including bowel, bladder, and wound care Instruct how to administer and monitor medications
Social worker	Evaluate family/caretaker and home factors Provide counseling Assess psychosocial factors Arrange home heath or outpatient post discharge services and equipment Coordinate team
Nutritionist	Assess nutritional status Recommend diet to optimize nutrition and compensate comorbidities Assist with recommendations for enteral and parenteral feeds when necessary
Neuropsychologist	Assess cognition: judgment, reasoning, insight, executive functioning, recall, learning Provide recommendations to patient, team, and family for compensating for deficits in cognition Provide assistance with coping
Orthotist	Make and fit orthotics such as braces, ankle-foot orthotics
Prosthetist	Make and fit prosthetic limbs

This chapter will focus on rehabilitation of patients hospitalized for orthopedic problems affecting the spine or lower extremities. Typical conditions requiring hospital-level rehabilitation include: traumatic spinal cord injury, intervertebral disc prolapse, transverse myelitis; joint replacement surgery, particularly hip arthroplasty; spinal surgery, limb amputation, limb trauma, heterotopic ossification, and compartment syndromes.

Optimal transitions to acute rehabilitation require a collaborative assessment with the multidisciplinary health care team to determine the therapeutic disciplines needed and the extent of recovery anticipated. The team should also identify any medical comorbidities such as cardiopulmonary disease, hospital-acquired complications such as delirium, and any unresolved issues that will impede the patient’s ability to participate in rehabilitation activities. The rehabilitation plan must address any impairment of motor, sensory, cognitive, communication, and emotional functioning.

Patients should expect three hours of therapy daily in 30 to 90 minute sessions, at least five days a week. They should view acute inpatient rehabilitation as the initial phase of their rehabilitation program and anticipate continuing that program post discharge with home-based therapies or in outpatient facilities. Patients and their caretakers will be informed of their rehabilitation goals and their expected length of stay within a few days of admission, and receive weekly progress reports following weekly team meetings reviewing attainment of stated goals and any barriers to progress.

Therapeutic Modalities

Exercise

Exercise, the cornerstone of rehabilitation, can be designed to improve strength, improve balance, and increase endurance and range of motion. Strength combats sarcopenia and imbalance. Strength training programs involve movement against resistance (typically with rubber bands or the body’s own weight). Balance exercises, for those individuals at high risk for falling involve practicing standing on uneven surfaces, one extremity, or on the balance beam. Exercises to improve endurance involve continuous activity such as walking and swimming. Improved endurance increases capacity for activities of daily living (ADLs) and for ambulation. Prolonged, low-intensity stretching exercises may also improve range of motion and increase flexibility.

Physical Modalities

Physical modalities such as heat, cold, massage, electrotherapy, and phototherapy may be used in conjunction with exercise to decrease pain and improve range of motion. The most substantial evidence for the efficacy of these therapies supports the use of electrotherapy, particularly in wound healing. Thermal therapies include superficial modalities such as paraffin, heat packs, heating pads, and whirlpool, and deep modalities such as ultrasound and acoustical energy, which after absorbed by tissues converts to heat. Thermal therapies help eliminate edema, decrease pain, and increase extensibility of connective tissues. Delivered by cold packs, ice massage, vasocoolant sprays, and cold water immersion, cryotherapies decrease pain, especially in spastic extremities, thereby allowing more painless movement. Electrotherapy can be used for wound care but also includes transcutaneous electrical nerve stimulation (TENS) for pain and neuromuscular stimulation to enhance functional movement patterns such as with foot drop. Delivered via pads that emit light energy, phototherapy may help manage pain and provide wound therapy by enhancing nitric oxide release from hemoglobin.