doi: 10.2522/ptj.20130087Originally published online September 12, 2013

2014; 94:40-51.PHYS THER. and Allison K. PayneBarbara Resnick, Chris L. Wells, Becky A. Brotemarkleand Factors That Influence Provision of TherapyExposure to Therapy of Older Patients With Trauma

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Exposure to Therapy of Older PatientsWith Trauma and Factors ThatInfluence Provision of TherapyBarbara Resnick, Chris L. Wells, Becky A. Brotemarkle, Allison K. Payne

Background. Rehabilitation as soon as possible after trauma decreases sedentarybehavior, deconditioning, length of stay, and risk of rehospitalization.

Objective. The study objectives were to describe exposure of older patients withtrauma to rehabilitation and to explore factors associated with the number andinitiation of therapy sessions.

Design. This was a retrospective study of data from electronic medical records.

Methods. Randomly selected older patients with trauma were described withregard to demographics, trauma diagnoses, comorbidities, preadmission function,and exposure to therapy. Regression analyses explored factors associated with num-ber of therapy sessions and days until therapy was ordered and completed.

Results. Records for 137 patients were randomly selected from records for 1,387eligible patients who had trauma and were admitted over a 2-year period to a level Itrauma center. The 137 patients received 303 therapy sessions. The sample included63 men (46%) and 74 women (54%) who were 78 (SD�10) years of age; most patientswere white (n�115 [84%]). All patients had orders for therapy, although 3 patients(2%) were never seen. An increase in comorbidities was associated with an increasein therapy sessions, a decrease in the number of days until an order was written, butan increase in the number of days from admission to evaluation. Injury severity wasassociated with a decrease in the number of days from admission to an order beingwritten. A postponed or canceled therapy session was associated with increases inthe number of days from admission to evaluation and in the number of days from anorder being written to evaluation.

Limitations. This study was a retrospective review of a small sample with sub-jective measures and several dichotomous variables.

Conclusions. Increased injury severity, increased numbers of comorbidities, andpostponed or canceled therapy sessions were associated with decreased time fromadmission to therapy orders, increased time from admission and orders to evaluation,and increased number of therapy sessions.

B. Resnick, PhD, CRNP, FAAN,FAANP, University of MarylandSchool of Nursing, 655 W Lom-bard St, Baltimore, MD 21201(USA). Address all correspondenceto Dr Resnick at: resnick@son.umaryland.edu.

C.L. Wells, PT, PhD, Departmentof Physical Therapy and Rehabili-tation Science, University of Mary-land School of Medicine, Balti-more, Maryland, and Departmentof Rehabilitation Services, Univer-sity of Maryland Medical Center,Baltimore, Maryland.

B.A. Brotemarkle, PhD, RN, Uni-versity of Maryland School ofNursing.

A.K. Payne, BSN, University ofMaryland School of Nursing.

[Resnick B, Wells CL, BrotemarkleBA, Payne AK. Exposure to therapyof older people with trauma andfactors that influence provision oftherapy. Phys Ther. 2014;94:40–51.]

© 2014 American Physical TherapyAssociation

Published Ahead of Print:September 12, 2013

Accepted: September 3, 2013Submitted: March 8, 2013

Research Report

Post a Rapid Response tothis article at:ptjournal.apta.org

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Older adults (65 years of ageand older) currently accountfor 25% of hospitalized

patients with trauma. This rate isanticipated to increase, so that by2050, approximately 40% of allpatients with trauma will be olderadults.1 Falls are the leading causeof trauma in these patients; othercauses are motor vehicle accidents,pedestrian–motor vehicle accidents,assault, and environmental injuries(eg, hyperthermia).1 Compared withyounger adults, older adults withtrauma have higher mortality rates,longer hospital stays, and increasedlong-term morbidity, regardless ofinjury severity.2,3 Older patients withtrauma are less likely to achieve fullrecovery and more likely to havecomplications than their youngercounterparts.1,4 They are also morelikely to develop infections or pres-sure ulcers and to fall when hospital-ized and to require unscheduledrehospitalization after discharge.5–10

Older adults who experience traumagenerally have multiple comorbidi-ties and decreased physiologicreserve because of normal changeswith age.11 When older adults areexposed to acute-care environ-ments with medical and nursing pol-icies and interventions that restrictmovement, a decline in physicalactivity and function unintentionallyoccurs.4,12–21 During hospital admis-sion, older patients with traumaexperience a decline of at least 1activity of daily living, and one-thirdwill be discharged to nursing homesand have a greater likelihood of mor-tality within 5 years than matchedcontrols.3,20 Functional decline isassociated with higher mortality rates;longer stays; and greater resourceconsumption, likelihood of dis-charge to nursing homes,22–28 riskof adverse events (eg, infections,8

pressure ulcers,9,29 and falls10), andlikelihood of rehospitalization.5,30

Although results vary,16,31 olderpatients who are hospitalized tendto spend very little time in physicalactivity (any activity that uses moreenergy than resting).3,4,12,13,31–33 Ear-lier research showed that, overall,older patients spend 83% of theirtime in bed14 and take only 739.70(range�89–1,014) steps per daywhile hospitalized.33 This level ofactivity is in contrast to daily recom-mendations of at least 3,000 steps (ata moderate pace of 100 steps/min-ute) over and above routine dailyactivity. This level of activity isneeded to achieve important healthbenefits (eg, improved bone densityand decreases in cardiovascular riskfactors).34 The lack of physical activ-ity noted during stays in acute-carefacilities is a primary contributor tofunctional decline.3,12,14,35,36

