Geriatric rehabilitation interventions

INTRODUCTION — The primary purpose of rehabilitation is to enable people to function at the highest possible level despite physical impairment. Rehabilitation includes a vast array of interventions provided by a diverse group of providers across the continuum of care. While rehabilitation may be provided to all age groups, the fastest-growing population of persons requiring rehabilitation services is adults >65 years of age. This is because the median age of the United States and worldwide populations is increasing [1,2]. Improvements in both medical and rehabilitative care have helped to reduce the prevalence of disability among older adults [3], but they come with a substantive demand for both medical and rehabilitation care [4].

Making good use of rehabilitation resources is facilitated by an appreciation for how disability occurs and the mechanisms by which rehabilitation is effective, particularly in older persons. This knowledge leads to an understanding of which specific rehabilitation services might best be provided, where to provide them, and who should provide them. This topic will review aspects of geriatric rehabilitation related to interventions. Indications, providers, and settings for rehabilitation and patient assessment are addressed separately. (See "Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation" and "Geriatric rehabilitation settings and reimbursement".)

CONCEPTUAL MODELS FOR DISABILITY — There are two major conceptual models for understanding disability and where rehabilitation services can be most effective:

●The International Classification of Function, Disability, and Health (ICF), developed by the World Health Organization (WHO) [5].

●A model variably known as the "Environmental Press," "Ecological," or "Person-Environment Fit" model, originally described by Lawton [6].

The WHO ICF model — The WHO ICF model (figure 1) indicates that an individual’s level of function (body function, ability to execute a task [activity], and participate in life activities) is determined by their health condition(s) within the context of personal and environmental factors. Medical and surgical interventions are directed at the underlying health conditions causing disability, while rehabilitation services target the impairment, activities, and participation levels of the disablement process, as well as personal and environmental contextual factors that influence activity and participation. Multiple chronic conditions or multimorbidity, also known as multiple comorbidities, with concomitant impairments, are common in older persons and influence the disablement process. Effective treatment of late-life disability, therefore, is typically multimodal [7]. (See "Multiple chronic conditions".)

The Ecological model — Disability results from a mismatch between individual capacity and task demands, which in turn are influenced by the environment and the way in which tasks are performed [6,8]. For example, walking imposes different physical demands when performed atop Mount Everest versus at sea level. Thus, the Ecological model helps to explain how personal and particularly environmental contextual factors, described in the WHO ICF model, interact with physical limitations to result in disability [5,6]. In the Ecological model, remediation of disability occurs through treatments that either increase individual capacity or reduce task demand. Medical (eg, oxygen supplementation or medication) or surgical (eg, cataract surgery, joint replacement) interventions have the potential to increase capacity but not reduce task demand. Rehabilitation interventions may improve capacity, reduce task demands, or accomplish both. Examples of rehabilitation interventions follow [9,10]:

●Improve capacity:

•Physical exercise

•Wearable or handheld devices (eg, hearing aids, reading magnifiers)

•Prosthetic devices (eg, artificial limbs)

•Orthotics (ie, braces, splints)

●Reduce task demands:

•Assistive devices and adaptive equipment (eg, a raised toilet seat or bath bench, which reduce the effort required to rise to a standing position)

•Environmental modifications, (eg, a ramp to replace stairs)

•Changing methods for task completion (eg, dressing the weaker arm first and then the stronger arm)

●Both increase capacity and reduce demand:

•A cane, which can enhance sensory capacity by providing proprioceptive feedback to improve balance and can reduce demand, for example, by offloading body weight from the leg to the arm to relieve arthritic joints or weak lower extremities

KEY CONCEPTS IN GERIATRIC REHABILITATION — There are interrelated conceptual areas specific to geriatric rehabilitation, including frailty, resilience, and multimorbidity [11].

Frailty — Frailty refers to a person’s physiological vulnerability, related to age-related decline in the function of multiple organ systems. Multiple studies have shown measures of frailty are predictive of adverse health outcomes (eg, hospitalization, institutionalization). Frailty is commonly measured either according to a frailty phenotype [12] based on key metrics (eg, weak grip, slow gait, fatigue) or on a frailty index [13] derived from totaling the number of deficits across multiple domains of health [14]. (See "Frailty".)

Resilience — Resilience is related to frailty, but it is not a direct opposite [15]. Resilience has been defined as one’s ability to withstand or recover from functional decline after an acute (eg, infection, physical activity, injury, or surgery) or chronic stressor. Physical resilience is an important new area of research in geriatrics [16].

