Mobility is Medicine Loretta Schoen Dillon, PT, DPT, MS Director of Clinical Education and Clinical Associate Professor UTEP Physical Therapy Program Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013

1. MOBILITY IS
MEDICINE
Loretta Schoen Dillon, PT, DPT, MS
Director of Clinical Education and Clinical
Associate Professor
UTEP Physical Therapy Program

2. OBJECTIVES
At the end of this presentation, the participant will:
1. Recall fall related injury statistics and assessment of fall
risk of hospitalized patients.
2. Recall negative effects of bed rest.
3. Identify risk of hospital associated disability with various
patient cases.
4. Compare/contrast Medicare reimbursement issues related
to various patient cases.
5. Recognize the need for skilled physical therapy services in
various healthcare settings.
6. Weigh risks and benefits of mobility in acute care for
various patient cases.
7. Formulate an outline to propose a “Mobility is Medicine”
program in the participant’s work setting.

3. BACKGROUND
 Falls and resultant injuries
 Acute care hospitals and long term care facilities
 Nursing to patient ratios
 Patient acuity
 The Joint Commission rules
 Medicare regulations and payment for performance
 Lack of education on importance of mobility
 Results in:
 “Hospital associated disability”
 How can we change our current practice settings
to understand that

4. FALLS1,2
 Unintentional fall are the most common cause of
non-fatal injuries in people > 65 years old
 Fall-related injuries are most common cause of
accidental death in people > 65 years old (41
deaths per 100,000)
 In 2010, direct medical costs of falls was $30
billion
 20-30% of older adult fallers sustain, lacerations,
hip or other bone fractures, or head trauma
 Fear of falling leads to further decline and
increased risk of falling

5. REGULATORY RESPONSE TO
FALLERS
 Fall Risk in acute or long term care settings
 Fall risk assessments
 Putting fear in patients
 The Joint Commission
 Medicare
 American Hospital Association
 Positive hospital strategies
 Avoid bed rest orders
 Low-low beds3
 Reducing preventable falls while increasing mobility4
 Negative hospital strategies

6. MEDICARE PAY FOR
PERFORMANCE5
 Payment for “non-performance” since 2007, “fall
from a bed”
 Care coordination/patient safety
 Screening for falls
 “Older people reporting a fall or considered at risk of
falling should be observed for balance and gait
deficits and considered for their ability to benefit
from interventions to improve strength and balance”

7. NEGATIVE EFFECTS OF BED
REST6,PP269-271
 Multisystem sequelae of bed rest have been
documented for > 60 years
 Cardiopulmonary and cardiovascular systems
 Down-regulation of O2 transport
 Loss of fluid-volume and pressure regulating mechanisms
 Loss of plasma volume
 Risk of DVT
 Musculoskeletal system
 Muscle and skeletal atrophy
 Discoordination and balance
 Psychological effects
 Other systems: Neurological, GI, and GU
 BOTTOM LINE: Bed rest should be prescribed as
judiciously as medication

8. POSITIVE HOSPITAL STRATEGIES
 Accurate fall risk assessment
 Intrinsic factors
 Medications
 Muscle strength
 Coordination and balance
 Medical diagnoses
 Cognitive status
 Extrinsic factors
 Accessibility to the bathroom
 Ambulatory aids
 Other DME
 Lighting
 Adequate nursing and ancillary staff

9. HOSPITAL ASSOCIATED
DISABILITY7
 Gill et al studied the relationship between
hospitalization and restricted activity from 1998
– 2003
 Participants were members of the Precipitating
Events Project, a study of 745 persons aged 70
years or older, who were not disabled in 4
essential ADLs
 Data were collected on gait speed, cognitive
status, depressive symptoms and chronic
conditions: hypertension, myocardial infarction,
heart failure, etc. fractures, amputations, cancer,
etc.
 Fraility defined by gait speed

10. HOSPITAL ASSOCIATED
DISABILITY7
 Results:
 During 5-year follow up, disability developed among
55.3% of participants.
 Physically frail were more likely to develop disability
 Hospital admissions for falls were most likely to lead
to disability
 Conclusion:
 Illnesses and injuries leading to either
hospitalization or restricted activity represent
important sources of disability for older persons
living in the community, regardless of the presence of
physical frailty.

11. HOSPITAL ASSOCIATED
DISABILITY8
 Volpato et al identified demographic, clinical, and
biological characteristics of older nondisabled patients
who develop new disability in BADL during medical
illnesses requiring hospitalization.
 At discharge 113 patients (6.7%) presented new
BADL disability. Functional decline was strongly
related to patients’ age and preadmission IADL
status. Multivariate analysis revealed older age, LTC
residency, low body mass index, acute stroke, high
level of comorbidities, polypharmacotherapy,
cognitive decline, and history of fall in the previous
year were independent and significant predictors of
BADL disability.