In addition to bed rest, patient fac-tors, acute care environments, andmedical and nursing interventionsare all associated with functionaldecline.14–21,37 Patient factors includeage, sociodemographic characteris-tics, pre-existing disability and dis-ease states, dementia, anemia, pain,fear of falling, depression, motiva-tion, nutritional status, hydration,sedation, and polypharmacy.20,38

Acute care environment factorsinclude a lack of accessible chairs forpatients, beds that do not facilitatesafe and efficient transfers, medicalequipment that limits mobility, anda lack of patient-friendly walkingareas. Finally, there are policies thatdiscourage walking, transportationpolicies that encourage the use ofwheelchairs, furniture alarms thatdiscourage movement, and posi-tional devices and restraints.38,39

Interventions such as rehabilitation(eg, physical therapy) or walkingand exercise programs initiated assoon as possible after an acute illnessor traumatic event have been testedas ways to increase physical activityand prevent deconditioning and func-

tional decline.37,40–46 Earlier findingssupported the safety of these inter-ventions and demonstrated thatthese interventions maintain func-tional ambulation, prevent decline inactivities of daily living, and decreasethe likelihood of rehospitalizationafter discharge.42,44,45,47–50 In addi-tion, a recent systematic review andmeta-analysis of 10 studies examin-ing the impact of early physical ther-apy for patients who were criticallyill and receiving intensive care con-cluded that exposure to physicaltherapy resulted in small but signifi-cant improvements in function andquality of life and a decrease in over-all hospital length of stay.36

However, older patients who arehospitalized do not always receiverehabilitation services in a timelyfashion (ie, within 24 hours). Thisdelay is due to factors such as alloca-tion of therapy resources; staffing;time wasted on evaluations ofinappropriate referrals; beliefs ofpatients, families, and health careproviders that do not necessarilyvalue therapy or physical activity;and persistent beliefs that rest andrestriction of physical activity willfacilitate recovery and preventfalls.5,51–54 Orthopedic surgeons, par-ticularly those new to practice andthose who have practiced for morethan 20 years, do not believe in thevalue of physical therapy and, there-fore, are less likely to order ther-apy.55 In addition, patients may refuseto participate in therapy when it isoffered (a motivational factor).5,53,56–58

Despite challenges to actual expo-sure to therapy, evidence suggeststhat inpatient therapy, particularlyphysical therapy, is beneficial forolder adults who are hospitalized.However, work describing the time-liness of exposure to therapy ofthese adults and the amount of ther-apy provided during the inpatientstay is limited. Given the growingnumber of older adults experiencing

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traumatic events, it is important toconsider their exposure to therapyso as to optimize their recovery pro-cess and limit the long-term cost ofcare due to a decline in function.Therefore, the 5 purposes of thisstudy were:

1. To describe the exposure of olderpatients with trauma to therapyduring their inpatient acute-carestay at a level I trauma center

2. To explore the association ofdemographic factors (age, sex,and race), diagnosis and severityof trauma at admission, comor-bidities, and function beforeadmission (being independentversus not being independent)with the number of treatmentsessions received by olderpatients with trauma (controllingfor length of stay and sessionspostponed or canceled for medi-cal reasons)

3. To explore the association ofdemographic factors (age, sex,and race), diagnosis and severityof trauma at admission, comor-bidities, and functional indepen-dence before admission with thenumber of days from admissionuntil therapy was ordered

4. To explore the association ofdemographic factors (age, sex,and race), diagnosis and severityof trauma at admission, comor-bidities, functional independencebefore admission, and whetheror not therapy was postponed orcanceled with the number of daysfrom admission to the therapyevaluation (controlling for lengthof stay)

5. To explore the association ofdemographic factors (age, sex,and race), diagnosis and severityof trauma at admission, comor-bidities, functional independencebefore admission, and whether or

not therapy was canceled or post-poned with the number of daysfrom a therapy order being writ-ten to the initial evaluation (con-trolling for length of stay).

The findings from this study willhelp identify barriers to exposure totherapy and guide the developmentof resolutions for these barriers soas to optimize the recovery of olderadults after trauma.