Multimorbidity — Multimorbidity is a distinct concept and of critical importance to rehabilitation treatment planning, both with regard to therapies directed at specific organ system impairments and with consideration of the potential interactive effects of the specific impairments in any given patient [17,18]. However, effective treatment planning also needs to consider the potential interactive effects of multimorbidity. For example, worse outcomes are seen among persons who have both impaired cognition as well as visual and/or hearing sensory loss, both because the cognitive impairment limits ability to learn coping strategies for the sensory impairment and because of the loss of cognitive stimulation due to the sensory impairment [19]. As another example, albeit for differing physiological reasons, worse outcomes also are found among persons who have both cardiovascular and musculoskeletal disorders [20]. (See "Multiple chronic conditions".)

Geriatric frameworks — Frameworks for rehabilitation decision making include the following:

The multiple chronic conditions framework [21]:

●Identify patients’ health priorities

●Make care decisions based on priorities, benefit versus harm/burden, and likely trajectory

●Align decisions across providers, caregivers, and the patient

The 5Ms approach [22,23]:

●Mind (cognition, mood)

●Mobility (function)

●Medications (optimize/simplify)

●Multicomplexity (complex, unique medical/social issues)

●Matters most (patient values)

REHABILITATION INTERVENTIONS

Exercise — Exercise is a type of physical activity defined as bodily movement produced by skeletal muscle contraction that substantially increases energy expenditure. This includes any physical activity that is planned, structured, and/or a repetitive bodily movement done to improve or maintain one or more components of physical fitness (eg, muscle strength, flexibility, balance).

Physical activity is beneficial for reducing overall morbidity and mortality in older adults (table 1) [24]. Exercise recommendations for all individuals >65 years of age are shown in a table (table 2) and discussed separately. (See "Physical activity and exercise in older adults".)

The physical activity recommendations intended for all older adults may need to be modified for particular health conditions and disorders, using specific types of exercise to correct or ameliorate identified impairments and functional limitations. Common conditions in older adults that would necessitate exercise modification include acute cardiac conditions (eg, cardiac rehabilitation), orthopedic and neurosurgery procedures, osteoporosis, acute/postacute stroke, or chronic respiratory disease (eg, pulmonary rehabilitation). Physical therapists, exercise physiologists, and physicians specializing in rehabilitation (physiatrists) can help to tailor the exercise prescription to meet patient needs. Pulmonary rehabilitation and cardiac rehabilitation in older adults are discussed elsewhere. (See "Cardiac rehabilitation in older adults" and "Pulmonary rehabilitation".)

Certain types of exercise may be beneficial for specific patient populations. As an example, resistive exercise and power training have been found to improve function in frail older adults [25]. A systematic review found that progressive resistance exercise (ie, weightlifting) can significantly improve muscle strength and, to a lesser extent, functional activities such as rising from a chair and ambulation [26].

During acute hospitalization, early mobilization seems to offer particular benefit, improving functional outcomes in multiple patient populations, including patients with hip fracture, acute pneumonia, or critical illness in the intensive care unit [27-29].

Assistive technology, adaptive equipment, and adaptive methods — Assistive technology, adaptive equipment, and adaptive methods encompass a diverse group of interventions designed to enable people with physical limitations to participate in a broad range of activities.

●Assistive technology and adaptive equipment refer to devices that may be used to make tasks easier or safer. While these terms are often used as synonyms, they are distinct. Assistive technology refers to any item, piece of equipment, or product system to increase or maintain functional capabilities [30], while adaptive equipment covers items that are specifically designed for persons with disabilities and would seldom be used by non-disabled persons.

●Adaptive methods refer to changing the way a task is done to make it safer or easier for patients (eg, a stroke patient might don a sweater more easily by putting the sleeve on the paralyzed arm first, the non-paralyzed arm second, and then over the head).

Often the multiple types of rehabilitation interventions are used together to act at all levels of the disablement process, targeting organ system impairments (eg, a prosthetic leg after an amputation) as well as particular types of activities (eg, a cane used when walking) and/or broadly enhancing access and opportunities for participation (eg, ramps allowing access to the home or public buildings).

Assistive technology and adaptive equipment are a particularly common way of coping with disability [31]. These devices include mobility aids such as canes and walkers, bathroom safety devices such as raised toilet seats and grab bars, self-care devices such as reacher tools and built-up utensils, and sophisticated computerized and electronic technology (eg, augmentative/alternative communication devices). Use of such technology has been increasing substantially, far exceeding the growth and aging of the United States population [32,33]. By some reports, technological advances may account for half of the decline in disability in the early 2000s [3]. There has been both an increase in evidence to support its effectiveness [34-36] as well as major improvements in the technology itself, with improved ergonomics, ease of use, and durability [37]. Reputable online resources can be a source of information about diverse assistive devices [38-41].

