Chapter 14 Rehabilitation
Introduction
• Rehabilitation has many definitions, most of which include the terms optimising function, multidisciplinary, quality of life and patient-centred (Sinclair and Dickinson 1989).
• It might be helpful to consider the word as an umbrella term covering many aspects of patient care.
• Traditionally rehabilitation has focused on the restoration of function as seen in many areas of sports medicine where full recovery is anticipated.
• Many of the patients that physiotherapists work with have progressive long-term conditions where the nature of the injury or illness results in a permanent changes in the structure and function of the body (impairments) (DOH 2005, WHO 2001).
• All therapists will encounter patients where age-related changes have occurred, some of which may be irreversible.
• In these presentations the restorative approach cannot fully meet the needs of the individual.
• Contemporary rehabilitation needs to be able to cover a range of care aims that together make up holistic patient-centred rehabilitation (Table 14.1).
Table 14.1 Holistic patient-centred rehabilitation
| Rehabilitation focus point | Intervention and treatment possibilities |
|---|---|
| Assessment and review | Use ICF to identify the impairments and activity limitations and participation restrictions to ascertain the nature and severity of the presentation |
| Empowering | Education and support to individuals and their carers about the situation to allow them to take an active role in their care |
| Supportive | Provision of appropriate support strategies to help the patient and family cope with their condition/presentation |
| Restorative | To promote/encourage/facilitate improvement in function for patients with new deficits resulting from a disease process, trauma or surgery |
| Maintenance | Provision of treatments, equipment, care and guidance to maintain gains made by the individual |
| Preventative | Anticipation of potential complications and difficulties |
| Palliative | To improve comfort and reduce discomfort, e.g. pain |
| Enablement | To maximise the use of existing functions |
| Conditioning | To improve endurance and strength in activities for patients who have become de-conditioned by poor nutrition or prolonged acute/chronic illness |
Rehabilitation of patients with neurological presentations
• The rehabilitation of patients with neurological issues will require the physiotherapist to follow a problem-solving, multidisciplinary approach in order to ensure that the patient receives effective management.
• The principles of assessment, team working, patient-centred care and goal setting will assist the physiotherapist to develop a timely, appropriate, patient-centred treatment plan for the rehabilitation of each patient.
• It is important to remember that treatment and intervention can be required at any stage in a person’s life. Rehabilitation may be needed following an injury and initial diagnosis or for many reasons including end-stage palliative care.
• Treatment can be provided in a variety of settings including outpatient clinics, acute hospital wards, intensive care units, community day hospitals, schools, at work and in the home and private services.
• Many of the patients and their families or carers will have encountered many different health care professionals and will have become experts in their condition. They may be seeking advice and guidance on how best to manage their condition at any one time. Long-term conditions require long-term management.
• Working in partnership and listening to what the patient says are essential to the effective management of their problems. As the expert in physical therapy the physiotherapist will be able to identify appropriate treatment or care plans with the patient, based on the findings of the assessment.
• The individual may require the services of several different members of the health and social care team at any one time, therefore the skill of the individual member of the team is to identify the most appropriately skilled health or social care professional for each patient. This requires ongoing communication over time, across service settings, with the need to access reviews both in the community and in the hospital being integral to the patient’s programme of rehabilitation.
• It requires health care professionals to have a knowledge and understanding of what their colleagues can offer and how to access their services and how to make onward referrals.
• In summary it’s about accessing the right services at the right time. Physiotherapy is often only part of the solution.
• Using a case history and referring to the International Classification of Function (ICF) the physiotherapy management of a patient presenting with neurological problems will be outlined in the following section (WHO 2001).
• To ensure that each patient has an appropriate treatment plan all of the components of the ICF must be included in the assessment.
ICF-based patient case study
• A 28-year-old male suffered a traumatic brain injury following a road traffic accident.
• He underwent neurosurgery to remove an intradural haematoma and suffered further anoxic brain damage during a postoperative cardiac arrest.
• Initially he was intubated and ventilated for 2 weeks and then had a tracheostomy.
• He had abnormal levels of consciousness for several weeks with a fluctuating Glasgow Coma Scale score ranging from 3/15 to 9/15 (Teasdale and Jennett 1974).
• He was weaned off the ventilator after 1 month, spontaneously breathing and opening his eyes.
• He had poor swallowing ability and dysarthric speech.