MethodDesignThis was a retrospective study withdata obtained from electronic medi-cal records containing physical ther-apist, occupational therapist, andspeech-language pathologist notesafter a level I trauma center admis-sion. The trauma center follows theMaryland Institute for EmergencyMedical Services Systems (MIEMSS)criteria and the American College ofSurgeons Committee “Gold Book” toallocate resources,59 is a teachingfacility, and consistently maintainedstaffing ratios and retention ratesduring the 2-year testing period asfollows: 1 nurse to 3 or 4 patients;less than 10% turnover of nursingstaff annually; 12 beds per physicaltherapist; 24 beds per occupationaltherapist; and 50 to 55 beds perspeech-language pathologist. Theaverage yearly trauma admissions forall patients in this facility is approx-imately 1,400, and a total of 1,387older patients with trauma wereadmitted during the study period(September 2009–September 2011).

SampleThe sample was randomly selectedfrom the list of 1,387 eligible olderpatients who had trauma and wereadmitted over the 2-year studyperiod. To be eligible, patients hadto be 65 years of age or older andadmitted for trauma. Patients admit-ted to the trauma unit includedthose with any of the followingICD-9 codes: 805 to 809—fracture of

spine, trunk; 810 to 819—fracture ofupper limb; 820 to 829—fracture oflower limb; 830 to 839—disloca-tion; 840 to 848—sprains and strainsof joints/muscles; 860 to 869—inter-nal injury of chest, abdomen, pelvis;870 to 879—open wound of head,neck, trunk; 880 to 887—openwound of upper limb; 890 to 897—open wound of lower limb; 900 to904—injury to blood vessels; 925 to929—crushing injury; 940 to 949—burns; and 950 to 957—injury tonerves and spinal column. A total of137 patients were randomly selectedand evaluated. Random selectionwas done by random ordering ofpatients in an Excel (Microsoft Corp,Redmond, Washington) file and pro-viding the 2 research nurses with alist of records to evaluate.

Data Collection and MeasuresThe charts were abstracted from theelectronic medical records by theresearch nurses. The data collectorswere not involved in the direct careof the patients, and all data wereobtained from the initial and subse-quent therapy evaluations and treat-ment sessions in the electronicrecords. Descriptive patient dataincluded age, sex, and race. Comor-bidities were determined by count-ing the number of diagnoses60,61

recorded in the initial therapy evalu-ation. Therapists obtained this infor-mation from the patients’ medicalrecords. The trauma admission diag-nosis, which was also obtained fromthe patients’ medical records duringthe initial therapy evaluation, wascategorized as sustaining either atraumatic brain injury or musculo-skeletal trauma. In addition, the pre-admission level of assistance (inde-pendent or not independent withregard to ambulation and activitiesof daily living) was obtained fromthe initial intake history. This infor-mation was obtained by the thera-pists from patients, family members,or other caregivers.

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Postponed or canceled therapy ses-sions also were noted, and the rea-sons for postponement or cancella-tion were documented on the basisof options in the electronic medicalrecords. These options includednurse/physician request; patient refus-al; patient unavailable; patient unsta-ble; patient in surgery; patient pend-ing or undergoing a procedure;patient inappropriate due to seda-tion, pain, agitation, or intubation;or other (write in). For the purposesof analyses, postponed or canceledtherapy was dichotomized to apatient having or not having a ses-sion postponed or canceled.

Injury severity was determined onthe basis of the number of injuries orreasons for admission and physiolog-ical factors (evidence of shock orcoma)62 at the time of admission,as recorded in the medical records.Injury severity was coded as beingeither severe (which involved havingmore than 1 trauma diagnosis andhaving a diagnosis of shock or a headinjury with coma) or mild/moderate(if there was only 1 trauma diagnosisand there was no diagnosis of shockor coma).62

To describe patient exposure totherapy, we obtained the followinginformation:

1. Day of the week (eg, Monday,Tuesday, Wednesday) on whichphysical therapist, occupationaltherapist, and speech-languagepathologist orders were written

2. Day of the week on which thepatient was first evaluated by 1 ofthe therapists

3. Length of time (in number ofdays) between admission of thepatient and an order for therapybeing written

4. Length of time (in number ofdays) between an order beingwritten and the first therapy eval-uation (physical therapist, occu-pational therapist, or speech-language pathologist)

5. Length of time (in minutes) ofeach therapy session

In addition, for descriptive purposes,we considered discharge recom-mendations from the therapists

(occupational therapist and physicaltherapist) and whether the recom-mendations matched the final dispo-sition of the patients on the basisof the therapists’ documentation atthe time of discharge (home, acuteor subacute rehabilitation, or long-term care facility).

