Current Knowledge and Gaps in Geriatric Rehabilitation among Physical and Rehabilitation Medicine Specialists

Abstract

Background

The global demographic shift toward an aging population necessitates a critical transformation in healthcare, particularly within physical and rehabilitation medicine (PRM). Older adults frequently present with complex geriatric syndromes, such as frailty, sarcopenia, and cognitive impairment, that demand specialized, multidisciplinary rehabilitation strategies.

Methods

The present global survey, conducted by the International Society of Physical and Rehabilitation Medicine (ISPRM) Special Interest Group (SIG) in Geriatric Rehabilitation, identifies systemic and educational gaps in the current PRM landscape.

Results

Despite a high clinical caseload of older adults, the majority of PRM practitioners report inadequate residency training in geriatric competencies and cite workforce shortages as primary barriers to care.

Conclusion

This article discusses the perspectives and future steps required to elevate geriatric rehabilitation, emphasizing the urgent need for structured academic programs.

INTRODUCTION

The rapid growth of the population aged 65 years and older represents a global demographic transformation that compels healthcare systems to adapt to the complex needs of older adults. Geriatric rehabilitation is an essential health service that optimizes functioning and reduces disability in older adults with health conditions, injuries, or age-related functional declines in interaction with their environment. Rehabilitation is essential to fostering independence and improving quality of life in older age. Effective rehabilitation interventions must extend beyond a traditional disease-centered focus and address interconnected geriatric syndromes, such as frailty, sarcopenia, malnutrition, and cognitive impairment, through a Comprehensive Geriatric Assessment (CGA)^1-5) and the Age-Friendly Health Systems (AFHS) 4Ms framework (Mobility, Mentation, Medication, and What Matters).⁶) The World Health Organization (WHO) World Report on Ageing and Health⁷) emphasizes that rehabilitation can reduce disability and dependency, prevent avoidable hospitalizations, and improve ageing trajectories. Its recent inclusion in the updated WHO Integrated Care for Older People (ICOPE) guidelines further underlines the growing recognition of rehabilitation as an important element of ageing-related care.⁸) Physical and rehabilitation medicine (PRM) physicians are uniquely positioned to lead these interdisciplinary efforts. However, to guide care transitions and manage multimodal treatments effectively, PRM specialists must be supported by adequate educational and institutional infrastructures. The International Society of Physical and Rehabilitation Medicine (ISPRM) Special Interest Group (SIG) in Geriatric Rehabilitation recently promoted a survey on the current level of knowledge and awareness regarding aging-related issues and age-friendly care among PRM specialists from diverse countries across Europe, the Americas, Africa, and Asia. This article summarises the principal findings and discusses the perspectives and next steps needed to advance geriatric rehabilitation through structured academic training.

MATERIALS AND METHODS

Survey Development and Delphi Process

We used a powerful, enterprise-grade survey software (Alchemer) to build, launch, and analyze the survey. The latter can be viewed at https://survey.alchemer.com/s3/8641088/the-current-level-of-knowledge-and-awareness-regarding-aging-related-issues.⁹) The study design was based on a Delphi methodology with the aim of reaching a consensus among the experts of the ISPRM SIG in Geriatric Rehabilitation on the final survey format. The Delphi method is a well-known method for determining a consensus opinion among subject matter experts to respond to a research question.¹⁰) Participants are allowed to nuance and reevaluate their views depending on the anonymous perspectives of others, allowing for participant evaluation. Anonymity of panellists in the survey rounds, controlled feedback and iterative discussions are the strengths of the Delphi procedure. A Google Form survey including 20 questions prepared by the Steering Committee (involving three domains, Project Committee, Enterprise Architecture, and Method of Procedure) was distributed for a first Delphi round, in which all 15 SIG members were asked to express their level of agreement on a 5-point Likert scale, or choose the response among multiple options, and eventually propose adding new questions or eliminating existing ones. Instability of the responses after the first round would lead to subsequent rounds reformulated by the Steering Committee. The SIG members involved in the Delphi procedure consisted of 15 highly homogeneous rehabilitation experts, which is considered an ideal size for this purpose. Twenty-nine questions (Q1 to Q29) were selected following three Delphi Rounds with an agreement >80% as relevant for the purpose from the ISPRM SIG members and were included in the final survey. The study was conducted in full concordance with the principles of the Declaration of Helsinki and will be reported according to the Conducting and Reporting DElphi Studies (CREDES) Guideline.¹¹) The survey was sent to ISPRM members with a QR code via the ISPRM Newsletter by the ISPRM Office in January 2026. The responses to the survey were analysed 2 months later, and are available at https://reporting.alchemer.com/r/491586_6980749a786311.23050624. We summarized the results using descriptive statistics. Since all of the variables were categorical, we reported the absolute numbers and proportions.