Mobility aids — Mobility devices are a subset of assistive technology and one of the most commonly used types. Mobility devices may be used for diverse types of physical limitations, including weakness, sensory limitations (vision or proprioception), impaired balance, and/or limited endurance. While such devices are intended to improve mobility, activity, foster independence, and provide some protection against falls, evidence from high-quality studies on the impact of these devices is sparse.

With increasing age, there is increasing need for mobility aids. Approximately 25 percent of all adults in the United States report a disability (mobility being the most common), with 18.1 percent of middle-aged adults and 26.9 percent of older adults affected [42]. Despite the high prevalence of mobility disability, regularly updated epidemiological information on use of mobility aids is hard to come by [43]. However, there is no reason to believe that there has been major change in usage of such devices in the last decade. Independent mobility was reported by 63.3 of men and 42.0 percent of women in 2018. Analyses of the 2011 National Health and Aging Trends Study show that 20 percent of older adults report using some assistive device for mobility and use of specific devices as follows: canes (15 percent), walker (9 percent), wheelchair (4 percent), scooter (2 percent), and two or more devices (7 percent) [44]. Canadian data from 2012 show that 81.3 percent of persons with a disability use some form of assistive technology [45], most commonly a mobility device [46].

There are multiple options for mobility aids, and their appropriate use is outlined below. An algorithm for selecting among mobility aids based on the primary need (endurance, balance, or weightbearing difficulties) and a table that reviews indications and the relative pros and cons of various mobility aids are provided (algorithm 1 and table 3).

Despite availability of insurance coverage, many older adults purchase mobility aids over the counter on their own or borrow them from friends or relatives without professional guidance, which can lead to problems using the device [47]. Mobility aids that are not properly fitted or are used incorrectly can increase the risk of falls and injury. Falls directly related to mobility devices account for over 50,000 visits annually to emergency departments in the United States [48]. Moreover, 30 to 50 percent of wheelchair users report tips and falls [49]. It is vital to observe older patients actually using their mobility aid to verify proper fit and correct use and to refer the patient to expert consultation with a certified Assistive Technology Provider (ATP), physical therapist, or occupational therapist if there are any questions.

Reimbursement issues in the United States are discussed separately. (See "Geriatric rehabilitation settings and reimbursement", section on 'Reimbursement for mobility aids'.)

Canes — Canes are the most commonly used type of mobility device [50,51].

●Who benefits? – Canes function to provide assistance in several ways, including to:

•Reduce the weight borne across an arthritic or otherwise compromised joint in the lower extremity (hip, knee, ankle), thereby reducing pain

•Assist with balance when the balance problem is due to impaired sensation and/or mild leg weakness

•Transmit proprioceptive input to the hand and arm, which can be helpful to people with neuropathic problems or visual deficit

Canes are most useful when the gait problem is unilateral and/or mild. Canes are lightweight and versatile but require good hand and arm strength and provide only minimal support.

●Available options – A variety of options are available in canes. For most patients, a standard walking cane with an ergonomic grip is most effective [52]. A quad cane has a four-legged base that provides good stability but can be heavier and more difficult to move than a standard, single-point cane. So long as the handle of the cane is over the base of support, ie, the bottom of the cane, the configuration (ie, offset, straight shaft) isn’t a key concern other than to make sure the grip is comfortable. An offset configuration allows for use of a pistol grip handle, which may increase comfort and weight support.

●Proper use – A cane should be used in the hand opposite to the affected limb to preserve a normal gait pattern and keep the body weight over the base of support to ensure good balance. Most persons are not properly instructed in cane use, and up to 70 percent of canes are used incorrectly or are the wrong height or design [53]. As a result, almost 30 to 50 percent of individuals abandon use of the cane after receiving it.

The cane needs to be at the right height so as not to throw off balance and to provide proper biomechanical support, with the handle of the cane at the level of the wrist with the arm fully extended. Most canes can be adjusted by cutting the cane at the tip or, for adjustable canes, with the button on the side of the cane. Most canes have a rubber tip to improve traction that should be inspected for wear and replaced when worn.

Occasionally, persons may benefit from use of a cane in both hands or from use of bilateral forearm crutches, which can offload weight to a greater extent and provide greater versatility in navigating environmental barriers such as stairs. However, use of bilateral canes or crutches requires greater strength and is more complex to coordinate than use of a wheeled walker, so it is best reserved for persons who have good upper extremity strength, have good coordination, are cognitively intact, and are guided by a physical therapist.

Crutches — Like canes, crutches come with various options (eg, axillary, forearm, and platform crutches). However, as all crutches require excellent arm strength and coordination for effective use, they are seldom used with older patients. Improper use of crutches, especially the more common axillary crutches, can result in injury to the shoulder (eg, brachial plexopathy and rotator cuff tendinitis). There are several different ways to use crutches (eg, swing through gait, touchdown, etc) and most require learning a different gait pattern, which can be challenging in the presence of even mild cognitive impairment.