Data AnalysisSPSS 20.0 (SPSS Inc, Chicago, Illi-nois) was used for all analyses. Inaddition to descriptive analyses ofmajor study outcomes, 4 stepwiseregression analyses were performed.As shown in Table 1, in model 1(controlling for length of stay andwhether or not the patient had apostponed or canceled session), thefollowing variables were regressedon total number of therapy sessions(occupational therapist, physicaltherapist, and speech-languagepathologist): demographic factors(age, sex, and race), severity oftrauma at admission, diagnosis atadmission, number of comorbidities,and independence before admission.In model 2, demographic factors(age, sex, and race), severity oftrauma at admission, diagnosis atadmission, number of comorbidities,

Table 1.Regression Analyses for Models 1 Through 4

Variable

Model 1: Total TherapySessions

Model 2: Days FromAdmission to Order

for Therapy

Model 3: Days FromAdmission to

Therapy Evaluation

Model 4: Days FromOrder to Therapy

Evaluation

� t b (SE) � t b (SE) � t b (SE) � t b (SE)

Length of staya .34 4.22c .13 (.03) .43 5.85c .14 (.02) .67 11.38c .29 (.15)

Postponed or canceled sessionsb .08 0.98 .28 3.96c .82 (.21) .25 4.24c .95 (.22)

Age .06 0.73 �.10 �1.31 .04 0.54 .08 1.26

Sex �.03 �0.40 .02 0.30 .04 0.56 .07 1.19

Race �.05 �0.60 �.07 �0.89 .02 0.25 .01 0.01

Injury severity .06 0.77 �.27 �3.41c �.93 (.27) .09 1.14 .11 1.79

Admission diagnosis (fracture ortraumatic brain injury)

.02 0.28 .10 1.37 .09 1.28 �.01 �0.03

Comorbidities .22 2.73c .16 (.06) �.21 �2.61c �.17 (.07) .20 2.69c .13 (.05) .08 1.37

Preadmission function .01 0.12 .04 0.44 .01 0.11 .02 0.28 .78

a Controlled for in models 1, 3, and 4.b Controlled for in model 1.c P was significant at less than .05.

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and independence before admissionwere regressed on number of daysfrom admission until therapy wasordered. In model 3 (controlling forlength of stay), postponed or can-celed sessions, demographic factors(age, sex, and race), severity oftrauma at admission, diagnosis atadmission, number of comorbidities,and independence before admissionwere regressed on number of daysfrom admission until the first evalua-tion was completed. Finally, inmodel 4 (controlling for length ofstay), postponed or canceled ses-sions, demographic factors (age,

sex, and race), severity of traumaat admission, diagnosis at admission,number of comorbidities, and inde-pendence before admission wereregressed on number of days fromthe order for therapy being writtenuntil the first evaluation was done.

After forced entry of control vari-ables in models 1, 3, and 4, a step-wise analysis approach was used,and criteria were set at an entry levelof .05 and a removal level of .10.Analysis of variance was used to con-sider whether there were differencesin the number of days until therapy

was ordered or until the patient wasevaluated after being admitted. Asignificance level of less than .05 wasused for all analyses. Age, numberof comorbidities, and length of staywere not normally distributed andwere corrected for normality byuse of a log10 transformation. Threepatients in whom the admitting diag-nosis was neither a musculoskeletalevent nor a traumatic brain injurywere excluded from the regressionanalyses. A sample size of 134 (137minus the 3 patients who wereexcluded from the regression analy-ses) was considered sufficient toensure a reliable model with a 10:1ratio of patients63 to variable.

ResultsRecords from 137 patients were ran-domly selected and evaluated; these137 patients received 303 therapysessions (initial evaluations andsubsequent therapy sessions). Asshown in Table 2, the sample wasrelatively evenly split between menand women, with 63 men (46%) and74 women (54%). Most patientswere white (n�115 [84%]), and theremaining were black and “other”(n�22 [16%]), with “other” includ-ing Asian, Hispanic, and AmericanIndian. The average age was 78(SD�10) years, with a range of 65to 92 years. Overall, the patientshad 2 (SD�2) comorbidities, with36 (26%) having no comorbid condi-tions, 18 (13%) having 1 comorbidcondition, 18 (13%) having 2 comor-bidities, 29 (21%) having 3 comor-bidities, and 21 (15%) having 4comorbidities. The remaining 15patients (�12%) had 5 or morecomorbidities.

As shown in Table 3, the most com-mon comorbid conditions includedcardiac disease (eg, valvular disor-ders, muscle damage), hypertension,atrial fibrillation, hyperlipidemia,hypothyroidism, cancer, dementiaand other psychiatric disorders, andchronic obstructive pulmonary dis-

Table 2.Description of the Sample

Characteristic Valuea

Sex

Men 63 (46)

Women 74 (54)

Race

Black and other 22 (16)

White 115 (84)

Function before admission

Independent 58 (42)

Not independent (needs help with activities of daily living or ambulation) 79 (58)

Reason for admission

Musculoskeletal injury 81 (59)

Traumatic brain injury 53 (39)

Other 3 (2)

Injury severity

Mild/moderate 48 (35)

Severe 89 (65)

No. of comorbidities

0 36 (26)

1 18 (13)

2 18 (13)

3 29 (21)

4 21 (15)

�5 15 (�12)

Descriptive variables, X (SD)

Age 78 (10)

No. of comorbidities, total mean 2 (1)

Length of stay 4 (3)

a Values are reported as number (percentage) of patients unless otherwise indicated.

