This article is sponsored by Infinity Rehab. This article is based on a Skilled Nursing News virtual presentation with Dr. Patty Scheets, Vice President of Quality and Compliance at Infinity Rehab in October 2022. The article below has been edited for length and clarity.

Dr. Patty Scheets, PT, DPT, NCS: Infinity Rehab was founded in 1999 and is based in Tualatin, Oregon, which is outside of Portland.

We serve over 200 post-acute settings, including skilled nursing, assisted living, independent living communities, home health agencies, outpatient clinics, and wellness programs. We are in 18 states. We’re proud to be a certified Great Place to Work© employer and our mission is to set the standard in rehabilitation for successful aging by delivering the best of science with the art of caring.

It’s that best-of-science part that we’ll really be focusing on today. Our objectives for the session are to really share a bit of information about a large-scale performance improvement project that we started a number of years ago and including some robust data analytics.

From these analyses, I’ll describe the characteristics of different groups of rehabilitation patients that we’ve identified in skilled nursing, and I’ll share with you the factors that we’ve identified as important in determining responsiveness to rehabilitation. I’ll describe then how we use this information to guide treatment selection, interdisciplinary planning and care transitions.

To begin, I’d like to talk in a global way about rehabilitation interventions. Rehab providers learn a number of therapeutic strategies to assist patients with activity limitations and participation restrictions. We can generally group these around these four pathways. Remediation, where we’re really treating the cause of the activity limitations, largely seeking to improve impairments and body structure and function.

In these situations, when patients can be responsive to these types of interventions, they have the potential to achieve maximal consistency, efficiency, and flexibility or adaptability of performance. Going down the compensation pathway though, rather than improving the cause of the activity limitation, we are teaching individual strategies to compensate for that limitation.

In their simplest form, these can be short-term things like teaching someone how to get from place to place or to transfer without loading a limb in the case of a fracture, or they can be more long-term strategies for those individuals whose impairments in body structuring function may not recover.

Adaptation is really a continuum on a continuum with compensatory strategies. Only to a larger degree, in both of these pathways, the individual usually has to give up some flexibility in performance or adaptability in order to gain consistency largely for safety or gain efficiency with that activity, decreased energy demands.

Finally, the prevention pathway are those strategies that we employ to essentially put ourselves out of work to prevent decline in mobility activity and overall health. Now, when we look at the science of rehabilitation, there’s been much more study and research around these remediation and prevention pathways than we see in the science for compensation strategies and adaptation pathways.

As clinicians, we are able to use more evidence-based strategies, things that inform what we do based on external literature, and when it comes to compensation and adaptation, where you rely more on experience or best practices.

At Infinity Rehab, what we have done is we have dug into the science of rehabilitation to identify interventions for which there’s a large body of evidence, and we’ve organized these into what we call our clinical model. We’ve used these four pillars, intensity, patient self-management, prevention and wellness, and tailoring care to cognitive need as really an organizing principle to kind of frame up both for ourselves, our clinicians, and our patients what it is we’re trying to accomplish in rehabilitation, and how we’re trying to bring in that best of science with the art of caring.

I’d like to take a few minutes to talk about this first pillar, the intensity pillar, as the concept around intensity has been one of the most dramatic shifts in understanding that we’ve learned from rehabilitation science in what really matters to individuals who receive rehabilitation services.

In rehabilitation science, intensity refers to challenge, not amount of therapy, and that’s a really important distinction in skilled nursing and in other post-acute settings where we really tend to focus more on the amount of therapy. If in rehabilitation science intensity refers to challenge, then what we’re really thinking about is how we use intensity to help patients maximize their gain.

Now, it’s rather intuitive that in rehabilitation we’re going to do things that are harder for individuals than what they do on their own. That’s actually not a big aha from the science. What the big aha from the science is, is that the care needs to not just be a little bit harder than what patients need to do, but can do on their own, but it actually needs to be a lot harder. It needs to be significantly more challenging than patients’ self-selected activity in order for it to help patients maximize their gains.

