PRINCIPLES OF

REHABILITATION
ELDERLY
Oleh :
Dr. Dedi Silakarma Sp.KFR

IN

REHABILITATION
One of the most basic component of comprehensive care
for the elderly.
A philosophical approach : to help achieve the highest
possible level of function, independence and quality of life.
Definition : Restoration of the ill or injured to an optimal
function level in the home or community in relation to
physical, psychosocial, vocational and recreational activity.

American Geriatric Society, defines :

Rehabilitation as the maintenance and restoration of
physical and psychological health
- Independent living
- Functional independence

 Rehabilitation

is concerned with :
Lessening the impact of disabling
condition on individuals and their
family members.

Especially important in the elderly

who often have multiple comorbid
condition that may impact on the
outcomes of rehabilitation.

WHO ( 1980 ) to characterize the

disablement process :

International Classification of Impairments, Disabilities and Handicaps

( ICIDH ) :
* disease : the underlying diagnosis or
pathological process, noticeable at a microscopic level.
* An impairment : A disease that progress to a point at
which an organ system is unable to function normally.
* A disability : an impairment of an organ system that
causes a restriction or lack of ability to perform ADLs.
* A handycap : a disability with unable to fulfill social rules.

May 2001 WHO released a revision of ICIDH

International Classification of Functioning, Disability and
Health (ICF) :
The function as the consequence of a dynamic interaction
between various health condition and contextual factors.
Various health condition : diseases, disorders, injuries or
aging
Contextual factors : environmental factors and personal
factors
The model : three domains of human function ( body
function and structures, activities and participation ).
Body function and structures : the physiologic functions and
the anatomical parts of the body
The execution of a task or action by a person is an activity
Participation is the application to a real life activity

Rehabilitation Site
Started as soon as patient is able to
tolerate the exercise to prevent
secondary functional loss and
promote early restoration of function.

Each setting has its own advantage

& disadvantages.

Acute Inpatient Rehabilitation

Usually provided for the patient who needs

at least 2 different therapies (PT, OT, ST).
Able to tolerate therapy at least 3h/day
6 days/week & is likely to show
significant improvement.
Monitored by interdiciplinary team, include
physician who is experienced in
rehabilitation
Weekly team meetings allow for review,
discussion, and planning of the
rehabilitation process.
The duration of inpatient rehabilitation
varies from days to months depending on
many factors.

 Subacute

Rehabilitation .

Patient who are not appropriate for

acute inpatient .
Home

Rehabilitation

Home is often the best site for the

rehabilitation process
Out

patient Rehabilitation

For some patient, out patient

rehabilitation is the best option.

Process of Rehabilitation
A comprehensive geriatric assessment is
often helpfull
The assessment should include measures
at a person ability to perform task to ADL,
leisure activities and social interaction.
Two people with the same impairment and
resulting disability may have different
goals.
It is important to select the functional
assessment instrument that are valid and
reliable for this purpose ( Barthel Index,
FIM )

Geriatric Rehabilitation Team

Physician especially in physical
medicine and rehabilitation)
Nurse
Physiotherapist
Occupational Therapist
Speech & language pathologist
Psychologist
Social Worker
Dietitian
Recreational therapist

PHYSICAL MODALITIES
Heat agents :
Superficial : Hot pack, Infra Red
- Deep : SWD, MWD, USD
Cold agents :
- Icing : cold pack
- Cryotherapy
Electrotherapy : ES, TENS

 Equipment

The best benefits and safety

Gait problem (+) : canes, crutches,
walker or wheelchair
Environmental adaptations :
modification bathrooms and
entryways.

Common geriatric problems

Stroke
Osteoarthritis
Hip fracture
Deconditioning
Falls & Instability
Amputation

Rehabilitation for common

Geriatric problems
STROKE
General consideration
The third leading cause of death in US
leading cause of serious, long term
disability.
Treatment

Acute care
Intensive rehabilitation
Long term care

Rehabilitation approach should be continuing

process, started as soon as life threatening
problem are under control during acute
hospitalization.
Candidates for intensive rehabilitation :

Medically stable but have residual disabilities

Need help with at least 2 ADLs :
are able to sit (with or without support) for 1 hour
and are able to learn and participate in active
rehabilitation treatments.
Intense inpatient program
Home or outpatient
program
Able tolerate 3 hours of
* Only supervision or minimal
therapy each day
assistance in mobility or ADLs

age worse functional

out come at hospital discharge and
follow up.

Increasing

An elderly person may have more

disabilities after stroke than younger
person but will have the same
degree of functional improvement
after the stroke.

Rehabilitation intervention strongly

associated with improve functional
outcome are early initiation of
rehabilitation services ( 72 hours
post stoke) & rehabilitation provided
in an interdiciplinary in patient
setting.

 Most

of the functional recovery in the

first 6 month after stroke

Some

patient continue to gain

functional abilities with physical
therapy and exercise after 6 month.

 In

patient who are initially aphasic,

50% recovery of speech occur in the
first month and then recovery
continue at slower pace for 6 month.

Complication :
a. Depression

Interfering with the ability to perform ADLs

Unrecognized but treatable condition that
improves with medication or
psychotherapy or a combination.

b. Falling

Stroke patient are susceptible to falling

Fall incidence can be reduced significantly
with appropriate evaluation and
intervention.

c. Spasticity & contractures.