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ease. Other comorbidities, such asgout, osteoporosis, sinusitis, obesity,and sleep apnea, were documentedin a few patients. For slightly morethan one half of the patients (n�81[59%]), the traumatic event resultedin a fracture, 53 patients (39%) wereadmitted for a traumatic brain injury,and the remaining 3 patients (2%)were admitted for a syncopal event,a burn, and a laceration.

All of the patients had orders to beseen by a physical therapist, an occu-pational therapist, a speech-languagepathologist, or some combination ofthese therapists, although 3 patients(2%) were never seen by a physicaltherapist, an occupational therapist,or a speech-language pathologist. Asshown in the Figure, 28 patients(20%) were seen by a physical ther-apist, an occupational therapist, or aspeech-language pathologist but notmultiple therapists, and 25 (18%)were seen by all 3 therapists. Ninety-five patients (69%) were seen byboth an occupational therapist and aphysical therapist, 4 patients (3%)were seen by a physical therapistand a speech-language pathologist, 1patient (1%) was seen by an occupa-tional therapist and a speech-language pathologist, and 1 patient(1%) was seen by a speech-languagepathologist only.

A total of 20 (17%) of the initial121 physical therapist sessionswere postponed or canceled, mainlybecause the patient was described asunstable, was in the operating room,or was undergoing a procedure (13cases, or 65% of the missed sessions).For the remaining 7 patients, thereason for postponing or canceling atreatment was inappropriate selec-tion of the patients (7 cases, or 35%of the missed sessions).

With regard to occupational thera-pist evaluations, 16 (15%) of the 104initial occupational therapist evalua-tions were either postponed or can-

celed, mainly because the patientwas unavailable, was described asunstable, or was in the operatingroom (8 cases, or 50% of the post-poned or canceled sessions); thenurse or physician requested thatthe postponement occur (4 cases, or25% of the postponed or canceledsessions); the patient refused to par-ticipate (3 cases, or 19% of the post-poned or canceled sessions); or thepatient was inappropriately selectedfor therapy because of pain (1 case,

or 6% of the postponed or canceledsessions). Physical therapists andoccupational therapists usually didnot indicate in the electronic medi-cal records why a patient wasdeemed to be unstable or why aselection was inappropriate. Only 1of 31 speech-language pathologistsessions (3%) was postponed; thispostponement occurred because thepatient was unavailable.

Table 3.Comorbidities of Patients

DiagnosisNo. (% of PatientsWith Comorbidity)

Hypertension 86 (63)

Cardiac disease (valvular disease, tissue damage) 44 (32)

Hyperlipidemia 36 (24)

Atrial fibrillation 32 (23)

Cognitive impairment (multiple infarcts/Alzheimer disease) 30 (22)

Diabetes 25 (18)

Hypothyroid disease 22 (16)

Chronic obstructive pulmonary disease 21 (15)

Cancer 20 (15)

Degenerative joint disease 18 (13)

Psychiatric disorders (eg, depression, anxiety, schizophrenia) 18 (13)

Kidney disease 17 (12)

Congestive heart failure 16 (12)

Stroke 16 (12)

Gastroesophageal reflux disease 15 (11)

Eye/visual disorders (glaucoma, cataracts, macular degeneration) 8 (6)

Anemia 8 (6)

Substance abuse 8 (6)

Seizure disorder 7 (5)

Gout 6 (4)

Obesity 5 (4)

Sleep apnea 5 (4)

Osteoporosis 5 (4)

Asthma 4 (3)

Rheumatoid arthritis 2 (1)

Bell palsy 2 (1)

Sinusitis 2 (1)

Diverticulosis 1 (1)

Sickle cell disease 1 (1)

Peripheral neuropathy 1 (1)

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Table 4 shows the findings regardingthe number of days from admissionto an order being written, the num-ber of days from an order being writ-ten to the evaluation, and the num-ber of days from admission to theevaluation for each of the therapies.Overall, less than 1 day transpiredfrom admission to an order for ther-

apy being written (X�0.67, SD�1.63,range�0–17). About 1.5 days passedfrom an order being written to thepatient being evaluated (X�1.56days, SD�1.67, range�0–10). Thenumber of days from admission tothe initial evaluation was also lessthan 2 (X�1.84, SD�1.32, range�0–6).

Most of the orders for therapy werewritten on the day of admission (139[54%]), 81 (32%) were written 1 dayafter admission, 19 (7%) were done 2days after admission, and the remain-ing 10 (4%) were written 3 to 17 daysafter admission. Sixty-one (24%) ofthe evaluations were done on theday on which the order was written,78 (30%) were done 1 day after theorder was written, 64 (25%) werecompleted 2 days after the order waswritten, 29 (11%) were done 3 daysafter the order was written, 10 (4%)were done 4 days after the order waswritten, 4 (2%) were done 5 daysafter the order was written, 6 (2%)were done 6 days after the orderwas written, and 2 (1%) were com-pleted 10 or more days after theorder was written.