Training and use of crutches in the older population should be guided by physical therapists.

Walkers — Walkers are the second most commonly used type of mobility aid [47,48].

●Who benefits? – Walkers are generally used to treat bilateral gait problems or when more body-weight or balance support is needed than a cane can provide. Walkers come with many options in the number of wheels and type of support.

●Available options – One of the most commonly used types of walkers is a two-wheel or front-wheel walker. A four-point or pick-up walker is seldom used any more as it is harder to use and offers little additional stability [54]. Persons with weak grip or hand deformities can attach forearm supports to a two-wheel walker to enable use.

Increasingly common is a four-wheel walker with brakes located on the handles like a bicycle (sometimes called a “rollator” or “Canadian walker”). Four-wheel walkers come with and without a seat and with or without a basket. A four-wheel walker is less stable than a two-wheel walker. It requires good hand coordination to use the brakes and is more expensive than a two-wheel walker; it is also more maneuverable, and the seat affords an opportunity to rest at will. It is a good choice for someone whose main problem is poor endurance from pain or shortness of breath (such patients often have the necessary balance and hand coordination to safely use this type of walker, and the seat allows for periods of rest).

A three-wheel walker can provide similar balance support as a four-wheel walker, but it is lighter-weight and more maneuverable; a three-wheel walker is particularly useful for patients dealing with mobility in narrow confines (eg, a trailer) [55]. However, a three-wheel walker does not come with a seat or basket, so it is less useful for people with limited endurance or who need to transport items while walking (eg, shopping).

A "Merry Walker" has four wheels, a sling seat, and railings on four sides so that the patient is protected from falling yet can propel themselves. The Merry Walker is larger than other walkers and is best used in an institutional setting with wide doorways/hallways.

A "Knee Walker" is a relatively new wheeled mobility device. It is similar to the foot-propelled or kick scooters used by children but with a platform on which the patient can rest their knee while walking. It is especially useful for people who must be nonweightbearing after surgery or injury to the foot or ankle as it is easy to use and it avoids the need for a wheelchair or crutches.

●Proper use – Like a cane, the handle of the walker (other than the knee walker) should be at the level of the wrist with the arm fully extended. For a knee walker, the knee support should allow the other leg to comfortably reach the ground with normal hip and knee alignment, and the handles should be at a level that allows the patient’s hips and torso to be in normal alignment (ie, upright). Generally speaking, any walker should be able to be used with the arms at a comfortable position (neither fully extended nor mostly flexed) and such that the individual’s head torso is over their base of support (ie, feet) and with good alignment.

Wheelchairs

●Who benefits? – Wheelchairs may be used when weightbearing is prohibited or in patients with significant functional impairments (eg, bilateral leg weakness, impaired balance, and/or motor coordination too severely impaired for safe use of a walker). The most commonly used wheelchair is a manual wheelchair with a sling seat that folds and has removable footrests and armrests.

●Proper use – Many older individuals pay for wheelchairs and other assistive devices themselves [56] and may be tempted to save money by use of nonremovable foot rests or by using a second-hand wheelchair. Fixed foot rests are a fall hazard and make it harder to get in and out of the chair and should be avoided. Borrowing a wheelchair can be problematic if the fit is not adequate or the seat is worn, reducing comfort and increasing the risk of pressure ulcers [57].

Important aspects of wheelchair fit for all wheelchair users include seat width and height. The seat width should allow about one inch between the thighs and the armrests, such that there is no pressure or rubbing on the lateral thighs while still allowing good biomechanics when propelling the chair. The seat length should allow about two inches between the end of the seat and the knees, and the foot rests are positioned so the thighs are slightly elevated or level such that the seat provides even support to the buttocks and thighs. Patients who use their feet to propel the wheelchair (eg, stroke patients) require a "hemi-height" wheelchair with a seat height that is lower to the ground. A seat cushion generally should be used with a wheelchair; a specialized pressure-reducing cushion is appropriate for persons in the wheelchair full time or who have difficulty with limited ability to shift their weight while seated [58,59]. Specialized seating systems can be provided for persons with truncal instability.

●Complications from use – Shoulder pain is common in manual wheelchair users, and it is likely that older adults with arthritic joints and women whose upper extremities are weaker are at particular risk for developing shoulder problems with prolonged manual wheelchair use [60]. Patients who develop shoulder pain with wheelchair use should be evaluated for rotator cuff tendinitis. (See "Evaluation of the adult with shoulder complaints".)

