社區預防性復健照護的物理治療服務

Physical Therapy in Preventive Rehabilitative Community Care

因應快速成長的高齡人口之健康醫療照護的需要，台灣醫療體系除了現行的全民健保外，應盡快建構中期照護[intermediate care；又稱急性後期照護（post-acute care）]以及長期照護體系。一般說來，高齡者從急性疾患治療後的恢復所需時間較長，且健康狀態變化較頻繁，因此中期照護以及長期照護階段的服務內容，除了一般照護外，亦強調復健與預防的雙重概念。本文擬以社區預防性復健為重點，討論物理治療師在社區照護中的角色與功能，期能促進高齡民眾在急性後期復健或反覆失能的短期復健服務，以便能充份恢復健康。本文所討論的社區預防性復健照護服務可於社區醫院、社區中的照護機構、或居家提供。本文主要介紹社區照護中物理治療師介入較深的預防性服務的內容，亦即活動失能（mobility disability）、衰弱（frailty）與跌倒之篩檢與介入。活動失能與衰弱是失能的早期現象，簡易問卷以及手握力、重複坐站測試可以早期篩檢預測未來一至二年內可能有顯著失能或衰弱退化的老年民眾；未來研究應針對早期活動失能或衰弱的老人進行物理治療療效研究。而跌倒篩檢與危險因子評估方面，物理治療師主要提供步態及平衡測試以及其他肌力、感覺等方面的評估；實證研究與指導方針已證實了物理治療介入中平衡訓練與肌力訓練的防跌效果。總之，全民健保實施有成、長期照護保險已在規劃階段，中期照護與預防性社區照護的規劃亦刻不容緩，才能提供民眾無間斷的連續性在地服務。

In response to the rapidly increasing need of health care of the elderly population, the medical system in Taiwan should promptly construct both systems of intermediate care and of long-term care in addition to the current National Health Insurance. Elderly people tend to require a longer recovery time from acute diseases and have more frequent episodes of fluctuating health status than those younger ones. Thus, the service of intermediate care and of long-term care should emphasize both concepts of rehabilitation and preventive care. The core of this article is on community preventive rehabilitation care. We describe the roles and functions of physical therapists in the community care, aiming for fully-recovered health status of elderly people by improving the quality of post-acute rehabilitation or of short-term rehabilitation service for fluctuating disability. The described community preventive rehabilitation care could be applied in community hospitals, community institutes of long-term care, or home settings. The two main parts of this article are the preventive areas in which physical therapists involve more, i.e., the screening and intervention of mobility disability, frailty, and accidental falls. Mobility disability and frailty are the early indices of physical disability that could be measured by simple questionnaires, grip strength test, or timed chair stands test. Future research needs to examine the effects of physical therapy for elderly with early mobility disability or frailty. The second part of this article regards the screen and identification of risk factors of falls; physical therapists are responsible for providing evaluations of gait, balance, muscle strength, and sensation etc. Evidence-based research and clinical guidelines have supported positive effects of physical therapy in enhancing balance and muscle strength, as well as in reducing falls. In light of the success of the National Health Insurance and the undergoing planning of long-term care insurance, the construction of intermediate care and community preventive care is in urgent need for a bright future of seamless, continuing local services for elderly people in Taiwan.