There were no differences betweenthe day of the week on which thepatient was admitted and either thenumber of days until an order waswritten for treatment by a physicaltherapist (F�.48; df�6,101; P�.82),an occupational therapist (F�1.12;df�6,102; P�.35), or a speech-language pathologist (F�0.84;df�6,26; P�.56) or the number ofdays between admission of thepatient and evaluation of the patientby a physical therapist (F�0.96;df�6,101; P�.73), an occupationaltherapist (F�1.42; df�6,102;P�.21), or a speech-language pathol-ogist (F�1.31; df�6,26; P�.29).There were no differences betweenadmission of the patient and thenumber of days from an order beingwritten to the initial evaluation ofthe patient by a physical therapist(F�1.91; df�6,102; P�.08) oran occupational therapist (F�1.54;df�6,102; P�.17). However, therewas a significant difference in thenumber of days from an order beingwritten to the completion of aspeech-language pathologist evalua-tion (F�3.01; df�6,26; P�.03). For aspeech-language pathologist, whenan order was written on a Saturday

Figure.Number of sessions of physical therapy (PT), occupational therapy (OT), and speech-language pathologist therapy (ST) patients received.

Table 4.Mean Number of Days From Admission to Therapy Order and Evaluation and MeanNumber of Days From Order to Evaluation

Time Frame Minimum Maximum X SD

All therapy sessions

Days from admission to evaluation 0 6 1 1.3

Days from admission to order 0 17 1 1.6

Days from order to evaluation 0 10 2 1.7

Physical therapy sessions

Days from admission to evaluation 0 6 2 1.3

Days from admission to order 0 17 1 1.7

Days from order to evaluation 0 10 2 1.6

Speech-language therapy sessions

Days from admission to evaluation 0 6 2 1.6

Days from admission to order 0 5 1 1.2

Days from order to evaluation 0 3 1 0.9

Occupational therapy sessions

Days from admission to evaluation 0 5 2 1.3

Days from admission to order 0 7 1 1.2

Days from order to evaluation 0 6 2 1.4

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or a Sunday, more days transpireduntil the patient was evaluated.

Initial evaluations were completedfor a total of 131 patients (95%); theaverage times per evaluation were55 (SD�29) minutes for physicaltherapists, 62 (SD�60) minutes foroccupational therapists, and 32(SD�22) minutes for speech-language pathologists (Tab. 5).There were 32 additional physicaltherapist sessions, with patientsbeing exposed to an average of 1(SD�0.6) physical therapist session;13 additional occupational therapistsessions, with patients being exposedto an average of 1 (SD�0.4) occupa-tional therapist session; and 7 addi-tional speech-language pathologistsessions, with patients being exposedto an average of 1 (SD�0.01) speech-language pathologist session. Treat-ment times were similar across allphysical therapist and occupationaltherapist sessions, with averagetimes of 55 (SD�25) minutes forphysical therapists and 61 (SD�25)minutes for occupational therapists.Speech-language pathologist sessionsduring the subsequent visits wereshorter, averaging 20 (SD�14)minutes.

The results of the regression analysesare shown in Table 1. In model 1,controlling for length of stay andpostponed or canceled sessions, theonly factors to significantly enter themodel to explain the number of ther-apy sessions received were comor-bidities (��.20, t�2.69, P�.008).Comorbidities explained an addi-tional 4% of the variance (F change�7.45; df�2,134; P�.007) in the num-ber of sessions received beyond theeffects of length of stay, whichexplained 16% of the variance in thenumber of sessions received(F�26.39; df�9,128; P�.001). Withevery increase in the number ofcomorbidities, there was an increaseof 0.16 in the number of treatmentsessions provided.

In model 2 testing, injury severityand comorbidities were the onlyvariables to enter the model toexplain the variance in the numberof days from admission to an orderbeing written for treatment by anoccupational therapist, a physicaltherapist, or a speech-languagepathologist. Specifically, injuryseverity accounted for an additional9% (F change�15.54; df�8,135;P�.001) of the variance (���.27,t��3.41, P�.001), and comorbidi-ties accounted for an additional 4%(F change�6.83; df�8,135; P�.001)of the variance (���.21, t��2.61,P�.01). More severe injuriesresulted in therapy being orderedalmost a full day sooner than lesssevere injuries. With every increasein the number of comorbidities,there was a decrease of 0.17 in thenumber of days until therapy wasordered.

Model 3 explored the factors thatinfluenced the number of days fromadmission to therapy evaluation.When we controlled for length ofstay, we found, as expected, thatpostponed or canceled sessionswere significantly associated withthe number of days from admissionto therapy evaluation (��.28,t�3.96, P�.02) and explained anadditional 7% of the variance(F�14.23; df�8,135; P�.001). Withevery increase in the number of post-poned or canceled sessions, there

was an increase of 0.28 day fromadmission until the first therapy eval-uation was done. Comorbidities(��.20, t�2.69, P�.008) alsoentered the model to explain thenumber of days between the day ofadmission and the day on which thefirst therapy evaluation was com-pleted. Comorbidities explained anadditional 4% (F change�7.23;df�8,135; P�.008) of the variancein the number of days from admis-sion to completion of an evaluationby a therapist. With every increase inthe number of comorbidities, therewas an increase of 0.13 day until anevaluation was done.