• A percutaneous endoscopic gastrostomy (PEG) was inserted to maintain his nutritional status (Kirby et al 1991).
• He was managed on a general neurological ward for 8 weeks and referred for rehabilitation.
• Following this he was transferred from the acute hospital setting to a specialist neurological rehabilitation inpatient setting with the PEG in situ.
• At the point of discharge from the acute setting the tracheostomy was removed and some verbal output was noticed with single words being uttered.
• Abnormal tone was present in all four limbs and he was unable to move independently in bed, e.g. rolling, lying to sitting.
• He demonstrated no ability to balance in sitting and had poor head control requiring specialist seating and support.
• Then followed 18 months of inpatient rehabilitation, involving specialist seating, splinting, swallow assessments, the use of communication cards, prevention of contractures, maintenance of range of movement, control of movement and strengthening.
• He was then moved into a long-term residential placement for fully supported living and was dependent for all personal activities of daily living.
• At this point he continued to need the PEG to maintain adequate nutrition, but was starting to take oral food and fluid as his swallow had improved.
• Behaviourally he often spat out drinks and would not take adequate volumes to maintain hydration.
• After 6 months in his long-term residential placement his family requested that he return home with support from health and social services.
• At this point 27 months after the initial injury the social worker who was supporting the re-settlement into the community requested involvement of the community rehabilitation team and made a referral to physiotherapy.
Assessment of the patient (using the ICF classification model)
See Tables 14.2 and 14.3.
Table 14.2 Body structure and function, activity and participation
| Impairments (body structure and function) | Activity limitations | Participation restrictions |
|---|---|---|
| Limited concentration Behavioural issues, shouting out | Difficulty following commands and listening | Limited options for social interactions. Unable to get outside bedroom easily |
| Poor memory Dysarthric speech Poor planning | Difficulty communicating his needs | |
| Slow oral phase of swallow | Difficulty learning new tasks Unable to maintain fluids without use of PEG | Difficulty getting carers that will look after the PEG site |
| Abnormal voluntary control of his trunk | Unable to sit independently without full support | Fully dependent for all activities of daily living |
| Abnormal voluntary control of his hands | Unable to manipulate objects effectively | |
| Abnormal voluntary control of the left leg, extensor spasms | Unable to keep feet on foot plate | Has limited control over his environment |
| Contracture of the left foot into plantar flexion and inversion | Unable to be placed in a standing position | |
| Contracture of the right knee (30° flexion) | Unable to straighten the right knee to assist with washing and dressing | Unable to shower dependent on bed wash only |
| Incontinent of urine and faeces | Unable to toilet himself or indicate when he requires toileting | |
| Fear of new movement | Takes time to get to know new care staff |
Table 14.3 Contextual factors: environmental and personal
| Environmental | Personal |
|---|---|
Interventions and treatment plan
Prioritising the interventions
• Using the structure of the ICF gives an overall picture of the patient’s issues and highlights the specific problems.
• The important issue for the rehabilitation team is to determine what they can influence most effectively and which area will have the biggest positive impact on the individual.
• Identification of which problem to tackle first may require careful discussion with the team and with the individual and the family.
• It is possible to work on several areas at once. Experienced clinicians will consider the risks involved in not addressing an issue and the consequence and likelihood of there being unacceptable risk if an area is not addressed.
• In this case the risks of social isolation, increasing frustration and disruptive behaviour as a result of being unable to access more than one room were deemed to be the priority issue.
• There was a high likelihood of isolation occurring and the consequences to the individual would impinge on his ability to improve during rehabilitation.
• The importance of giving him some control was also considered to be of high importance to facilitate improvements in his behaviour.
• Removal of the PEG was viewed as being low priority and low risk, but it was something that could have been addressed relatively easily.
• In summary, this case illustrates the type of patient that may be encountered and the multiple issues that they may be associated with. Logical organised assessment and effective communication with other team MDT members will ensure that patients receive an appropriate treatment plan and effective interventions.
Patient-centred care and team working
• Considering activity and participation issues in the case can be used to illustrate patient-centred care and team work.
• This young man is fully dependent on others and at the time of assessment had difficulty communicating his needs to others.
• There was fear and frustration present with evidence of behavioural issues.
• A patient-centred approach should explore the appropriateness of the environment, control over the environment and the communication difficulties and access issues.
