family not only to help the patient become oriented, but also to provide important verbal and tactile cues for his safety. The patient should be educated on the hip precautions, but the family should receive this education, too, so frequent reminders to the patient can be given. While this limitation has been addressed, the focus on therapy can be on strength training of the quadriceps and the hip, weight bearing and functional activities, as well as improving ambulation and transfers, to return this patient to his prior level of function. It is unlikely that this patient will return home until the delirium is gone. As previously mentioned, hip replacements can be either cemented or non-cemented. As non-cemented total hip replacements were originally developed to improve the length of time that the prosthesis would stay in place, it is most common Discharge planning The goal of returning a patient to his/her prior level of function (or even a functional level that would allow the patient to return home) is not always possible during an acute stay. In many hospital systems, the medical team will request recommendations from the therapy staff for appropriate discharge settings. There is no standardized recommendation for the most appropriate discharge location; however, there are some important considerations: The primary considerations are the goals of the patients, and - by extension - their families. The prior level of function of the patient is also an important consideration. A patient who was dependent with mobility prior to surgery is unlikely to become mobile and function at a higher level after surgery. It is important to ask the patient what they need to be able to do to go home. Are there stairs? Handrails? Will the patient have assistance, or will he or she be alone? A patient that will have assistance and who is able to walk short distances in the hospital with an assistive device and/or stand by assist may be able to go home directly from the hospital. However, the same patient at the same level of function may need to go to a rehab or skilled unit if there are several stairs to get into the home or if the patient will be going home alone. Each recommendation should be carefully considered; recommending fewer services than the patient needs may increase the risk of a fall upon discharge. Consider the following for how discharge recommendations by the physical therapist can affect the patient in this example: An 86 year old woman has been in the hospital for three days after an ORIF of her right hip. She lives in her family home with her 82 year old sister. There are three stairs with one rail to get into the house. The laundry is in the basement. Prior to this hip fracture, the patient was doing both her own laundry and her sister’s laundry. The patient and her sister took turns cooking. It is the goal of the patient to return home directly from the hospital. She has been walking 150 feet in the hospital with a roller walker with SBA. The patient does well when walking straight, but occasionally is unsteady when turning corners. The patient has been able to self-correct without falls. The patient requires min assist to ascend three stairs with one rail. She has 4-/5 strength in the right knee, 5/5 strength in the right ankle, and 3/5 strength in the right hip. The patient is modified independent with transfers, requiring an elevated seat and handrails on the toilet. Discharge options have been discussed with the patient, and the consensus of the rehab team is to recommend a short inpatient Continuing physical therapy Once the patient leaves the hospital, the patient is not done with physical therapy. Very few- if any - patients attain their prior level of function while in the acute stages of healing. (Patients who were dependent with all mobility prior to hip fracture are the exception.) Ongoing physical therapy will be indicated so that each patient can reach either the prior level of function (or the maximum level of function) after surgery. This ongoing therapy in whatever the setting is- outpatient, home health, inpatient rehab or a skilled nursing unit- will need to progress the program
for a hip replacement in an elderly patient to be cemented, because the prosthesis is not expected to need to remain in place for as long. This type of surgery will allow for immediate weight bearing, and typically the patient complains of less pain. A non-cemented hip, however, will be non-weight bearing for several weeks following the surgery. This can further complicate the rehabilitation process, as gait training is significantly more difficult with non-weight bearing restrictions. As already discussed, the patient is most likely to return to the prior level of function if weight bearing activities are included in the rehabilitation program. When a patient is non-weight bearing, the focus of therapy is on maintaining weight bearing precautions with transfers and gait, and also improving LE strength and balance in a single leg stance. rehab stay to improve high level balance, to reduce risk of falls when turning, and to improve her independence on the stairs. The patient, however, is adamant about going home. With this in mind, what recommendations can the physical therapist make to give this patient the support she needs to be successful at home? This patient will need assistance to get into her house, so she will need to arrange for a friend or family member to help. She will need a roller walker and an elevated toilet seat. She will need to talk to her sister about doing the cooking for the next few days or weeks. She will also need to figure out how to get the laundry done. If her sister is not able to do it, she can arrange for a laundry service to pick up and do her laundry, or hire a home health aide to come in a few hours a week to assist with light cleaning, shopping, laundry and bathing. All equipment needs and arrangements for assistance from friends and family should be arranged prior to discharge from the hospital. With this level of support at home, the only remaining concern is the patient losing her balance when turning corners. Before the patient leaves the hospital, additional education can be provided by the therapist to provide strategies for walker placement to reduce this risk. It should also be recommended that the patient receives either outpatient or home health physical therapy to focus on helping her to return to her prior level of function. Providing a patient with a written home exercise program will also assist her in maintaining the gains she made in the hospital. These specific recommendations should allow for the patient to return home safely. Contrast this example in which the therapist and team educates the patient in the importance of receiving follow up care in an inpatient rehab facility; yet when the patient expresses instead that she is going home, the team allows her to return home but simply states that it is “against medical advice.” The team then provides no other recommendations to her. This patient is much more likely to fall under these circumstances - perhaps as soon as she tries to go up the stairs without help to get into her house. The therapists and physicians may feel as if they have given the patient the best advice, but as it wasn’t followed it didn’t benefit the patient. This illustrates the importance of including the patient in the discharge planning process so the best recommendations for each individual patient are made. already established on acute. Neuromuscular stimulation of the quadriceps should begin within one week after surgery. Strength and weight bearing activities are important to rebuild the hip musculature after surgery. If possible, balance activities should also be incorporated so that if prior level of function included walking without an assistive device, the goal of walking without an assistive device can be attained.
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