Ethics Statement

This study did not involve patients or identifiable personal data and was limited to the voluntary, anonymous professional opinions of PRM specialists; therefore, Institutional Review Board approval was not required. Participation was voluntary, and completion of the survey implied consent.

RESULTS

The 75 respondents represented a broad international spectrum, including practitioners from South Korea, South Africa, Colombia, Uruguay, Portugal, Switzerland, the Democratic Republic of Congo, Niger, the USA, Mexico, Germany, Romania, Italy, Austria, Turkey, Greece, Luxembourg, Sudan, and others. The vast majority of respondents regularly see patients aged over 65 years, often constituting 40%–80% of their caseload (Fig. 1).

Fig. 1.

Global survey of geriatric rehabilitation in physical & rehabilitation medicine: (A) geographic distribution of respondents, (B) clinical practice and institutional readiness, and (C) main barriers to providing age-friendly rehabilitation.

Their settings were predominantly hospital-based (83.8%), with half of respondents also working in out-of-hospital contexts, and a minority in other settings (9.5%). Rehabilitation areas spanned musculoskeletal, neurological, geriatric, and spinal cord injury rehabilitation, among others.

Responses to the other survey questions are presented in two separate tables: Table 1 for self-rated competencies and practices in geriatric rehabilitation on a 0–5 Likert scale, and Table 2 for reported barriers and use of standardized assessment tools with multiple-choice questions. We aggregated the responses under the following different areas: institutional readiness, barriers to age-friendly rehabilitation, educational gaps, and clinical knowledge.

Table 1.

Self-rated competencies and practices in geriatric rehabilitation (Likert scale questions 0–5) (unit: %)

Question	0	1	2	3	4	5
Q9. In my daily practice, I implement age-friendly rehabilitation principles when treating older patients.	0	5.40	14.90	32.40	31.10	16.20
Q11. I can effectively consult other specialists in order to manage age-related issues.	0	2.70	14.90	24.30	39.20	21.60
Q12. PRM residency/training provided the adequate skills to manage specific agerelated aspects.	0	5.60	16.70	45.80	22.20	11.10
Q13. I am interested in international training or guidelines.	4.10	5.40	6.80	18.90	27.00	40.50
Q14. I am familiar with clinical practice guidelines on the management of older patients.	1.40	5.50	9.60	32.90	35.60	15.10
Q15. I feel confident in in evaluating and managing geriatric syndrome.	1.40	5.40	27.00	17.60	32.40	16.20
Q22. I am confident in prescribing rehabilitation exercises to geriatric patients.	0	0	8.10	25.70	31.10	35.10

Values are percentages of respondents. Percentages may not total 100 owing to rounding and non-response.

Likert scale: 0=strongly disagree/not at all; 5=strongly agree/fully.

Table 2.

Multiple choice questions for reported barriers (Q10, Q24) and use of standardized assessment tools (Q16, Q17, Q18, Q19, Q20, Q21, Q23, Q25, Q26, Q27, Q28, Q29)