A variety of options are available to treat shoulder pain in manual wheelchair users, including exercises to strengthen the shoulder musculature, training on how to most efficiently propel the wheelchair, and/or provision of a lightweight wheelchair that is easier to propel or even a power wheelchair [61,62]. Ultra-lightweight manual wheelchairs can be adjusted for optimal biomechanical advantage when propelling the wheelchair, and interchangeable power assist wheels are available that can reduce the force needed to propel the wheelchair. Wheelchairs with special adaptations to meet specialized needs (eg, ultra-lightweight, elevating leg rests, reclining backrests, power wheelchairs, etc) may require additional justification to ensure reimbursement [63].

●Motorized options – Motorized wheelchairs and scooters are increasingly common and are most helpful for community mobility [64]. Even the most compact motorized wheelchair has a larger footprint than a manual wheelchair, making it hard to maneuver in the home. The cost-benefit tradeoffs for these devices need to be considered carefully: financial costs include not only the device but a car lift to transport the device and an entry ramp if it is to be used in the home. There also is a risk of accidents (collisions, tipping over).

At least in the short term, power scooters do not appear to be overused or to cause deconditioning [65]. It appears that most wheelchair users choose locations where they use their wheelchair depending on needs, abilities, and environmental constraints [66]. Benefits from wheelchairs relate to increased mobility and participation in activities that would be prohibitive otherwise [67].

●Choosing the best option – A systematic review of the evidence regarding the best way to obtain the optimal wheelchair found that there is only limited evidence to determine best practices [68]. There is some evidence that expert assistance, wheelchair fitting, and training is helpful for improving wheelchair use [69-71]. For patients with complex rehabilitation and seating needs (eg, deformities, increased muscle tone/spasticity), a multidisciplinary team can be helpful, including a rehabilitation physician (physiatrist), an occupational or physical therapist with expertise in wheelchairs, a certified rehabilitation technology supplier, and/or a rehabilitation technician [68]. For individuals with complex needs, several components of a wheelchair program will help to assure a good outcome: education to reduce accidents and maximize mobility, involving the individual in the prescription process, and active follow-up to reduce accidents and make adjustments as needed to improve fit and usage [68]. Expert evaluation and training is also important for patients who will use the wheelchair full time, for patients who are at increased risk for pressure sores (eg, due to incontinence or inability to weight shift), for persons with postural problems, or if a motorized wheelchair or scooter is being considered. However, even short-term and intermittent wheelchair users likely benefit from fitting and training by an occupational or physical therapist in use of the device, with beneficial effects related to comfort and ability to safely navigate with the wheelchair [70]. Multidisciplinary wheelchair clinics with specialized medical personnel are available in the United States, within the Veterans Health Administration (VHA), and are frequently located at academic medical centers as well.

Bathroom and self-care aids — A wide variety of devices and environmental modifications can be used to make self-care tasks easier and improve safety, particularly in the bathroom. While the evidence to support the efficacy of particular bathroom devices is limited [72], the theoretical rationale for their provision is strong. Several randomized clinical trials have demonstrated beneficial clinical outcomes (eg, physical function, and/or balance confidence and/or reduced falls) from home health interventions that include provision of assistive devices, environmental modifications, and home visits by rehabilitation therapists [73-77]. Evidence suggests that simply providing home safety assessments and equipment without involvement of a professional such as an occupational therapist is less effective [78]. Commonly used bathroom equipment includes raised toilet seats, seats in the tub/shower, handheld showers, and grab bars.

●Raised toilet seats – It is easier to rise to standing when starting from a higher level than a lower level [79], so a raised toilet seat or tub/shower bench may be helpful to someone with weak legs, painful joints, or poor balance. Raised toilet seats may be freestanding (eg, bedside commode) or attached directly to the toilet. Tub/shower benches also come in a variety of shapes and sizes.

●Grab bars – Bars may allow patients to rise more safely by enabling use of the arms to compensate for weak legs or limited sensation. Patients may rely on items already in their home such as a nearby sink or towel bar for this purpose, which is fine if they are stable or securely attached to the wall but can be dangerous if the item is unstable. Placement of grab bars can eliminate some of the risk.

There is considerable variation in grab-bar technology [80], with options such as direct attachment to the toilet or a raised toilet seat, swing-away bars, or attachment to the side of the tub or directly to the wall itself.

For patients who need help from another person for transfers, use of a gait belt can improve safety, and hydraulic lifts are available that can be used even by quite frail caregivers.

Prosthetics and orthotics — A prosthesis is an artificial device that replaces a missing body part (eg, artificial limb), while an orthosis is an external device applied to the body to support or improve the function of that body segment/joint (eg, ankle foot orthosis, carpal tunnel splint).

Prostheses — Prosthetic devices require detailed patient evaluation for an optimal prescription. Careful consideration of medical comorbidities and the premorbid functional status is required, particularly in older persons. Such factors may be of lesser importance for younger patients with traumatic amputation.