Common after stroke
Treatment :
- Aggressive and consistent ROM
exercise
- Proper positioning
- Splinting
Oral medication unsuccessfull

Selective local intra muscular injection low

dose of Botulinum Toxin A has been
effective in reducing local muscle true for
3-6 month, resulting in improved function
in selected patients.

d. Poor Caregiver Health

Support services for families have been

shown to increase social activities
significantly and improve quality of life for
caregivers.

OSTEOARTHRITIS
General Consideration
OA is the most common disabling
condition in older people.

The first step in evaluating the

rehabilitation potential of a.person with OA
is Physical Examination with special
attention paid to ROM/ Range of Motion
(active & passive) condition of joint
(inflamed, deformed, swollen, unstable) ,
MMT/ muscle strength, postural or gait
instability, CV fitness and subclinical
conditions that could be exacerbates by
exercise.

Treatment
Superficial heat commonly used than
deep heat (MWD, SWD, USD) for OA
joint
Many patient prefer cold to heat for
symptom relief.
Superficial heat (+) , before exercising and
early in the morning to help relieve
morning stiffness.
Topical ointment : capsaicin and trolamine
salicylate (+) in OA joint but are often
poorly tolerated by elderly patient.
TENS helpfull for hand, wrist & knee pain

The best program for patient

functional problem are most
important to the patient help
prioritize them work with the
patient to set spesific short and long
term goals.
Flexibility exercise stiffnes
, joint
mobility , prevent soft tissue
contractures
Strength training essential part of
rehabilitation for people with OA.

Isometric training better option if the

joint inflamed or unstable can improve
muscle strength & static endurance.

Isotonic training
Isotonic muscle contraction(+) perform
ADLs

Has positive effects on energy

metabolism, insulin action, bone density
and functional status .

Joint damage is severe contracture

(+) more aggressive treatment
may be beneficial including:
- Arthroplasty Indication : Pain
relief !!
- Serial casting
- Serial casting combined with
traction
- Manipulation under anesthesia.

HIP FRACTURE
- Major cause of disability in older adult
- Rehabilitation (+) reduce the
disability of hip fracture.
Treatment
The typical post op course of hip
fracture is as follows:

ROM exc , WB locomotion as

tolerated, pivot transfer :, isotonic
ankle exc and isotonic gluteal exc.

 4-6

weeks post surgery (endosteal

and bridging calluses (+)

Active ROM exc around hip and knee,

Active resistive exercise as tolerated

8-12

weeks post surgery

WB transfers & ambulation

Weaning from assistive devices

Deconditioning
Result
The

of prolonged limited mobility

reason for the limitation of

mobility can be physical (eg. pain,
imbalance, reduced ROM),
psychological (fear of falls,
depression), environmental (restraint
neglect) or a result of lifestyle
choices.

Significant deconditioning (+) 3 days of

Immobilization
The primary manifestation of
deconditioning are :
- Muscle strength (espc in the antigravity
and
large muscle )
- Joint flexibility
- Contracture
- Fatique
- Resting tachycardia or abnormal high HR
with
sub max exc.
- Orthostatic intolerance.

Treatment .

Providing adequate sensory and

intelectual stimulation.
Regaining an upright posture
Improving joint ROM (active or passive
exc)
Increasing strength and coordination with
combination of isometric, isotonic and
functional activities.
4-8 weeks of resistance excercise
strength and improve functional activity.
To prevent deconditioning bed rest is
generally avoided

Falls & Instability

Each

year 30% of community

dwelling people older than 65 and
50% those older than 80 fall.
Falls leading cause of accidental
death in the elderly.
Besides physical injury, falls also
cause psychological and social
consequences such as fear of falling,
anxiety and admission to long term
care institution.

Risk factor of falls are :

- Muscle weakness
- History of falls
- Gait deficit
- Use of assistive deficit
- Visual deficit
- Arthritis
- Depression
- Cognitif impairment
- Age > 80
- External factors : environment etc

Because of fall is usually the result of

many interacting factors intervention
(+)
Intervention are usually :
A combination of gait training and
appropriate of assistive devices
Treatment of postural hypotension
Modification of environmental hazards
Treatment of CV disorder (incl. arrythmias)
Taichi helpfull
Home assesment to ensure elimination
of environmental risk factor !.

AMPUTATION

> 100.000 new amputatee yearly in US.

Elderly with PVD
Because of advances in vascular surgery
and technology decrease the number of
AK amputation
BK amputation >>
Important (+) BK amputation : Reduce
- Energy cost for ambulation

- Psychological morbidity
Successful Rehabilitation

Treatment
Evaluated preoperatively
rehabilitation plan
Start measure to improve muscle
strength (espc. Hip extensors and the
upper body) and prevent contracture.
Emotional effect of limb loss is
significant patient and families
need supportive environment.

Bed excercise first post op day

Get out of bed & begin balance training
within 3-4 days
Temporary prosthesis usually fitted 6-8
weeks after surgery when the limb stump
has resolved and healed.
Take care the stump with massage and
wrapping edema , Prevent infection
and pressure.
Phantom sensation >>
Phantom pain <
Neuroma at the amputation problem
need injection with a steroid anesthetic
mixture or excition.

Canes (Tongkat)

Walkers (Alat Bantu Jalan)

Crutches (Kruk)

Wheel Chair (Kursi Roda)

THANKYOU