12. HOSPITAL ASSOCIATED
DISABILITY9
o Ettinger commentary in JAMA
o 7.4% of Medicare beneficiaries who where
hospitalized in 2008 experienced preventable
adverse events including the loss of independence
and/or the inability to perform self-care functions
(ADLs).
o Quality of life and sustainability of independence
are not measured as outcomes of care.
o Risk factors for the hospital-associated disability
are advanced age, existing dependence in ADLs,
physical frailty, cognitive impairment, low
albumin level, and acute stroke or metastatic
cancer.

13. HOSPITAL ASSOCIATED
DISABILITY9-11
• Hospital environment may contribute to physical
disability, patients should be encouraged to
ambulate with sufficient supervision.
• Clinicians should assess ADLs in all older
patients at admissions and during
hospitalization.
• When is it time to call in:

14. PHYSICAL THERAPISTS (PTS)
 PTs earn entry level doctoral degrees and must pass
a national licensing exam to practice. State licensure
is required in each state in which a physical therapist
practices.
 PTs help patients reduce pain and improve or restore
mobility.
 PTs examine each individual and develop a plan,
using treatment techniques to promote the ability to
move, reduce pain, restore function, and prevent
disability.
 PTs provide care for people in a variety of settings,
including hospitals, private practices, outpatient
clinics, home health agencies, schools, sports and
fitness facilities, work settings, and nursing homes.

15. PHYSICAL THERAPY
 Physical Therapists and Physical Therapist
Assistants are NOT:
 Massage therapists
 Moving companies (ie transfer dependent patients in
and out of bed)
 Walking companies (ie ambulate patients who do not
require skilled care)
 Physical Therapists and Physical Therapist
Assistants DO:
 Provide skilled interventions to assist patients to
achieve their goals
 Provide assessments to plan the transition to the
next level of care

16. PATIENT CASES
 Mrs. Gonzalez is an 80 y/o F presented to the ED
with AMS. She was admitted to the hospital with
pneumonia and a UTI. Prior to admission she
lived alone and was independent in all BADL
including ambulation without an assistive device.
She is 5’6” and weighs 160lbs (BMI= 25.8). PMH
of HTN, hyperlipidemia, and DM II. Home
medications include atenolol, Zocor, and insulin.
New medication includes Levaquin.
 The nursing screen yielded this patient as a “fall
risk”.
 Does PT need to be consulted? (Think about
effects of medications on this patient, BMI and
co-morbidities)

17. PATIENT CASES
 Pt is a 65 y/o M who fell while intoxicated and
sustained minor head trauma without any
neurological sequalae. He is admitted for
observation through the ED. PMH includes
hepatitis C and HTN. Home medications include
lisinopril and metoprolol. Prior to admission, pt
was independent in all BADL and IADL
including driving. He still works full time as an
attorney.
 Does PT need to be consulted?

18. SCREENS FOR FALL RISK12
 Rehabilitation Measures Database12
:
 Timed up and Go
 Dynamic Gait Index
 Berg Balance Scale
 Tinneti POMA
 Five Times Sit to Stand
 Nursing looks at a variety of factors on admission
in various settings
 STRATIFY
 Hendrich II Fall Risk Model
 Morse Fall Scale

19. RISK V. BENEFIT
 Risks of mobilizing patients (must be
hemodynamically stable)
 Injury
 Lines and tubes
 Embolus
 Benefits of mobilizing patients:
 Prevent DVT13
 Improve pulmonary function6
 Improve patient affect6
 Improve overall strength, ROM, and endurance6

20. INTERVENTIONS TO PREPARE
PATIENTS FOR MOBILIZATION
 Respiratory therapy
 Beds that convert to chair positions
 Equipment to transfer patients out of bed
 Bed exercises (trunk and extremity)14
 TED hose and/or abdominal binders
 Head of bed elevation
 Proning

21. PATIENT CASES
 Pt is a 72 y /o F who lives alone and was found by
a neighbor to be unconscious in the front yard.
She was admitted to the hospital to ICU. She has
multiple co-morbidities and developed acute
respiratory distress requiring intubation. Two
weeks later she has been stabilized and is now on
telemetry. She has contracted C difficile and has
now been bedbound essentially for 2 weeks. The
ICU staff did transfer her bed to chair on 2
occasions, but pt did not tolerate upright
postures and demonstrated orthostatic
hypotensive events. PT has now been consulted.
What are some interventions that might have
prevented this patient being in her current

22. PATIENT CASE15
 Pt is a 68 y/o M with end stage renal disease
requiring hemodialysis three times a week. PMH
includes DM II, HTN, OA, s/p MI 5 years ago
with stent placement, and polypharmacy to
manage all of his conditions. He uses a front
wheeled walker when ambulating outside the
home and doesn’t believe in exercising. He is very
deconditioned and has no energy after dialysis.
He feels he is becoming more of a burden on his 2
sons who are his primary caregivers.
 What can we do with him to improve his quality
of life?