Actions for the health team
• Submit reports to housing and social services to ensure client becomes a priority for re-housing. Information sharing between health and social services is important to ensure that the impact of the housing issue is understood in terms of its impact on the individual’s potential for recovery and improved health status.
• These reports are best compiled as an MDT report.
• The physiotherapist information should focus on the mobility issues, e.g. wheelchair dependence and need for a hoist for transfers from bed to chair and chair to commode.
• The occupational therapist will report on other equipment issues, e.g. the need for a wet room that is wheelchair accessible, and that will allow a carer to shower the patient using a specialist shower cradle.
• The report will identify that the patient requires specific access in and out of the property to facilitate the care plan, which includes 3-weekly trips to a day centre for therapy intervention.
• Education and advisory role for the family, to explain why the patient needs accommodation that does not impose restrictions on the way in which he is managed at home.
• To review the need for a PEG feeding system.
• Control over the environment and communication of needs (Barnes 1994, Young 2003).
• During this time the patient was re-housed and further assessments for equipment needs to assist the issues the patient had with limited balance and mobility.
• A problem identified in the new accommodation was a difficulty with showering, the patient required 2-3 people to be able to shower due to the risk of slipping out of the shower chair.
SMART goals for the patient and his family
• To drink sufficient fluid over a 24-hour period to maintain adequate hydration on an ongoing basis.
• To be able to operate a lap switch when sitting in the wheelchair and be able to turn the television on and off consistently in 2 months time.
• To shower in safety with assistance of two people in 2 months time.
• The goal attainment scale was used to evaluate the input, with goals set and achieved (Turner-Stokes 2009).
• All the goals required input from the patient, family and team.
• The team worked together to share skills and knowledge for the benefit of the patient.
• The case is ongoing with long-term monitoring and support available for the patient.
• Chronic conditions require ongoing assessment, patient-centred goal setting and involvement of the multidisciplinary team.
• The goals need to be reviewed and progressed as needed following reassessment.
Treatment of complex trauma
• Rehabilitating complex trauma patients can be a daunting undertaking when the patient presents with multiple injuries, both physical and psychological.
• This section provides an indication of the framework with which to progress the patient through the stages of recovery.
• Guidance is provided to assist the reader to recognise when it is appropriate to take the next steps in rehabilitation and when the progression has been too rapid.
Getting started
• The trick to getting this right is in the assessment, planning, and being logical in the way treatment is applied.
Things to consider when planning a rehabilitation programme
The ability of the patient to learn and retain information
• Have they had a traumatic brain injury?
• Are they able to process the information they have been given to aid their recovery?
• Are they able to remember the information, exercises and treatment in their planned programme?
• Is the medication they are taking having an influence on their mental state/memory/processing ability?
• There is no point in giving the patient verbal information if they have poor short-term memory, and are likely to forget.
• Think of the alternatives, e.g. write plans down, write instructions for exercises or provide the patient with pictures of the exercises they need to do.
• A good idea is taking pictures of the patient doing their own exercises using their camera or mobile phone, it can be a fun activity and helps to remind them what to do.
• They will need to provide consent for copies of the photographs of their exercises to be included in their patient records.
• Use visual cues to remind them to actually do their exercises or treatment, e.g. sticking post-its or coloured stickers around the room in key places, can help to jog the patient’s memory.
Goal setting
• The setting of long- and short-term goals and making them specific to the patient is key to achieving a successful outcome in rehabilitation.
• A problem-orientated approach to goal setting is most commonly used, with rehabilitation teams defining specific, measurable goals that have been developed in conjunction with the patient.
• Patients often pick a goal which is difficult to achieve in the short term, e.g. climbing stairs in their house, so they can go home from the hospital.
• Break down the task for them into smaller goals, which they can realistically achieve.
Goal-setting example
• To get up stairs a patient needs to be able to flex their knee and hip to 90°, currently they are able to flex to 20° in each joint.
• Grade 4 quadriceps, gluteal muscles and good balance are required to achieve this.
• Setting them a goal of increasing their ROM by 10° increments per week, their power and balance in similar increments, is achievable.
• If they are given a time line (Table 14.4), they will have an idea about how long it will take to reach their target.
• Warning! Before setting goals and targets are set ensure all pathology and healing times and possible setbacks are taken into consideration.
• If more than one pathology is in existence at any one time, things will often not go according to plan.
• It is essential to constantly reassess and redefine goals as necessary.
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