Now, in doing this well, every therapy session then needs to have a specific intensity target. That’s our entire goal. Our entire purpose is to help the patient work at that level of intensity that’s going to be sufficiently challenging to them to actually maximize their gains.

We don’t exactly know about the dosage on this. It’s still a question that is being answered in science, but generally speaking, when you look at the interventions that are being provided, the goal has been to target these high-intensity interventions four out of seven days. I think this is a really important thing for all of us to know and understand, as this is not yet usual care in rehabilitation. There have been a number of observational studies that kind of tell us what is usual care in post-acute rehabilitation, and we are not yet consistently delivering on this intensity principle.

Let’s talk a little bit more about what this actually means. There are multiple ways that you can measure intensity when it comes to rehabilitation in order to apply this principle of intensity. We’ve selected two ways. One of the ways is through strength training and the evidence for older adults is that resistance training or strength training in order for it to be maximally effective for older adults should be a net 60% to 80% of the one repetition maximum, essentially starting at 60% and really progressing to 80% of a one repetition maximum.

Well, what does that look like? 60% of a one repetition maximum is a tasker activity that an individual can do about 13, maybe 15 times before reaching biomechanical failure. 80% of a one-repetition maximum is a load that a patient can do or an individual can perform 8 to maybe 10 repetitions before reaching biomechanical failure.

Now, in this video clip, you’re seeing a patient getting to that biomechanical failure using a sit-to-stand task. Some important things to note, she’s not using her upper extremities, because using upper extremities is a compensatory strategy for lack of strength-producing capacity, and we don’t want her to compensate for that inability. We want to challenge that ability.

She’s also doing this from a very low surface, and these were the conditions that we had to bring this task under in order for her to reach that biomechanical failure after eight good repetitions.

In this particular clip, Patrick is doing a different task, a getting in and out of bed task. Again, I want you to take note of how we’ve removed some of the compensatory strategies that we often see in inpatient care, we’re flattening the bed, we’re lowering the bed rails so that the patient can use those compensatory strategies, and in order to increase load for the task, we’ve added a weighted vest for this individual in order for him to reach, again, that biomechanical failure in 8 to 10 repetitions.

Our general goal is to do at least two activities to that level of intensity, four out of seven days.

Let’s look at another way that we traditionally and systematically measure intensity. That’s by looking at heart rate, particularly with aerobic training. Here, what we’re trying to do is get the heart rate into the moderate to vigorous training zone, and we use a heart rate reserve formula in order to help us determine what that should be for each individual patient.

We find that most skilled nursing patients are challenged to do anything at a continuous level, so we always start with three continuous minutes to begin, that’s our initial training duration. Again, we’re trying to identify an activity, the goal is to do an activity that does indeed get the patient’s heart rate up into that moderate to vigorous training zone.

In these images, I’m illustrating for you an OT task, it was a laundry task, she was folding. What we did in order to increase the intensity is that the patient is doing the task and is standing. We were encouraged to get her arms up as high as possible, as that increases demand as well. In the first three images, she gets through three continuous minutes, but her heart rate is still in the light training zone. We weren’t successful in reaching our exercise target, which was that moderate to vigorous training zone.

In the last figure here, you can see we added wrist weights to her, and now she was able to get her heart rate into that heart rate training zone. This is where we would start in the next session.

Another way that we do intensity by using heart rate is to do interval training. In these figures, we see an individual walking on the left, and then she’s doing a brief running trial on the right. These principles of interval training can be applied to walking tasks. It doesn’t always have to be running at a fast pace. As a matter of fact, that’s unusual for what’s going on, but it might be faster walking with or without a device, again, in order to increase the energy demand of the task.

What we’re trying to do is build to 20 continuous minutes. You can use these interval training principles not just with a walking task, but with other tasks as well. A slow bout followed by a brief or short bout. A slow bout followed by a brief or short bout. Again, trying to reach that level of intensity at least four out of seven days.

This excerpt has been edited for length and clarity. To watch the full discussion on video, please visit:

Infinity rehab’s mission is to set the standard in rehabilitation for successful aging by delivering the best of science with the art of caring. To learn more, visit: https://infinityrehab.com/.