23. HEALTH LITERACY16
 National Literacy Act of 1991 defined literacy as
“an individual’s ability to read, write, and speak
in English, and compute and solve problems at
levels of proficiency necessary to function on the
job and in society, to achieve one’s goals, and
develop one’s knowledge and potential.”
 Limited health literacy and health outcomes
 Cultural differences
 Interpersonal communication
 Social interaction
 Does education lead to behavioral change?

24. DEVELOP YOUR PROGRAM
 Group work to formulate an outline to propose a
MOBILITY IS MEDICINE program in your work
setting.

25. REFERENCES
1. Currie L. Fall and Injury Prevention in Patient Safety and Quality: An Evidence-Based Handbook
for Nurses. Agency for Healthcare Research and Quality website,
http://www.ahrq.gov/professionals/clinicians-
roviders/resources/nursing/resources/nurseshdbk/CurrieL_FIP.pdf Accessed August 5, 2013.
2. Falls Among Older Adults: An Overview. Centers for Disease Control and Prevention website.
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Accessed August 5, 2013
3. Barker A, Kamar J, Tyndall T, Hill K. Reducing serious fall-related injuries in acute hospitals: are
low-low beds a critical success factor? J Adv Nurs. 2013 69(1):112-21. doi: 10.1111/j.1365-
2648.2012.05997.x. Epub 2012 Mar 27.
4. American Hospital Association website. Injuries from falls and Immobility. http://www.hret-
hen.org/index.php?option=com_content&view=article&id=5&Itemid=130. Accessed August 5, 2013.
5. Accountable Care Organization 2013 Program Analysis Quality Performance Standards Narrative
Measure Specifications. CMS website. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf Accessed August
7, 2013.
6. Dean E. Mobilization and Exercise in Frownfelter D, Dean E. Cardiovascular and Pulmonary
Physical Therapy: Evidence and Practice. 4th
ed. Mosby Elsevier. St Louis, MO. 2006.
7. Gill TM, Allore HG, Holford T. R., Guo Z, Hospitalization, restricted activity, and the development
of disability among older persons. JAMA, 2004;292 (17):2115-2124.
8. Volpato S, Onder G, Cavalieri M, et al. Characteristics of nondisabled older patients developing
new disability associated with medical illnesses and hospitalization. Soc Gen Intern Med.
2007;22:668-674. doi: 10.1007/s11606-007-0152-1.

26. REFERENCES
9. Ettinger W. Can hospitalization-associated disability be prevented? JAMA. 2011; 306 (16):1800-
1801.
10. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “she was probably
able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-1793.
11. Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or
restricted activity in older persons. JAMA. 2010;304(17):1919-1928.
12. Rehabilitation Measures Database. http://www.rehabmeasures.org/default.aspx. Accessed August
8, 2013.
13. Gay V, Hamilton R, Heiskell S, Sparks A.M. Influence of bedrest or ambulation In the clinical
treatment of acute deep vein thrombosis on patient outcomes: a review and synthesis of the
literature. Medsurg Nursing 2009;18:293-299.
14. Miokovic T, Armbrecht G, Felsenberg D, Belavý DL. Differential atrophy of the postero-lateral hip
musculature during prolonged bed rest and the influence of exercise countermeasures. J Appl
Physiol. 2011;110:926-934. doi: 10.1152/japplphysiol.01105.2010
15. Lo D, Chiu E, Jassal SV. A prospective pilot study to measure changes in functional status
associated with hospitalization in elderly dialysis-dependent patients. Am J Kidney Dis.
2008;52(5):956-961. doi: 10.1053/j.ajkd.2008.04.010
16. Nemmers T.M, Jorge M, Leahy T, Health literacy and aging: an overview for rehabilitation
professionals. Topics in Geriatric Rehabilitation. 2013;29:79-88. doi:
10.1097/TGR.0b013e31827e4820

27. Contact Information:
Loretta Dillon, PT, DPT, MS
ldillon@utep.edu
915-747-8215