REHABILITATION OF THE TRAUMA PATIENT

11 REHABILITATION OF THE TRAUMA PATIENT



Valerie Summerlin


The evolution of the specialty of trauma during the past 30 years has been accompanied by great strides in medical technology. Emergency services and trauma care have become highly sophisticated, creating the ability to save the lives of even the most severely injured people. The introduction of rapid transport from the scene of injury, often involving air evacuation, to designated trauma centers offering expert care has resulted in a new population of injured people who probably would have died several decades ago.


Highly effective emergency and critical care services have created a demand for services that restore quality of life to people who have survived severe injury. The result is the specialty practice of trauma rehabilitation. Needs continue to be identified and services designed to complete the cycle of trauma care.


Trauma rehabilitation begins the instant health care services are provided to a trauma patient. At first the focus is on preventing further injuries by thorough assessment and stabilization. As the patient’s condition stabilizes, the focus changes to restoring and maximizing function. Rehabilitation attempts to meet the patient’s physical, intellectual, and psychosocial needs at each point throughout the trauma cycle.


An understanding of the philosophy of rehabilitation is essential for all nurses engaged in the trauma cycle of care, from those in emergency departments and critical and intermediate care units to those in rehabilitation hospitals, subacute units, long-term acute care (LTAC)/chronic care hospitals, skilled nursing facilities or transition teams, and in-home care agencies. Nurses must think as rehabilitation professionals throughout the trauma cycle to support the patient and family system toward optimal return to function.



DEFINITION OF REHABILITATION


Rehabilitation is “the process by which physical, sensory, and mental capacities are restored or developed in (and for) people with disabling conditions, reversing what has been called the disabling process, and therefore called the enabling process.”1 This is achieved both through functional changes in the individual and through changes in the physical and social environments that surround them.1


Among the many factors that affect patient outcome, the one most influential is the patient’s motivation. It is the role of the rehabilitation professional to support trauma patients until they assume full responsibility for themselves.2,3 For example, depression following a spinal cord or brain injury may hinder self-motivation and prevent the patient from setting his or her own recovery goals.



HISTORY OF TRAUMA REHABILITATION


The focus of rehabilitation following trauma has changed through its development. In its early stages, rehabilitation was referred to as “physical medicine,” primarily referring to restoration of motor skills and adaptation by compensation following physical disability.4 Most early benefits in rehabilitation were seen in patients with acute diseases, such as polio, and in veterans, many of whom sustained disabling spinal cord injuries or lower extremity amputations. Other forms of rehabilitation, such as for psychiatric problems; substance abuse; traumatic brain injury; stroke; behavioral and learning disability; and developmental disorders, received far less attention and treatment. Therefore most of the early rehabilitation programs were oriented to the treatment of the physically disabled. Today an emphasis on motor recovery continues within rehabilitation.


Vocational rehabilitation emerged as a need after the success of individual adaptation to a physical disability. Vocational rehabilitation programs initially involved evaluation of the patient’s physical capacity followed by vocational testing, training, and placement. Subsequently, emphasis was placed on neuropsychological assessment to identify cognitive factors related to work performance. The complex interrelationship among physical, cognitive, and psychosocial rehabilitation remains underappreciated by professionals, patients, families, society, legislators, and third-party payers.


During the 1980s greater attention was given to the development of rehabilitation programs for people recovering from severe brain injury. More than any other disabled population, brain-injured survivors require treatment from professionals in all disciplines working with them on cognitive, physical, and psychosocial issues. For example, it is difficult for a physical therapist to treat a gait disorder and ignore impaired attention and memory. It is impossible for a speech pathologist to help a person overcome a severe dysarthria while ignoring motor control problems that prohibit the person’s use of an augmentative communication system. The brain-injury rehabilitation model expanded rehabilitation from its limited focus on physical and vocational disability to include cognitive, behavioral, and psychosocial disability.


The knowledge gained and techniques learned from the treatment of psychiatric disorders, including substance abuse, have also been integrated into trauma rehabilitation. Substance abuse is becoming more common as a coexisting factor among the injured, requiring addiction treatment to be more available in the rehabilitation process. Also, patients with brain and spinal cord injury who have preexisting learning disabilities will require special consideration during their recovery process. Improvements in rehabilitation programming better meet the needs of all trauma patients. There is heightened sensitivity among health care professionals to identify all the rehabilitation needs of the trauma patient.