Finally, model 4 explored the factorsthat influenced the number of daysfrom an order for therapy being writ-ten until the evaluation was com-pleted. When we controlled forlength of stay, we found that post-poned or canceled therapy sessionswere the only factors to influencethe number of days from the orderbeing written to the evaluation(��.24, t�4.24, P�.001) andexplained an additional 6% (Fchange�18.04; df�8,130; P�.001)of the variance in the number of daysthat transpired. When therapy waspostponed or canceled, there was anincrease of almost 1 full day (0.95day) from an order for therapy tocompletion of the evaluation.

Table 5.Length of Therapy Sessions (Minutes)

Therapy Session (n) Minimum Maximum X SD

Initial evaluations

Physical therapy (120) 0 130 55 29

Occupational therapy (104) 0 381 62 60

Speech-language pathologist therapy (27) 0 77 32 22

Subsequent therapy sessions

Physical therapy (32) 9 96 55 25

Occupational therapy (13) 11 98 61 25

Speech-language pathologist therapy (7) 10 50 20 14

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The average length of stay forpatients was 4 (SD�4.0) days, with arange of 1 to 26 days. Most patients(n�73 [53%]) were discharged toeither rehabilitation settings orlong-term care facilities; 58 (42%)were discharged to home; for 3patients, the discharge location wasunknown; 2 patients expired; and 1patient left against medical orders.Generally, there was a matchbetween the therapists’ recommen-dations and the patients’ dischargelocations (matches for 127 patients[93%]). The discharge locationswere divergent from the therapists’recommendations for 3 patients(2%). In 2 of these cases, the recom-mendation was that the patient betransferred to a skilled facility, butthe patient went home; in the thirdcase, the recommendation was thatthe patient go home, but the patientwas placed in a skilled nursing facil-ity on the basis of the preferences ofthe caregiver. In 7 cases (5%), therewere no stated recommendations bythe therapists.

DiscussionThis article describes exposure totherapy of older adults who haveexperienced a traumatic event.Although 98% of the patients whoserecords were examined in the pres-ent study were exposed to therapy,the overall nontreatment rates(which were 15% for occupationaltherapists and 17% for physical ther-apists) were on the lower side ofthe 15% to 26% nontreatment ratesreported previously for rehabilita-tion services for patients in acutecare settings.51,64 The lower non-treatment rates in the present studymay have occurred because thepatients whose records were studiedwere all older patients with trauma,and it was assumed that therapywould be needed.

However, our findings did not sup-port earlier research64 indicating arelationship between the day of the

week on which an order was writtenand the number of days until thepatient was seen by an occupationaltherapist or a physical therapist. Thisfinding likely was related to week-end occupational therapist and phys-ical therapist coverage. We did notea difference between the day onwhich the order was written andthe number of days until an evalua-tion was done by a speech-languagepathologist. Compared with orderswritten for a speech-language pathol-ogist on weekdays, orders writtenfor a speech-language pathologiston weekends resulted in more dayspassing until the evaluation actuallyoccurred. As expected,65 less week-end coverage for a speech-languagepathologist (only 1 of 2 weekenddays were covered) accounted forthis finding.

Although more than one half of theinitial evaluations across all profes-sions were done within the recom-mended standard of 24 hours,66 115evaluations (45%) were done 2 ormore days after the orders werewritten. Only a relatively small per-centage of cases that were not seenwithin this time frame could beexplained by the therapy being post-poned or canceled because theselection of the patient was inappro-priate, the patient was unavailable(for nonmedical reasons), or thepatient refused therapy (15 of the115 cases [13%] were not seenwithin 24 hours). Other reasons(not captured in the present study)why patients were not seen within24 hours might have included insuf-ficient staffing or priority settingamong therapists.67,68

Consistently, early exposure to ther-apy, starting in the intensive care set-ting, has had a positive impact onpatients’ function, length of stay, andquality of life.69,70 In addition, inac-tivity, which is commonly notedamong older adults admitted to acutecare settings,3,14 is a major contribu-

tor to deconditioning and associatedcomplications. Therefore, early expo-sure to rehabilitation services andengagement of patients in nonseden-tary activity should be initiated asearly as medically possible. Contin-ued evaluations of barriers to earlyexposure, including system factors(eg, staffing and the ways in whichpatients are prioritized and sched-uled) and patient-related factors (eg,sedation and pain management), areneeded.

The therapy evaluations and treat-ment sessions in the present studywere somewhat longer than thetimes reported previously. Specifi-cally, we noted that sessions rangedfrom approximately 32 minutes fora speech-language pathologist to 62minutes for an occupational thera-pist. In contrast, sessions in earlierstudies of patients in acute-care set-tings ranged from 33 to 49 min-utes.51,71 It is well recognized thatthere is much variability in thelength of therapy between settings;this variability may be related to fac-tors such as specific requirementsper setting, caseload differences,degree of mobility, and patient symp-toms (eg, pulmonary symptoms orpain).

