What is the scope of practice of physiatry in long-term care?

Scope of Practice of Physiatry in Long-Term Care

Physiatrists in long-term care serve as specialized rehabilitation physicians who assess functional decline, prescribe and oversee rehabilitation interventions, manage medical complications affecting function, and coordinate interdisciplinary care teams to optimize residents' physical function, independence, and quality of life.

Core Clinical Responsibilities

Initial Assessment and Care Planning

• Physiatrists should conduct comprehensive functional assessments as soon as possible after admission to long-term care, evaluating physical status, cognitive status, and functional capabilities 1.
• Assessment should include body composition, aerobic capacity (6-minute walk test), strength (30-second sit-to-stand), flexibility (neck, limb, and spinal range of motion), and balance (single leg balance, timed up-and-go test) 1.
• Results must be used to develop individualized care plans addressing physical, functional, emotional, cognitive, and social needs 1.
• When functional decline is identified during reassessments, physiatrists should update care plans, address safety issues, and initiate referrals to appropriate healthcare professionals 1.

Rehabilitation Service Delivery

Ongoing Rehabilitation Management

• Residents with ongoing rehabilitation goals must have continued access to specialized rehabilitation services including physiotherapy and occupational therapy 1.
• At any point during recovery, residents who experience functional status changes or improvements should be offered trials of active inpatient or outpatient rehabilitation 1.
• Physical rehabilitation interventions reduce disability with few adverse events and do not increase mortality risk (risk ratio 0.95% CI 0.80 to 1.13) 2.

Exercise Prescription

• Physiatrists should prescribe multicomponent exercise programs typically consisting of three 30-45 minute group sessions per week 3.
• For residents with severe fatigue (7-10 on symptom scales), prescribe light exercises while avoiding high-intensity activities 1.
• For fall-risk residents, incorporate core and lower extremity strength, balance, and coordination exercises while avoiding activities requiring significant balance or coordination 1.
• Exercise interventions improve Barthel Index scores by 6 points (95% CI 2 to 11), Functional Independence Measure scores by 5 points, and Rivermead Mobility Index scores by 0.7 points 2.

Medical Management of Rehabilitation Barriers

Infection Recognition and Management

• Physiatrists must recognize that infection often manifests as functional decline rather than fever in long-term care residents 1.
• Suspect infection when residents exhibit new or increasing confusion, incontinence, falling, deteriorating mobility, reduced food intake, or failure to cooperate with rehabilitation 1.
• A single oral temperature ≥100°F (37.8°C) or repeated oral temperatures ≥99°F (37.2°C) indicate possible infection requiring evaluation 1.
• Infection is present in 77% of episodes of functional decline 1.

Stroke-Specific Rehabilitation

• For stroke survivors in long-term care, physiatrists should ensure access to specialized stroke services including physiotherapy, occupational therapy, and speech therapy 1.
• Secondary stroke prevention must be aggressively managed with optimized risk factor reduction strategies 1.
• Residents should be monitored for communication capacity and referred to speech-language services as needed 1.

Interdisciplinary Team Leadership

Team Coordination

• Physiatrists function as leaders of interdisciplinary rehabilitation teams, coordinating care among nursing staff, physical therapists, occupational therapists, speech therapists, and recreation therapists 4.
• The interdisciplinary team-management system is the key to successful physiatric services in long-term care 4.
• Long-term care staff should be educated in stroke care, maintenance and recovery goals, and rehabilitation best practices 1.

Resource Management

• Physiatrists must work within the constraints that long-term care facilities have considerably lower staff-to-resident ratios than acute hospitals (CNAs 1:12, RNs plus LPNs 1:30, RNs 1:120) 1.
• Diagnostic technologies and physician visits are less frequent than in hospitals, requiring physiatrists to rely more on clinical assessment and nursing observations 1.

Specialized Populations

Cancer Rehabilitation

• Physiatrists are uniquely suited to manage cancer patients in long-term care due to their expertise in identifying and treating functional loss 1.
• Exercise should be integrated across the entire cancer continuum to reduce symptom burden and increase independence 1.
• For advanced cancer patients in palliative settings, exercise interventions improve quality of life and reduce cancer-related fatigue, with benefits retained at 6 months 1.
• Physiatrists should assess for cytopenia, active infection, fracture risk, and severe fatigue before prescribing exercise 1.

Pediatric Stroke Survivors

• Infants and children who have experienced stroke require ongoing developmental surveillance throughout their growth, as deficits may not become apparent until different developmental stages 1.
• Developmental screening should include cognitive, motor, social, behavioral, emotional, and physical assessments 1.

Outcomes Focus

Primary Functional Outcomes

• The goal is to maximize functional outcome for physically challenged patients, improving activities of daily living, mobility, and independence 4.
• Rehabilitation interventions improve walking speed by 0.03 m/s and reduce Timed Up and Go test times by 5 seconds 2.
• Physical rehabilitation provides beneficial effects on strength, flexibility, balance, and possibly mood 2.

Quality of Life and Psychosocial Management

• Physiatrists should screen residents for cognitive concerns, mental health issues including depression, and psychosocial problems 1.
• Residents should have access to recreation therapy, leisure opportunities, and exercise programs 1.
• Psychosocial and support needs should be reviewed regularly to minimize caregiver distress 1.

Common Pitfalls and Challenges

Implementation Barriers

• Time constraints, inadequate staffing, cost limitations, and lack of organizational support are major barriers to implementing evidence-based rehabilitation 1.
• Administrative barriers often limit implementation of integrated care models 5.
• Guideline implementation is challenged by workforce knowledge gaps and clinical workflow issues 5.

Clinical Considerations

• Not all residents can tolerate higher-than-normal therapy levels, and some may not benefit if they don't belong to subsets for whom benefit has been demonstrated 1.
• Most interventions last less than 20 weeks, and only 12 trials have conducted post-intervention follow-up (maximum one year), indicating uncertainty about sustainability 3.
• There is insufficient evidence about which specific interventions are most appropriate, cost-effectiveness, or improvement sustainability 3, 2.

Patient and Family Engagement

Education and Advocacy

• Families and caregivers should be involved in decision-making and treatment planning as early as possible and throughout rehabilitation 1.
• Patients and families should receive training on advocating for active participation in care planning and shared decision-making 1.
• Physiatrists should maintain up-to-date information on community resources and provide assistance in obtaining needed services 1.

Advance Care Planning

• Provide patients and families with information and counseling on appointing alternate decision makers, developing advance directives, and palliative care options 1.