There has been a proliferation of rehabilitation services and settings in response to the demand for rehabilitation, yet access to these services remains inconsistent, particularly in the community reintegration phase. Appropriate services are not conveniently available to all trauma patients because of poor understanding of what specialized services are required, decreased appreciation for recovery potential, and lack of funding. Infrequently, disabled patients must go out of state for specialized rehabilitation programs. This does not support continuity from the trauma center to a rehabilitative environment. It is important that the full continuum of services be available within the patient’s community if possible.


The Balanced Budget Act of 1997 (BBA) deeply affected health care delivery in the United States. This Act contained numerous cost-saving measures for rehabilitation hospitals, home health agencies, skilled nursing facilities, and outpatient programs. The payment method was restructured and reduced reimbursement, particularly Medicare reimbursement, for rehabilitation services.5 A dramatic impact has already been experienced by health care providers.6,7 In response, numerous rehabilitation providers have eliminated staff, sold their practices, or closed their programs. Without funding to support rehabilitation services, the availability of care will decline significantly. The government’s goal is to eliminate overuse and abuse of services.



TRAUMA POPULATIONS THAT REQUIRE REHABILITATION


Most trauma patients require some rehabilitation services. Services may be as basic as the emergency department staff providing patient and family education about postconcussive symptoms and the availability of follow-up services for a patient with a mild brain injury. Provision of this rehabilitative teaching can avoid unnecessary patient suffering. More severely injured persons require specialized rehabilitation services based on their diagnosis. Patterns of services have been established for many disabilities. The most common specialized rehabilitation programs in trauma are for spinal cord injury, brain injury, orthopedic and soft tissue injury, and multiple trauma. Pediatric and adult rehabilitation are distinct subspecialties. Each group benefits from different rehabilitation program components, including unique facilities, equipment, mix of professionals, and approaches to treatment. The Commission on Accreditation of Rehabilitation Facilities (CARF) provides standards for comprehensive integrated inpatient rehabilitation programs, spinal cord system of care, brain injury, home- and community-based rehabilitation, health enhancement, medical rehabilitation case management, outpatient medical rehabilitation, pediatric family-centered rehabilitation, occupational rehabilitation, and stroke specialty programs. These standards have evolved and been refined over 40 years with input from providers, consumers and purchasers of services.8 These standards define the expected input, processes, and outcomes of rehabilitation programs.


Spinal cord injury programs place a strong emphasis on patient/caregiver education, offering a comprehensive program addressing issues such as coping with spinal cord injury, sexuality, attendant/caregiver issues, skin/nutrition, parent and child care issues, travel issues with mobility and home accessibility, bowel and bladder management, and health and wellness. A CARF-accredited spinal cord system of care program maintains expertise to provide services in both its inpatient and outpatient components.8 This specialized system of care provides or formally links with key components of care that address lifelong needs of the persons served.8 Advances in computer technology, electrical muscle stimulation, management strategies for neuropathic pain, and research in nerve cell growth are shaping the future of spinal cord injury rehabilitation. (See Chapter 23 for additional information.)


Patients with head trauma benefit from programs specializing in brain injury that focus on reaching the best possible patient outcomes. These outcomes will drive the treatment plan and delivery for each individual patient.9 The goal for patients in such a program is to reduce disabilities while obtaining the maximum independence and best quality of life in the least restrictive setting. The pace and the extent of a patient’s recovery from a brain injury can vary considerably, even between patients with similar injuries, depending on whether proper physical and cognitive rehabilitation was provided.9 In patients with traumatic brain injury, two different scoring systems are used that can help determine needs for rehabilitation services: the Glasgow Coma Scale10,11 which quantifies level of consciousness and severity of brain injury, and the Rancho Los Amigos Scale,10,12 which levels patients based on their cognitive deficits and behavioral characteristics. (For more information on these scoring systems, see Chapter 20.)


Recovery from a brain injury is a long, unique, complex process, and rehabilitation is just one phase in the continuum of care. The acute phase is often followed by outpatient rehabilitation or home care. The rehabilitation program used depends on the degree of deficit resulting from the injury.10 Patients in coma require multisensory stimulation and prevention of physical complications caused by immobility. Confused patients or those displaying inappropriate behavior need specific behavioral modification and therapeutic behavioral approaches, taking into consideration the safety of the patient. Patients with mild brain injury who have persistent problems, such as difficulty concentrating or poor memory, may find outpatient rehabilitation or therapy sufficient. All health care team members should address improvement in cognitive function and social awareness. The physical effects of brain injury are as varied as the cognitive deficits. (See Chapter 20 for information specific to the brain-injured patient.)