After controlling for the number ofcanceled or postponed sessions andthe length of stay, we found that thenumber of comorbidities was theonly variable associated with thenumber of therapy sessions deliv-ered to patients. This finding wasnot surprising because, logically,patients with degenerative joint dis-ease or patients with pulmonary orcardiovascular disease compromis-ing endurance likely would havemore difficulty regaining functionand, therefore, might require moretherapy.72,73 It is also possible thattherapists prioritized the need fortherapy in patients with comorbidi-ties and, therefore, decreased thelikelihood of a visit being missed.

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Given the sample size and the largenumber of comorbidities and combi-nations of comorbid conditionsexperienced by patients, it was notpossible to consider the impact ofspecific comorbid conditions on out-comes. Moreover, associated symp-toms and severity of diseases werenot captured in the assessments ofpatients, and such factors might havehad a greater impact on outcomesthan simply the diagnosis of thedisease.

The number of comorbidities alsowas associated with the number ofdays from admission until an orderfor therapy was written and the num-ber of days from admission until theinitial therapy evaluation was done.Orders tended to be written soonerfor patients with multiple comorbidi-ties, particularly if they had moresevere trauma, but the time until theinitial therapy evaluation was donewas longer. The differences noted interms of time frame for the therapyevaluation to occur (ie, 0.13 of a daylonger to be evaluated for everyincrease in the number of comorbidi-ties) may have been small, but withshortening lengths of stay, exposureto therapy as early as possible may beclinically useful. More than 50% ofolder adults have 3 or more chronicdiseases, and the combination ofthese cumulatively can have animpact on function and quality oflife.73,74 It is possible that olderpatients with trauma require special-ized management to optimallyaddress the often competing medicaland functional issues that arisebecause of their underlying comor-bid diseases.75

Consistent with an earlier studydescribing rates and reasons for non-treatment of patients in acute caresettings,64 our findings indicated thatsessions were most commonly post-poned or canceled because patientswere in an operating room or under-going some type of medical proce-

dure or because of their medical con-ditions (eg, instability).64 Postponingor canceling a session was associatedwith a longer period of time fromadmission until the initial evaluationwas done and from the time at whichtherapy was ordered until the initialevaluation was done. However, whatwas not noted in the present studywas how soon after a cancellationor postponement the therapist againtried to see the patient. Earlierresearch testing interventions toimprove response times for referralsto physical therapists in acute caresettings focused on system-relatedissues, such as ensuring adequatestaffing, particularly on weekends.67

Future research should examinehow to optimize response times forinitial therapy evaluations by alsoconsidering how soon and howoften therapists re-attempt a visitafter a cancellation or postponement.

The present study was limitedbecause it was based on retrospec-tive data and included only a smallsample from a single trauma center.Assessments by the therapists werebased on electronic medical recordsand were subjective in nature ratherthan based on reliable and valid mea-sures. The comorbidity measure wasa simple count of diagnoses and didnot take into account the severityof the diagnoses. In addition, mostfactors used in the regression analy-ses were dichotomous and thereforelacked variability. All of these mea-surement issues may have influencedthe findings. Moreover, additionalfactors, such as the cognitive statusof the patient, motivation, mood, orsome combination of these factors(not included in the models used inthe present study), likely influencedexposure to therapy. Recognizingthese limitations and the sparsepublished data in this area, webelieve that our findings provide use-ful descriptive data to guide futureresearch in considering ways to

optimize the exposure to therapy ofolder patients with trauma.

In conclusion, the findings from thepresent study suggest that for thesmall sample of older adults aftertrauma, therapy was ordered, andthe rate of treatment was high. How-ever, the mean time from the orderto the first evaluation was more than24 hours. The severity of the injury,the number of comorbidities, andpostponing or canceling a sessionwere all factors associated withthe number of treatment sessionsreceived, the number of days fromadmission to an order for therapybeing written, the number of daysfrom admission to a therapy evalua-tion, or the number of days from anorder being written to the therapyevaluation. Study findings should beused to stimulate future researchfocused on exploring the effect ofspecific comorbid conditions or acombination of comorbidities onexposure to therapy and the reasonsfor and impact of postponing or can-celing therapy in older adults aftertrauma.

Dr Resnick and Dr Wells provided concept/idea/research design, writing, and projectmanagement. All authors provided datacollection. Dr Resnick provided data analysis,fund procurement, facilities/equipment, andclerical support. Dr Wells provided patientsand institutional liaisons. Ms Brotemarkleprovided consultation (including review ofmanuscript before submission).

This study was approved by the InstitutionalReview Board of the University of Maryland.

DOI: 10.2522/ptj.20130087

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doi: 10.2522/ptj.20130087Originally published online September 12, 2013

2014; 94:40-51.PHYS THER. and Allison K. PayneBarbara Resnick, Chris L. Wells, Becky A. Brotemarkleand Factors That Influence Provision of TherapyExposure to Therapy of Older Patients With Trauma

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