James H. Rimmer, Ph.D., Director

This past decade has been very tough on physical therapists (PTs) and occupational therapists (OTs). Managed care, or as some call it, managed competition, has severely truncated the amount of time that PTs and OTs have available to rehabilitate people with injuries and disabilities in hope of getting them to a point where they can function independently or semi-independently when they return home. To the dismay of many therapists, patients are often discharged prematurely, leaving them ill-prepared to handle new and challenging environmental obstacles.

This weighs heavily on the hearts and minds of PTs and OTs, who during their school years take "vows" to serve people with disabilities to the best of their ability, but quickly learn upon entering the workforce that they are actually serving the myriad insurance companies who dictate the amount of rehabilitation that a person will receive after incurring an injury or disability. Upon discharge from rehabilitation, the patient and caregiver are often left with many unanswered questions: Who can I turn to if I injure myself performing a transfer? How can I avoid an upper-respiratory or urinary tract infection? Will I be able to recognize an early-stage pressure ulcer? What kind of exercises should I do to reduce shoulder pain?

An article in New Mobility magazine last fall noted that in 1974 the average time a person spent in rehab after sustaining a spinal cord injury was 127 days. Today that number is closer to 50. The early return home often results in a spiraling decline in health, evidenced by increased social isolation, sedentary behavior, weight gain, and loss of function. Dr. David Chen of the Rehabilitation Institute of Chicago asks: "When you take patients who are physically and emotionally unprepared and move them through the rehab system like widgets on a conveyor belt, how much can they be expected to achieve?"

The therapists' role in getting the individual to transition from rehabilitation back into community life has diminished. An acute injury, such as a spinal cord or head injury, stroke, amputation, etc., leaves the newly injured person with a formidable list of tasks that must be accomplished before reentering the home setting. With hardly enough time to teach vital skills essential for survival, the therapist is left with little or no time to discuss the importance of improving one's health through proper nutrition, exercise, and general health maintenance. Who will inform the person that there is a local gym two blocks from home that is ADA-accessible, offers discounted memberships, contains a few pieces of accessible exercise equipment, and has a warm-water pool?

While the therapist focuses on vital skills necessary for compensating a new injury, secondary condition or disability, no one is advising the client that life after rehab begins with a membership at the local fitness center. Offering people with disabilities and chronic health conditions the opportunity to enroll in a community fitness program is vital to maintaining the improvements attained during rehab, and allows the person to transition into a self-directed and empowering physical activity program. Reimbursing a few sessions of rehab without a fitness membership is like paying for the surgical procedure but charging the patient for the recovery room expenses! Rehab can take a long time, and improvements are often measured in months rather than days. Participating in lifetime physical activity has the potential to reverse the cycle of deconditioning and keep the person out of the hospital.

We must begin to close the gap between rehabilitation and lifetime physical activity. Everyone needs movement and lots of it. HMOs, Medicare, and Medicaid must provide subsidized fitness memberships to people with disabilities and chronic health conditions so that there is a seamless transition from rehab to wellness. This service should include on-site instruction in using various kinds of exercise equipment, accessing the pool and locker room, and participating in group exercise classes and other health-promoting activities. The client, therapist, and fitness instructor should work together to ensure the safest and most effective program possible. Some of the larger HMOs are starting to offer subsidized fitness memberships, but we still have a long way before every private and government-sponsored health insurance plan provides this benefit to its members.

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