Lower-extremity amputations are common, with the majority being due to peripheral vascular disease in diabetic patients [81,82], and with overall incidence increasing in recent years. The underlying disease that resulted in an amputation (eg, diabetes, peripheral vascular disease) often affects the function of other organ systems and the patient’s ability to cope with the increased work of walking required with a prosthesis. Comorbid conditions such as cognitive impairment, arthritis, pulmonary disease, or stroke can also affect the use of a prosthesis. A systematic review noted that the following factors were most predictive of functional walking ability after a prosthetic limb: cognition, fitness, preoperative mobility, ability to stand on one leg, and independence in activities of daily living [83].

Anything that affects the biomechanical integrity of a joint will increase the work of walking [84]. While some newer prosthetic limbs come close to the efficiency of a normal leg, in general the higher the amputation the greater the increase in the work of walking. Patients with concomitant heart or lung disease, or other comorbid conditions that impact the functionality of the remaining lower limb, may not be able to meet the added work of walking with a prosthetic limb. For some severely debilitated amputees, a manual or power wheelchair with a cosmetic leg may provide the best functional outcome. For other amputees, functional needs may be met with a low-tech prosthesis, such as a simple knee or ankle joint, rather than a computerized knee or multiaxial ankle joint. By contrast, those with an above-knee amputation who are likely to be able to ambulate in the community may benefit from a high-tech prosthesis with a computerized knee [85]. Determining the best type of prosthetic limbs for an individual patient depends not only on the level of the amputation but also on the presence of other medical conditions. For those clinical reasons, the Centers for Medicare & Medicaid Services (CMS) in the United States has created “K-levels” that identify the rehabilitation potential for someone with a lower-extremity amputation, and those levels in turn determine the type of prosthetic limb covered by CMS (table 4) [86].

A multidisciplinary amputee clinic including a physiatrist, a physical therapist, and a prosthetist is the optimal resource for determining the proper prosthesis and assuring correct fit and function. If this is not available, it is vital for the ordering clinician to work closely with a certified prosthetist and include a physical therapist early in the process. In general, obtaining proper prosthetic fit and function requires a skilled prosthetist. Unfortunately, there is limited research available to assist in determining the optimal prosthesis for an individual patient [87]. Prosthetic training is typically completed on an outpatient basis by a physical therapist who may then work with the prosthetist to modify the prosthesis if abnormal gait patterns or skin breakdown are noted; ideally, there are intermittent evaluations and supervision by a physiatrist skilled in amputee rehabilitation.

Orthoses — Orthoses (ie, splints and braces) are available for virtually every joint in the body including the spine. There are several prefabricated, "off-the-shelf" orthoses (eg, carpal tunnel splints, soft cervical collar). Custom orthoses are generally fabricated by an orthotist, although occupational therapists may also perform this function, particularly for upper-extremity joints. Prefabricated splints and braces are most appropriate for uncomplicated conditions that don’t have substantial deformity.

Commonly used prefabricated lower-extremity braces in the geriatric population include those for the knee (eg, knee sleeve, unloader knee braces), ankle foot orthoses for foot drop, and heel cushions for plantar fasciitis/heel pain. There are few randomized trials with any braces. The available evidence indicates that knee braces may reduce pain and improve function for patients with osteoarthritis [88,89].

●Knee sleeves may be used for mild to moderate severity knee osteoarthritis; devices to control patellar motion (eg, patellar cutout) may be beneficial for patellofemoral osteoarthritis. Due to the limited evidence of benefit for any particular knee sleeve, patient preference should be the deciding factor.

●Unloader knee braces are designed to alleviate pain by unloading the osteoarthritic medial or lateral compartment of the knee. Medial/lateral unloader braces should be reserved for patients with more severe knee osteoarthritis and are best prescribed by an orthopedic surgeon or rehabilitation clinician/physiatrist, or with input from a physical therapist. Patients with knee instability may be prescribed a hinged knee brace that can be set to limit range of motion to a particular arc; however, such braces should only be prescribed under the direction of a rehabilitation or orthopedic provider, as they should be used in conjunction with a rehabilitation program.

●Foot drop occurs most commonly after a stroke but may also be seen with a neuropathy affecting the fibular/peroneal nerve. Ankle foot orthoses maintain the foot in a neutral position during ambulation and can improve gait speed and self-confidence in patients with foot drop [90,91].

●There is fair evidence that heel cushions may be beneficial for plantar fasciitis, and prefabricated heel cushions appear to be just as effective as higher-cost, custom-molded foot orthoses [92,93]. (See "Plantar fasciitis", section on 'Treatment'.)

●Patients at prolonged bedrest benefit from a protective orthosis to maintain the foot in a neutral position, preventing contractures of the Achilles tendon and protecting the heels from skin breakdown/pressure ulcers.

