1. 
   

   What are the roles of physical and occupational therapy in the inpatient setting?

   
   
2. 
   

   When should I consult a physical or occupational therapist?

   
   
3. 
   

   What is a physiatrist? What role does he or she play in the care of hospitalized patients, and how does it differ from the role of the hospitalist?

   
   
4. 
   

   How can rehabilitation services assist in discharge planning?

Physical therapists (PTs) and occupational therapists (OTs) address the functional needs of patients through mobilization, conditioning, and training in self-care, and other specific tasks. PTs and OTs practice in many settings, including the hospital, clinic, skilled nursing facility (SNF), long-term care facility, freestanding inpatient intensive rehabilitation center, and home. A smaller number also practice in emergency departments in the assessment and treatment of musculoskeletal injury. Less heralded is the role that PTs and OTs play in minimizing specific in-hospital complications, and optimizing successful transitions to outpatient care. Given the growing economic pressures on hospitals, including nonpayment for some nosocomial complications or for rapid readmission to the hospital after discharge (“bounce-backs”), PTs and OTs are not only crucial in helping patients regain functional capacity, but are also vital to the financial well-being of inpatient hospitals. Unfortunately, the scope of practice of PTs and OTs often lies beyond the focus of physicians. Medical education often underemphasizes the role of allied health providers and their contributions to restoring health and function. This chapter attempts to correct this underexposure by delineating the roles and responsibilities of these therapists, and indicating their impact on specific diagnoses commonly encountered by the hospitalist.

Physical therapists have completed four years of postgraduate training, with a focus in musculoskeletal assessment and treating impairments of mobility and safety. Although they most actively provide care for orthopedic and neurosurgical patients, they also clinically assess patients with medical problems such as breathing dysfunction, the need for cardiac rehabilitation, and chronic vertigo. For example, patients with respiratory disease often are readmitted due to exacerbations of their chronic disease. PTs focus on breathing, posture, mobility, range of motion of joints, and strengthening of the respiratory muscles, and they use physical modalities for those patients with musculoskeletal derangements in the thoracic or rib area. On a busy medical service, PTs can guard against the sequelae of long-term hospitalization by improving the patient’s ability to move within a bed, and progress from supine to sitting, sitting to standing, and finally to ambulation. PTs use a review of the medical record, the history provided by the patient and family, and a focused musculoskeletal examination to identify deformities, atrophy, limitations in range of motion (ROM), weakness, and functional impairments that can be addressed with various interventions. They also provide a wide range of tests and measurements.

Hospitalists find PTs helpful in many areas, but may not request their services until the time of discharge, when the therapist is urgently requested to “assess for home safety.” Involving the therapist as early as possible is ideal, since early interventions may decrease the length of hospital stay and increase the likelihood of the patient being discharged directly to home. As well, the patient’s mood, appetite, sense of well-being, and general medical condition may all benefit from increased activity.

PT interventions may be educational, such as teaching a patient how to safely roll in bed to allow nursing care, or they can be more complex, including moving from supine to sitting, evaluating and improving sitting balance, and progressing to standing while monitoring for hemodynamic changes. Once upright, the patient may be able to ambulate, and the therapist can recommend assistive devices such as canes or walkers. For those patients with neurologic or musculoskeletal disorders, new impairments of gait may require further training, and occasionally the use of lower-extremity bracing with orthoses. If the patient is unable to reliably stand or walk or lacks adequate endurance, he or she may need a wheelchair. The power wheelchair and the much-promoted power scooter allow greater mobility, with the loss of the aerobic challenge of self-propulsion. In the United States, Medicare will often cover part of the cost of powered mobility devices in patients who meet certain criteria.

A common concern in patients with neuromuscular dysfunction is the risk of joint contractures. Up to 39% of patients who stay in the intensive care unit (ICU) for longer than two weeks develop at least one joint contracture. A stay of eight weeks in the ICU increases the odds ratio of contracture to 7.09, compared with patients staying two to three weeks. Joint contractures may result in pain, permanent deformity, gait abnormality, and loss of mobility. Contractures also predispose the patient to skin breakdown. Prevention is again best facilitated by early PT consultation. Stretching, strengthening, and protective splints all reduce the likelihood of plantar flexion deformity and other lower-extremity contractures. OTs usually address concerns with the upper extremity, as discussed below.

The PT may help prevent and treat skin injury by ensuring adequate movement to reduce the risk of decubitus ulcers, protect surgical incisions and skin grafts, and reduce discomfort from malpositioning or immobility. The therapist may also instruct the patient about the avoidance of faulty transfer techniques or seating arrangements that may lead to shear injuries to the skin.

Falls, and the fear of falling, contribute to morbidity both in and out of the hospital. In the debilitated elderly, falls may lead to fractures, especially of the hips and forearms, or intracranial pathology, including subdural hematomas. Fear of falls may lead to a downward spiral of immobility and progressive weakness that actually increase the risk of falls. Prevention should begin in the hospital. The PT can assess fall risk using the Berg Balance Scale, and intervene as needed. For some patients, simple reminders and strengthening are adequate protection; for others, an assistive device may suffice. Still others may require intervention in an intensive, interdisciplinary rehabilitation environment. Patients in the latter group usually need evaluation by a physiatrist prior to transfer to in-patient rehabilitation.

The title “occupational therapist” may confuse both patients and other health care professionals. An occupation is defined as a job or profession, but in OT it is defined as a task or activity fulfilled in daily life. OTs focus on restoring patients to their basic self-care, and ideally to independent living. Like the PT, OTs have completed four years of postgraduate training, but with a special focus on assessing, preserving, and restoring upper-extremity strength, function, and ROM. Some undergo additional training to become certified hand therapists. OT interventions include stretching and ROM exercises. Bracing and splinting may be recommended for patients with increased upper-extremity tone from neurologic disease, or scarring from burns that place them at risk for joint contracture. OTs participate in identifying postdischarge needs, and in some hospitals, they perform home-safety evaluations by observing patients in typical tasks done at home, such as cooking a meal. As with physical therapy, the wise clinician will involve OT early in the hospitalization.

The ability to swallow or eat affects nutritional status and also quality of life. Many conditions increase the risk of swallow disorders, which are more common in the elderly (Table 258-1).

As part of the functional assessment of patients at admission, hospitalists should evaluate for the possibility of a dysphagia disorder. Family members may be the first to suspect a problem. Recurrent pneumonias, malnutrition, and social isolation may be important clues that a problem exists (Table 258-2).