Patient collaboration with therapists is key
by Dr. Tim Fox
December 7, 2017

According to the American Academy of Orthopedic Surgeons, over 900,000 Americans undergo total hip or total knee replacement every year. Additionally, 53,000 Americans undergo total shoulder replacement each year.

Joint replacement surgery can be beneficial to decrease pain, increase range of motion and increase function in older adults, but the surgery itself is only half of the story. Following surgery, patients receive many different types of medical interventions, including physician consultations and nursing services. They also receive rehabilitative services.

A certain amount of anxiety may set in at discharge. The physician has determined the patient is “medically well.” The patient has doubts of his or her functional wellness, ability to get up and down steps or in and out of that favorite recliner. Physical and occupational therapists, the professionals who are trained in the area of functional wellness, can help.

The Role of Rehabilitation Services

Following an orthopedic surgery, physical and occupational therapy services typically will begin while a person is still in the hospital and will continue until their functional ability is restored. Physical therapy helps a person reduce pain, regain strength, increase range of motion, improve balance and reduce the effort needed to access the community. Occupational therapy helps people regain the ability to care for themselves, care for the people that depend on them and to care for their home.

The Rehabilitation Process

The first step to a successful recovery of function is for a thorough assessment to be completed by the rehabilitation professional. The focus of this assessment is on the patient’s prior level of function, current level of function and the mutually agreed upon outcomes within the plan of care. A comprehensive assessment looks at more than just range of motion and strength; those things only touch the surface of the true picture of the client’s function.

Rehabilitation professionals use functional outcome measures that provide incredible amounts of information about a person’s functional capacity. For example, did you know that the average 75-year-old man can stand up from a chair, walk 10 feet, turn around and sit down all in nine seconds? Or that the typical 80-year-old woman should have enough leg strength to stand up from a chair 12 times in 30 seconds?

Using a battery of tests, the rehabilitation professional can identify limitations as well as refer to baseline measurements of function. The “why” behind the poor balance, dizziness and other deficits drives the chosen interventions—it is the hallmark of how a tailored plan of care is developed.

House Calls and Rehabilitation

As a patient moves through the health care continuum after a surgical procedure, he or she will come to a point where a decision needs to be made: to use traditional homecare services or outpatient services. Homecare services tend to focus on recovery to a point where the client is no longer homebound, as well as clinical needs.

Homecare services allow for physical therapy, occupational therapy, speech language pathology and nursing care. Outpatient therapy allows for physical therapy, occupational therapy and speech language pathology services, but does not offer the services of a nurse. Outpatient services focus on higher-level functional goals and go beyond the homecare goals of medical stability while focusing on overcoming being homebound.

Some practices have chosen to provide outpatient services as a house call. This way, the clinician can evaluate a client’s ability to transfer to standing from their favorite chair, climb the stairs to their second-floor bedroom, step down the curb to enter their garage, and even walk on the grass outside to get to their outdoor patio where their grandchildren gather every Sunday for a barbecue—all things that a traditional clinic setting does not allow.

A house call care delivery model may have advantages over the traditional clinic-based rehabilitative services. According to a 2006 article published in the Journal of the American Geriatrics Society, older adults who received physical therapy services at home reported improvements in their quality of life, a decrease in their perception of functional difficulties, and an increase in their confidence level. Even more astounding is that these reported gains remained present up to six months after therapy services concluded.

While physical therapy works on regaining overall function, occupational therapy (OT) focuses on the finer details of daily functioning. Occupational therapists are the troubleshooters of the rehabilitation process; they make the impossible possible through the use of adaptive equipment, home modifications and functional strengthening. When occupational therapists complete evaluations, they ask the questions, “What do you want to be able to do? What is important to you?” The occupational therapist starts to identify where the client wants to go and starts to make a plan on how to get there, in the comfort of the home. Together, client and OT work on opening medication bottles and making a checklist for setting up the weekly pill organizer; fastening buttons and zippers; or teaching a client how to use tools such as a dressing stick or a reacher. Being able to complete one’s own self-care tasks is key for successfully aging in place.

A Real-Life Encounter: Coming Home After a Hip Fracture

Ann was an active grandmother at 78 years old. She religiously attended her Wednesday Mahjong game. She never missed a water aerobics class on Tuesdays. She picked up her grandchildren from school on Fridays and took them to the park. But one day, while stepping out of the shower, Ann slipped on the wet bathroom floor and could not stand. It was several hours until her husband came home from his round of golf when he found her lying on the floor, in tears, unable to get up and reach her phone to call for help.

Ann was brought to the hospital where she found out she had broken her hip and would need a hip replacement. Her surgery took place the next morning. By the afternoon, she was out of bed having her first physical and occupational therapy sessions in her hospital room. Two days later, she was walking with a walker and was discharged home with her husband and some medical equipment. Ann thought she was ready to go home but when she got there, she realized that she could not get dressed by herself, she needed help to use the bathroom, she was afraid to get into and out of the shower, and she could not climb her stairs.

While in the hospital, the physical and occupational therapists practiced getting up and down from a chair. At home, though, Ann liked to sit on her couch, but she couldn’t figure out how to maintain her hip precautions on her soft couch. So, she just sat in the kitchen by herself. Her bathroom was bigger than the one she practiced in with the hospital therapists. She couldn’t figure out where to hold on in order to step into the tub to take a shower. Her sink was not right next to the toilet as it had been when she was training. She was so afraid of falling that she chose to take a sponge bath and use the bedside commode.

That first night, Ann stood at the bottom of the stairs leading up to her second story bedroom and cried. She had to climb 14 stairs to get to her bedroom. For the first time in 46 years, she slept alone in the guest bedroom, and her husband slept on the couch so he could be nearby in case she needed help overnight.

Ann started in-home physical and occupational therapy within one week of coming home. What made the difference?

The physical therapist assessed Ann’s environment and made recommendations on how to build up the height of the couch cushions; made a plan based on Ann’s range of motion, strength and balance; and figured out how to adapt Ann’s climbing technique so she could be safe and sleep in her own bed.
The occupational therapist assessed the bathroom, took measurements and determined that Ann could put the commode over her toilet so she could still use the toilet and and with armrests to assist.

Within a few short weeks, Ann had transitioned from a walker to a cane and resumed grocery shopping with her husband. She was showering daily and going up and down her stairs with ease. Less than one month after her surgery, Ann was welcomed back to her usual Wednesday afternoon Mahjong game.

Conclusion

Difficulty with everyday physical functioning is a substantial driver of cost that is typically overlooked and unaddressed in traditional medical care, Drs. David B. Reuben and Mary E. Tinetti wrote in 2012 in The New England Journal of Medicine. Further, people with functional limitations and chronic conditions are four times more likely than the general population to be among the top users of all health care services. This makes addressing limitations early in the recovery critical to regaining lifelong independence.