●For the upper extremity, carpal tunnel functional wrist splints are effective for reducing numbness and pain [94]; over-the-counter splints are as effective for treating carpal tunnel syndrome symptoms as custom-fit splints [95]. However, the patient should be referred for neurologic evaluation (eg, electrodiagnostic testing) and possible surgery if there is any evidence of thenar muscle weakness or atrophy. (See "Carpal tunnel syndrome: Treatment and prognosis", section on 'Assess the severity of symptoms and nerve injury'.)

●Osteoarthritis of the first metacarpal phalangeal joint is common and it can be effectively treated with an opponens splint. These splints typically are hand-crafted by an occupational therapist, hand therapist (physical therapist or occupational therapist), or prosthetist.

Environmental modification — "Environmental modification" and "universal design" describe interventions and methods used to minimize the effects of the environment in exacerbating disability and to enhance "accessibility" for all persons irrespective of their abilities. The term "universal design" highlights an overarching goal of enabling access for the widest possible breadth of physical abilities. However, the effects of medical conditions on physical function are variable among individuals [96]; similarly, interactions with the environment are not uniform across conditions and impairments. The environment/person interface can be particularly important for persons with impairments affecting mobility and for persons with low vision.

Environmental modification may be used in isolation or in conjunction with assistive technology to enhance access and utility of both public and private spaces for persons with disability [74]. Increasing evidence supports the influence of the physical environment (ie, terrain, housing) on functional outcomes in older adults [97]. For example, older adults who live in neighborhoods with a mixture of residential and business facilities (ie, “mixed use”) and higher-density neighborhoods report greater independence with instrumental activities of daily living, with the effect most prominent among those with greater physical limitations [98].

The Americans with Disabilities Act (ADA) of 1990 directed that new public and private business construction must be accessible, and it supports widely used guidelines for accessibility. Technical information on the ADA is available from the ADA National Network, and information on accessibility is available from the United States Access Board. Helpful information on environmental modification and universal design pertinent to both public and private spaces can be found at the website for the Center for Inclusive Design and Environmental Access.

Occupational therapists have particular expertise in the person-environment interface within the home and can work in conjunction with architects and structural engineers to recommend the most beneficial home modifications; physical therapists are particularly helpful with mobility impairments, equipment, and methods for coping with environmental challenges both inside and especially outside the home; a low-vision specialist (eg, an optometrist or an ophthalmologist) provides unique expertise for these same kinds of problems in older adults coping with low vision (eg, macular degeneration).

Modalities used by physical/occupational therapy — Several therapeutic modalities may be employed by rehabilitation providers, including various types of electrical, thermal, or mechanical energy that cause physiological changes. Patients may request referral for such treatments. In addition, depending on third-party reimbursement considerations, physicians or non-physician providers (eg, nurse practitioners) may be asked to provide specific orders for use of particular modalities, most commonly to treat pain.

Heat/cold — Two of the most used therapeutic modalities are heat and cold. Both heat and cold may be delivered to the patient in several different ways. Mechanisms of thermal transfer include conduction (eg, hot or cold pack), convection (eg, whirlpool bath), and conversion (eg, ultrasound, diathermy). The effect of commonly used modalities for delivering heat and cold is at the superficial level of the body; core temperature is altered very little by localized thermal modalities. Ultrasound, particularly low-frequency ranges, is used to heat deeper tissues (up to several cm in depth). Heating modalities include heating pads/hydrocollator packs, heat lamps, hot tub/whirlpool, paraffin baths (paraffin mixed in mineral oil heated to 45 to 54°C), and ultrasound (0.5 to 3.0 MHz). Heat causes local vasodilatation and hyperemia. Cooling modalities for rehabilitation include ice cubes/packs/wraps (recommended duration 10 to 20 minutes per session; thin damp towel between skin and ice), ice massage, and whirlpool baths.

While both heat and cold are frequently utilized for their pain relieving effects, other indications include muscle relaxation for heat and relief of swelling and edema for cold (table 5). Contraindications for thermal modalities must be considered (table 6). Heat is generally contraindicated in patients with acute injury, and application of cold is to be avoided for patients with insensate skin or Raynaud phenomenon.

Evidence for the relative benefits of different methods to provide heat is limited and comparisons of modalities (eg, hot pack versus diathermy) appear to show equal benefit for pain relief [99]. Although one study showed more rapid resolution of calcific rotator cuff tendinitis with ultrasound compared with exercise alone, there was no difference between the groups at nine months [100].