Question	Option	Percentage
Q10. What do you consider to be the main barriers to implementing age-friendly rehabilitation principles in your clinical practice?	Cultural	24.70
	Equipment	32.90
	Funding	43.80
	Workforce	65.80
Q16. Which standardized tools do you routinely use to assess the cognitive status of older patients?	CDR	11.00
	Others	16.40
	BIMS	32.90
	MMSE	50.70
	MoCA	54.80
Q17. Which screening tools do you use to assess mood disorders (such as depression or anxiety) in older adults?	Geriatric Anxiety	7.70
	HADS	26.20
	Others	32.30
	Geriatric Dep.	53.80
Q18. Which clinical tests or instrumental assessments do you routinely use to evaluate dysphagia or swallowing safety?	Yale Protocol	4.60
	Burke Test	10.80
	FEES	13.80
	VFSS	20.00
	Others	26.20
	Clinical Swallow	60.00
Q19. Which screening tools or criteria do you utilize to identify or diagnose malnutrition in older patients?	MUST	6.30
	GLIM	12.70
	MNA	20.60
	Nutritional Risk	25.40
	Others	52.40
Q20. Which methods or instruments do you use to screen for or diagnose sarcopenia and assess muscle strength?	Others	14.50
	BIA	14.50
	DEXA	27.50
	SARC-F	27.50
	Chair stand	39.10
	Manual scale	43.50
	Hand dynamometer	50.70
Q21. Which standardized tests or scales do you routinely use to assess the risk of falls in older adults?	Conley	1.50
	Stratify	4.40
	Morse	10.30
	Others	38.20
	Tinetti	38.20
	Berg	47.10
Q23. Which types of tele-rehabilitation programs or digital health tools do you currently incorporate into your practice?	Wearables	9.10
	Exergames	9.10
	Videocall	34.50
	Apps	38.20
	Others	41.80
Q24. What are the main barriers or challenges you face when implementing tele-rehabilitation or digital tools for older adults?	Others	13.40
	Data security	13.40
	Adherence	34.30
	Infrastructure	49.30
	Digital literacy	52.20
	Tech access	53.70
Q25. Which tools do you use to assess social support networks or caregiver burden for older patients?	MSPSS	27.60
	Others	74.10
Q26. Which tools or criteria do you use to review polypharmacy and potentially inappropriate medications during consultations?	Anticholinergic	11.10
	GASS	20.60
	Others	73.00
Q27. Which clinical scales or tools do you routinely use to systematically assess and monitor chronic pain in older adults?	Others	31.50
	Verbal Descriptor	35.60
	NRS	58.90
Q28. Which standardized outcome measures or batteries do you routinely use to evaluate functional outcomes and physical performance?	Others	12.20
	CGA	12.20
	Frailty Scale	13.50
	SPPB	25.70
	Sit-to-stand	33.80
	Timed-Up-Go	45.90
	FIM	60.80
	Barthel	64.90
Q29. What specific adaptations do you make to rehabilitation materials to ensure accessibility for older patients with impairments?	Others	16.20
	None	22.10
	Videos	22.10
	Larger font	22.10
	Step-by-step	58.80

Values are percentages of respondents; multiple responses were permitted, so percentages within a domain may exceed 100.

BIA, bioelectrical impedance analysis; BIMS, Brief Interview for Mental Status; CDR, Clinical Dementia Rating; CGA, Comprehensive Geriatric Assessment; DEXA, dual-energy X-ray absorptiometry; FEES, fiberoptic endoscopic evaluation of swallowing; FIM, Functional Independence Measure; GASS, Glasgow Antipsychotic Side-effect Scale; GLIM, Global Leadership Initiative on Malnutrition; HADS, Hospital Anxiety and Depression Scale; MMSE, Mini-Mental State Examination; MNA, Mini Nutritional Assessment; MoCA, Montreal Cognitive Assessment; MSPSS, Multidimensional Scale of Perceived Social Support; MUST, Malnutrition Universal Screening Tool; NRS, Numeric Rating Scale; SARC-F, Strength, Assistance, Rising, Climbing, Falls; SPPB, Short Physical Performance Battery; VFSS, videofluoroscopic swallowing study.

Institutional Readiness

On the question of whether an interdisciplinary management unit for older patients exists in their hospital (Q7), responses were divided nearly equally, with slightly more than 50% of the centers lacking such a structure. Yet, geriatric rehabilitation is multidisciplinary, requiring the coordinated expertise of PRM, geriatricians, neurologists, pneumologists, cardiologists, nurses, physiotherapists, occupational therapists, speech-language therapists, nutritionists, pharmacists, psychologists, and social workers operating under a CGA framework.

When asked to rate the adequacy of their rehabilitation service to the needs of older people on a 0–5 scale (Q9), the largest share of respondents (32.4%) selected the response value 3, with 31.1% choosing the response value 4 and only 16.2% rating their service as fully adequate (5) (Table 1).

Regarding interdisciplinary consultation capacity (Q11), only 21.6% rated the access to nutritionists, geriatricians, dentists, and other specialists as fully adequate (response value 5), while 39.2% selected the modal response 4, and 14.9% rated it just 2.

Barriers to Age-Friendly Rehabilitation

In Q10, the survey identified workforce shortages as the predominant barrier to providing age-friendly rehabilitation (65.8% of respondents), followed by funding constraints (43.8%), equipment limitations (32.9%), and cultural factors (24.7%) (Table 2). Despite growing need, substantial policy barriers and awareness gaps persist worldwide.

Educational Gaps

One of the most revealing findings concerns the adequacy of PRM residency training in geriatric-specific skills (Q12). Nearly half of respondents (45.8%) rated their training as only moderately adequate (response value 3), with 16.7% rating it 2 and 5.6% 1. Only 11.1% felt fully prepared (response value 5).

The picture becomes more encouraging when examining access to continuing education and interest in international training and guidelines (Q13). A striking 40.5% of respondents gave the highest rating (response value 5) for their interest in accessing international training, with a further 27.0% rating 4. This strong signal suggests that PRM practitioners are aware of their knowledge gaps and are motivated to address them, a crucial foundation for educational reform and ISPRM-led capacity-building initiatives.

