rehabilitation

Introduction

Restoration of the disabled person to self-sufficiency or maximal possible functional independence.

Indications

• deconditioning
• contractures, paralysis
• injury, trauma

Procedure

Includes

• physical
• psychological
• social
• vocational
• leisure
• educational

Goals

• stabilize primary disorder
• prevent secondary complication
• treatment of functional deficits
• adaptation
  • patient to disability
  • environment to patient
  • family to patient

Rehabilitation settings

• acute medical/surgical ward
• acute inpatient Rehab unit
  • long-term acute care hospital (mechanical ventilation)
• subacute inpatient - transitional care unit (TCU)
• nursing home
  • for older patients who require posthospital rehabilitation, but cannot tolerate standard rehabilitation (3 hours/day, 5 days/week) rehabilitation may be performed in a skilled nursing facility
  • 5 days/week or rehabilitation are required in the nursing home for Medicare reimbursement
• outpatient
• in home therapy

Rehabilitation team

• physical therapy
• occupational therapy (not required in SNF for Medicare reimbursement)
• speech-language pathologist
• therapeutic recreation therapist
• rehab nurse
• psychiatrist
• social worker
• psychologist
• prosthetist/orthotist
• vocational counselor

Assessment

• functional independence measure
• Barthel index

Management

progressive mobilization

• bed position/ bed mobility
  • avoid neck flexion
  • avoid pillows under knees
  • avoid external rotation of hip
    • stroke
    • hip fracture
  • keep ankles flexed to 90 degrees
  • keep arms abducted
• range of motion (ROM)
  • use functional activities for ROM
  • muscles crossing 2 joints more likely to tighten
    • hamstrings, gastrocnemius, finger flexors
• sitting tolerance
  • end goal: out of bed 12-14 hours/day
  • day 3 goal: 2.5 hours sitting tolerance
  • limited by pulse & blood pressure response
  • correlates with ability to strengthen
  • add 15 minutes to sessions TID
  • sitting balance also important
• transfers
  • bed height so feet touch floor
  • put shoes on: do NOT transfer in stockings
  • chair parallel to bed, on patient's stronger side with raised footplate between patient's foot & bed
  • make sure chair is locked
  • remove obstacles
  • stand in front of patient - close
  • NEVER pull on arm
  • patient sits on edge of bed with slight lean forward
  • have patient stand with strong hand on armrest of chair, weak hand on bed
  • strong foot, then weak foot with small steps turning until in front of chair
  • back legs against chair, sit
• standing
  • enables transfers & ADLs
  • strengthes multiple muscles
• stair climbing
  • if bad leg, use crutches, don't step on bad leg
    • up: good leg 1st, crutches & bad leg follow
    • down: crutch down 1st, bad leg down, the good leg
• ambulation
  • requires patient to sit unsupported & stand up unassisted
  • stand slightly behind weak side
  • place your right hand on belt & left hand on front of patient's shoulder, but give him/her freedom to move
  • never hold patient just by arm or let him/her hold onto you
  • always turn to good side
  • turns need wide base of support
  • to sit down again, walk up to chair (bed/toilet, etc), turn around, back up stepping with good foot 1st, until back of legs against chair
  • let go of walker with one hand, reach back to chair armrest, ease down

exercise

• early gains in strength (1st days to weeks)
  • little change in muscle size
  • due to neural adaptations
    • improves coordination & muscle activation
• exercise in elderly requires longer warm-up & cool-down period
• complete fitness program should contain
  • aerobic conditioning
    • 20-60 minutes/day
    • may be interspersed throughout day
    • minimum of 10 minute sessions
  • strength training
    • isokinetic training better than isotonic or isometric training
  • flexibility training
• exercise tolerance testing prior to exercise program
  • known coronary artery disease
  • symptoms of cardiac angina
  • risk factors for coronary artery disease
• diabetics: monitor blood sugar before & after exercise

specific conditions which may require precautions

• osteoporosis
  • protect the spine & extremities
  • avoid high impact exercises
    • jogging
    • high-impact aerobics
  • avoid exercise risky for falls
  • avoid strenous twisting
  • keep spine in proper alignment
  • avoid forward flexion
• diabetes mellitus
  • watch for hypoglycemia after exercise
  • increase carbohydrate intake prior to exercises
    • 15 g of carbohydrate for every 30 min anticipated exercise
  • proper foot care
  • avoid jogging/running if neuropathy or peripheral vascular disease is present
  • avoid resistance training if retinopathy is present due to risk of ocular hemorrhage
• osteoarthritis
  • avoid high-impact activities
  • swimming or cycling can be helpful
  • goal: strong & balanced muscles with good joint range of motion
• hypertension
  • ensure blood pressure is well controlled before starting exercise program
  • moderate intensity exercise is preferable
  • avoid caffeine before a workout
  • resistance training should use high repetitions, low weights

Notes

• futile cycle beginning with hospitalization -> rehabilitation -> rehospitalization -> rehabilitation ... death without ever returning home described; C difficle colitis, delirium & falls implicated in the cycle
• for risk of poor outcome related to transitional care see transitional care

More general terms

• medical therapy; therapeutic intervention

More specific terms

• auditory rehabilitation
• cancer rehabilitation
• cardiac rehabilitation
• comprehensive rehabilitation
• intense rehabilitation
• neurorehabilitation
• peripheral arterial disease rehabilitation
• pulmonary rehabilitation
• remediation
• subacute rehabilitation
• vestibular rehabilitation
• vision rehabilitation

Additional terms

• comprehensive rehabilitation
• deconditioning
• disability
• functional independence measure (FIM)
• handicap
• intense rehabilitation
• long-term acute care hospital (LTAC)
• rehabilitation hospital
• subacute rehabilitation