The patient education component of brain injury rehabilitation is also unique. Because of the patient’s cognitive and behavioral deficits, most of the teaching about the injury, its effects, and management of problems is provided to the patient’s family and support systems. As the patient recovers enough insight to learn and use the information, more teaching is provided. This is also true in the provision of psychosocial support.


Patients with orthopedic or soft tissue injuries and those with multiple-system trauma need a rehabilitation program with both medical and surgical emphasis. Complex injuries may require an extended time for recovery because of multiple surgeries. Attention is given to prevention of infection and other complications during tissue healing. Amputees may require the use of prosthetic or adaptive devices. Psychosocial support addresses changes in body image, loss of independence and control, and lower self-esteem. Health education commonly emphasizes the patient’s physical needs and should expand to address psychosocial issues.



COMPONENTS OF REHABILITATION


Although certain trauma populations require a specialized rehabilitation program for the best outcome, several components are common to all programs regardless of the setting. Two key elements to maximizing the patient’s potential are the integrated team approach and the development of an individualized rehabilitation plan.



REHABILITATION TEAM


Not unlike other specialties in health care, trauma rehabilitation requires an integrated team approach. The concept of a team as a group of specialists working toward a common goal is simplistic, yet it is implemented quite literally in the rehabilitation setting. Also inherent in this team philosophy is congruency in goals, consistency in approach, and communication among all team members.13 Most teams treat a specific group of patients exclusively. Members of the interdisciplinary team constantly ensure that everyone on the team is aware of the plan of care for each person served. Exchange of information is fostered between team members, and the established plan is implemented.8 Decisions about the plan are made in collaboration with the persons served and communicated to all members of the team.


Early rehabilitation teams were multidisciplinary, with each specialty having separate goals and approaches. This method offered the benefit of input from many specialties to the patient’s plan of care, but each discipline had individual goals. Fragmentation of care became a major problem.


The use of an interdisciplinary team avoids fragmentation. Each member of the team focuses on a particular area of expertise and blends with the expertise of other team members. In an interdisciplinary approach, patient goals are developed by the team rather than by each discipline. An example of this is the cooperative effort of behavior modification strategies used to manage a brain-injured patient’s agitation. Consistent approaches to patient behavior may include reducing external stimuli, avoiding patient fatigue, and providing treatment in a quiet area.


A growing approach in team dynamics, the transdisciplinary team,14 is similar to the interdisciplinary team in the method in which mutual goals are formed. Team members often include family and patients. Team members bring their special expertise to the group. The distinguishing characteristic in this model is that each member is responsible for sharing observations about all aspects of the patient’s rehabilitation, particularly when the team meets to review progress. An observer of the team would find it more difficult to determine each member’s primary discipline based on his or her verbal input during a team conference. Disciplines may approach therapeutic treatments collectively rather than individually. Physical and occupational therapists may have joint therapy sessions with the patient to establish the most appropriate custom wheelchair for proper positioning. A speech pathologist, occupational therapist, and rehabilitation nurse may schedule a mealtime session with the dysphagic patient to assess and establish team approaches to feeding.


Each team specialist has the responsibility to address the overall functional goals for the patient. It takes mature professionals to let go of the traditional territory associated with each discipline, allowing team members to make observations across disciplines while understanding the perspectives of fellow team members.



Composition of the Team


The team is composed of those who have input into the rehabilitation plan, including the patient, family members, and care providers. The team can number just a few or consist of a large group of specialists. Rehabilitation for specific injuries requires a complement of appropriate specialists who are able to meet the comprehensive needs of the patient. In some cases the mix of team members reflects more physical rehabilitation emphasis in the early phases (e.g., a comatose patient on a ventilator). Often the cognitive and psychosocial components of rehabilitation are implemented further along in the cycle. By the time the patient is in the reintegration phase, the physical impairments may have been largely resolved, leaving the team focused primarily on psychosocial adaptation after injury.


All members of the team are equally essential to the patient’s success. Some disciplines, such as nursing, case management, and social services, remain involved with the patient throughout the continuum of care, but the focus of their involvement may change. Other primary team members are involved for limited periods during the initial critical care phase, working with the patient more extensively through the intermediate and rehabilitation phases. For example, physical, occupational, and speech therapists are intensively active during the intermediate and acute care periods and throughout rehabilitation hospitalization.