Clinical Knowledge

Familiarity with clinical practice guidelines

Q14 asked respondents to rate their familiarity with clinical practice guidelines for the management of older patients in rehabilitation. Most participants (32.9%) selected a response value 3, with 35.6% selecting 4 and 15.1% a response value 5. However, 9.6% selected a response value 2 and a combined 6.9% response values 0–1, indicating that a minority has very limited guideline awareness.

Confidence in managing geriatric syndromes

Q15 addressed confidence in evaluating and managing geriatric syndromes including frailty, osteoporosis, sarcopenia, cognitive impairment, and incontinence, the very conditions identified as the quintessential targets of geriatric rehabilitation. The distribution was relatively balanced across the scale (Table 1), suggesting heterogeneous levels of self-assessed competence across the participants. Questions reported in Table 2, with the exception of Q10 and Q24, asked about the use of specific assessment tools across key domains (cognitive status, mood disorders, dysphagia, malnutrition, sarcopenia, fall risk, polypharmacy, and chronic pain), as well as the use of tele-rehabilitation and social support assessment.

DISCUSSION

The ISPRM survey paints a portrait of a specialty that is deeply engaged with aging patients but shows that PRM specialists are currently inadequately equipped at both the individual and systems levels to meet the full complexity of their needs. The findings of the survey indicate that the foundational competency domains required for geriatric rehabilitation are insufficiently embedded in global PRM training programs. The lack of structured education directly contributes to the workforce shortages and the heterogeneous levels of confidence practitioners report when evaluating core geriatric syndromes. The survey reveals that while practitioners demonstrate reasonable familiarity with clinical guidelines and a genuine commitment to improving their skills, as evidenced by high demand for continuing education, persistent gaps in residency training, interdisciplinary structures, and assessment tool standardization remain. The strong desire for knowledge among practitioners is evident, with 40.5% of survey respondents expressing the highest level of interest in accessing international training and guidelines. Bridging these gaps will require coordinated effort across ISPRM, national societies, training programs, and health systems. The strong appetite for international guidance expressed by respondents is an invitation that ISPRM should seize with urgency, translating it into concrete educational products and policy recommendations that can meaningfully advance geriatric rehabilitation care globally. The survey responses about the adequacy of rehabilitation services to the needs of older people suggest that while a reasonable quality of service exists in most settings, significant room for improvement remains and full age-friendliness is the exception rather than the rule (Table 1). Regarding interdisciplinary consultation capacity, a structural gap was evident from the respondents, as a CGA requires precisely collaborative input. The prevalence of workforce-related barriers also raises a fundamental question about training pipelines and the current adequacy of PRM specialty education in geriatric competencies, a question the survey addresses directly (Table 2, Fig. 1C). Results about the familiarity with clinical practice guidelines for the management of older patients in rehabilitation suggest that enhancing guideline dissemination to PRM practitioners globally should be a priority for ISPRM. While the full quantitative data for the open-ended items of questions are not captured in the survey, the breadth of clinical domains queried reflects the multifaceted competency profile that geriatric rehabilitation demands. The multifaceted rehabilitation framework encompasses physical rehabilitation, nutritional support, cognitive and psychological care, social and environmental adjustment, and medical optimization. Each of these pillars requires practitioners to possess both the theoretical knowledge and the practical tool-based skills to assess and intervene. They represent the core competency domains that PRM education and training systems must address.

Based on the survey findings, the following priority gaps and corresponding recommendations are identified:

1) Residency training curricula: The inadequacy of geriatric content in PRM residency programs is the most structurally significant gap identified. ISPRM and national PRM societies should develop harmonized core curriculum standards that include dedicated modules on CGA, geriatric syndrome assessment, frailty screening tools (e.g., Fried phenotype), sarcopenia assessment protocols (e.g., Strength, Assistance, Rising, Climbing, Falls [SARC-F], grip strength measurement, dual-energy X-ray absorptiometry [DEXA]), dysphagia screening, nutritional assessment (e.g., Mini Nutritional Assessment [MNA], Malnutrition Universal Screening Tool [MUST]), fall risk evaluation, polypharmacy review, and cognitive screening (e.g., Montreal Cognitive Assessment [MoCA], Mini-Mental State Examination [MMSE]).

2) Interdisciplinary team structures: The absence of formal interdisciplinary elderly management units in many centers, combined with limited access to various specialists, limits the implementation of CGA and comprehensive care planning. Advocacy for healthcare system-level investment in interdisciplinary geriatric teams, as recommended by both WHO Rehabilitation 2030 and the European consensus, should be central to ISPRM's policy agenda.