Electrophysical agents — Transcutaneous and percutaneous electrophysical agents are an increasingly common approach that may be used by rehabilitation providers treating painful conditions. They are a subset of a group of devices sometimes referred to "electroceuticals," "bioelectric medicine," or "electrotherapy." Electrophysical agents use electromagnetic stimulation, with devices varying in the type of electromagnetic stimulation (ie, alternating current, direct current, pulsed direct current) and in the degree of stimulation. Evidence for efficacy of some individual devices can be hard to determine due to manufacturers providing limited information about the nature of the stimulation provided, heterogeneity of patients treated, and the rapid evolution of the technology itself.

One of the most commonly used devices is the transcutaneous electrical nerve stimulation (TENS) device. TENS devices use alternating current at a low but palpable level of sensation.

A 2014 meta-analysis indicates that application of appropriately dosed TENS may be helpful for musculoskeletal pain and other acute pain [101]. In addition, a 2015 systematic review of 19 trials concluded that TENS reduced pain intensity in patients with acute pain when compared with placebo [102]. However for patients with chronic pain, a review of data did not find support for the use of TENS due to methodologic limitations of the relevant trials [103].

Interferential current therapy also uses alternating current, but with differing dosage patterns, and one systematic review indicates it may be effective when TENS is not (or vice versa) [104]. Finally, a 2013 Cochrane review showed that electromagnetic field therapy using direct current may provide pain relief for persons with osteoarthritis [105], including knee pain [106,107].

Other devices use electrical stimulation to enhance motor performance (eg, functional electrical stimulation for foot-drop post-stroke) [108], to compensate for sensory deficits to improve balance [109], or to treat conditions such as migraine [110] or incontinence [111]. Treatments may be used in conjunction with a rehabilitation plan that includes other interventions (eg, exercise). The mode of stimulation delivery can include percutaneous and transcutaneous delivery [112]. One randomized trial of transcutaneous tibial nerve stimulation in older women showed long-lasting benefit for urinary incontinence [113], but another did not show benefit among nursing home residents [114]. (See "Acute treatment of migraine in adults", section on 'Neuromodulation' and "Female urinary incontinence: Treatment", section on 'Other specialty treatments'.)

Electric current (iontophoresis) or ultrasound energy (phonophoresis) may be used to force a therapeutic medication (eg, glucocorticoid) into tissues. Both are used to treat soft tissue musculoskeletal injuries. Evidence is limited and indicates that these modalities are generally no more effective than placebo [115,116].

Multiple devices are available that incorporate several types of electrophysical interventions (eg, TENS, interferential current, and/or direct current), as are devices that use electrical stimulation in combination with other types of devices, such as braces [117-119].

Swallowing rehabilitation — Persons with dysphagia may be helped by special feeding techniques (eg, tucking the chin, swallowing a second time after every bite) and/or dietary modifications (eg, use of gelatin to thicken liquids) [120]. A speech language pathologist (speech therapist) can use radiographic and/or endoscopic studies to clarify the nature of the dysphagia and fine-tune recommendations. Treatment of dysphagia may be directed by the speech language pathologist individually or in collaboration with a nutritionist and/or occupational therapist. This is discussed in detail elsewhere. (See "Oropharyngeal dysphagia: Clinical features, diagnosis, and management", section on 'Swallowing rehabilitation and nutrition'.)

SUMMARY AND RECOMMENDATIONS

●Conceptual models of disability – A model from the World Health Organization (WHO) describes disability as determined by an individual’s health condition(s) within the context of environmental and personal factors; rehabilitation services target the impairment as well as personal and environmental contextual factors that influence activity and participation. In another model, disability results from a mismatch between individual capacity and task demands; remediation of disability occurs through treatments that either increase individual capacity or reduce task demand. (See 'Conceptual models for disability' above.)

●Exercise – The physical activity recommendations intended for all older adults may need to be adapted to meet particular needs, using specific types of exercise to correct or ameliorate identified impairments and functional limitations. Physical therapists, exercise physiologists, and physicians specializing in rehabilitation (physiatrists) can help to tailor the exercise prescription to meet particular patient needs. (See 'Exercise' above.)

●Mobility aids – An increasing variety of patient assistive technology aids can improve capacity for activity and/or reduce task demands, but they can be hazardous if not used properly. Physical therapists and occupational therapists can provide prescription guidance as well as fitting and training in use of these devices to enhance functional benefits and safety. Mobility aids (canes, crutches, walkers, wheelchairs) meet different needs (table 3). (See 'Mobility aids' above.)

●Prosthetics and orthotics – Orthoses (ie, splints and braces) are available for virtually every joint in the body including the spine; prefabricated splints and braces are most appropriate for uncomplicated conditions that don’t have substantial deformity. A multidisciplinary team including a physical therapist, prosthetist, and/or physiatrist can provide guidance and fitting as may be needed for more complex devices such as a prosthetic limb. (See 'Prosthetics and orthotics' above.)