3) Continuing professional development: Given the high demand expressed for international training and guidelines, ISPRM is uniquely positioned to develop accessible CME pathways in geriatric rehabilitation—including online modules, international webinars, and regional workshops—targeting practitioners in all resource settings. Development or endorsement of clinical practice guidelines tailored for PRM contexts would provide actionable guidance to the large proportion of practitioners who rate their guideline familiarity as moderate.

4) Assessment tool standardization: The survey reveals variable practice in the use of validated assessment instruments across multiple clinical domains. Dissemination of a core set of recommended tools—validated, feasible, and where possible, freely available—would help standardize practice and improve comparability of outcomes across rehabilitation settings internationally.

5) Resource-equitable implementation: With respondents from low-resource settings citing workforce and funding barriers at higher rates, any educational or clinical framework developed by ISPRM must be designed with scalability and equity in mind. Context-specific adaptations of training resources and assessment tools—particularly those that do not require expensive equipment—will be essential to bridging the gap between high- and low-income settings.

Similar surveys have been conducted with regard to physical therapy,^12-15) nursing,¹⁶) and healthcare professions curricula.¹⁷) Their findings offer compelling insights into the integration of geriatric-related content into the curricula of healthcare professional degree programs offered by universities around the world. Deficiencies have also been reported in medical education,¹⁸) indicating inadequate preparation for managing complex comorbidities and a lack of multidisciplinary skills required of older people. A revision or update of the current healthcare professional curricula should consider these elements to better address the health needs of the aging population.

Effective geriatric rehabilitation demands mastery of a CGA and management, including frailty, sarcopenia, malnutrition, polypharmacy, dysphagia, risk of falls, and cognitive/mood disorders, competencies that clearly require dedicated curricular attention. The survey data suggest these topics remain insufficiently embedded in many PRM and allied professionals’ training programs globally.

Study Limitations

Our findings should be considered while acknowledging that the respondents’ sample, although embracing all of the five continents, was limited to 75, which is a relatively low number for a society like ISPRM. Africa and Oceania were represented by only n=3 respondents each. This could be due to survey fatigue, since ISPRM members are frequently reached by survey requests, a relatively long questionnaire (more than 10 minutes), lack of regular reminders, not using more than one recruitment strategy. Also, a response bias cannot be excluded, as those who answered the survey were likely interested in geriatric rehabilitation. Another limitation is represented by the formulation of Q13 in the survey, which combines two distinct questions (access to continuing education vs. interest in international training) in a single item. The response distribution should therefore be interpreted with caution.

Conclusion

Geriatric rehabilitation physicians have the potential to lead the necessary healthcare transformation required by a rapidly aging global population and are instrumental in achieving the goals of the United Nations decade of healthy ageing. The demographic reality in many countries, where, even without specialized geriatric care, a large share of outpatient and inpatient populations now consist of older adults, makes the adequacy of the geriatric knowledge in PRM not merely an academic issue but a matter of immediate clinical urgency. To address these critical shortcomings, the field of PRM must prioritize educational reform at the university and postgraduate levels. To build capacity and bridge the current educational gaps, several future steps must be undertaken:

- establish dedicated university curricula and launch an internationally recognized Executive Master in Geriatric Rehabilitation, so that the academic community can cultivate a highly skilled workforce. Bridging this educational gap is not merely an academic exercise, but a clinical imperative to ensure that aging populations receive the high-value, personalized, and age-friendly rehabilitation they require to maintain their independence and quality of life. Currently, there are very few structured academic programs specifically dedicated to this subspecialty, creating a worldwide educational void. This proposed Master's program should be officially endorsed by universities and supported by a global, interdisciplinary faculty to provide rigorous, standardized, and advanced training in geriatric care.

- harmonize University and Residency Curricula. There is an immediate need for ISPRM and national PRM societies to develop and enforce core curriculum standards in university residency programs. These programs must include dedicated modules on the CGA, frailty screening tools (e.g., the Fried phenotype), sarcopenia assessment (e.g., DEXA and grip strength), nutritional screening, and cognitive assessments, allocating an adequate amount of internship hours specific to working with the older population

- access to Continuing Medical Education (CME) and Academic Forums. While university programs are reformed, immediate knowledge translation can be achieved through targeted CME pathways. The ISPRM SIG plans to develop educational seminars and academic forum activities, including a series of webinars delivered in local languages (starting with Spanish) to ensure global accessibility and equity, particularly for practitioners in low- and middle-income settings.