The most important member of the rehabilitation team is the patient. It is the responsibility of the professionals on the team to help the patient understand his or her active role in rehabilitation. In many outpatient rehabilitative settings, patients are referred to as “clients,” reflecting the cooperative investment between the injured person and the rehabilitation professionals. As the patient moves through the trauma care cycle, he or she sheds the patient role and returns to a status of self-responsibility.15



Team Leadership


To ensure that the most appropriate and individualized team is organized, a team leader assumes a holistic view of the patient’s rehabilitative process and anticipated outcome. The team leader defines a realistic expected outcome for each patient. In addition, the team leader, either directly or indirectly, determines which specialists will be needed on the team. The form of leadership used by a team may vary. Models of team leadership include the physician-led team, the multidisciplinary team, the rehabilitation coordinator role, and the case manager role.


Early team models were based on physician leadership. The physician ordered rehabilitation therapies and progress reports from the therapists to establish patient goals. The advantage of this model was consistency of goals for all members. But by limiting the input and influence of a variety of disciplines, this structure can yield goals based only on the physician’s perspective. In the early years of trauma rehabilitation, most rehabilitation goals were related to mobility and self-care achievements, often neglecting cognitive, linguistic, and psychosocial needs. This scope of rehabilitation reflected the priorities the physician chose for the patient’s outcome. Many of the physicians attending to trauma patients had limited knowledge of and experience in the specialty of rehabilitation. Currently, in all CARF-accredited rehabilitation programs, the medical director of the program is board certified in his or her specialty area and has completed a formal residency in physical medicine and rehabilitation, a fellowship in rehabilitation for a minimum of 1 year, or has a minimum of 2 years’ experience as a collaborative team member providing rehabilitation services in a comprehensive inpatient rehabilitation program.8



Rehabilitation Nurse.


As a member of the integrated disciplinary team, the goal of the rehabilitation nurse, as identified by the Association of Rehabilitation Nurses, is to assist individuals with disability and/or chronic illness to attain and maintain maximum function.16 The rehabilitation nurse, in addition to providing hands-on nursing care, is responsible for coordinating the educational activities. The rehabilitation nurse is teacher, caregiver, collaborator, and client advocate.16



Case Manager.


The role of case manager was introduced when managed care sought to save costs by streamlining care. Managed care initiated the use of external case managers—that is, clinicians, who do not provide direct care but who review and manage catastrophic cases with high costs to insurance companies and are employed or contracted by the insurer.17 Many of these cases involve traumatic injuries. Facility-based case management has become the standard of practice for many rehabilitation programs.


Most case managers are registered nurses, but there are other models that combine the social worker and case management role together. They monitor and coordinate a rehabilitation plan that is clinically advantageous to the patient but also extends the patient’s health care funding to the best use of coverage and clinical benefit as projected over the long-term course of recovery. Some case managers, often those employed by third-party payers, follow the care during the patient’s lifetime, spanning multiple clinical settings.17 Case managers working for medical care providers do not follow the patient on a long-term basis; however, they do consider the future impact of health care decisions.


The case manager’s role is to coordinate and facilitate access to timely and appropriate health care services and ensure continuity throughout the recovery continuum. The case manager is a valuable resource to help ensure that the patient receives the health services and benefits needed to make the best recovery possible. The case manager keeps the patient served, and the family and the insurance company informed about the treatment and progress toward rehabilitation goals. They act as advisor, mentor, and advocate throughout recovery and return to work. Some organizations also include the role of discharge planner in the case manager role.


It is important in all aspects of rehabilitation care to encourage patients and families to become informed and active members of the health care team. Initiatives nationwide are promoting this concept as the health care industry focuses on patient safety. During the recovery phase it is important to keep the family involved and, as the patient is able to participate, the case manager, along with the team, will need to bring the patient into the decision-making process.



REHABILITATION PLAN



Rehabilitation Potential


Thorough assessment and evaluation of the patient’s rehabilitation potential are the first steps following trauma. Although it is difficult to predict a final outcome after trauma, there are parameters that help to determine the amount and rate of a patient’s potential progress. These factors represent the patient’s strengths and weaknesses in the areas of physical, cognitive, and psychosocial functioning.2,18 Other factors that influence rehabilitation potential are the patient’s age, length of time since injury, premorbid health, support systems, secondary complications, and availability of resources.



Physical Factors.


For some disabilities there are wellestablished outcomes. These outcomes are changing as technology advances. Perhaps in the future there will be fewer physical limits because medical technology will be able to replace, rebuild, or stimulate regrowth of injured areas of the body. For example, there is an extensive body of research focused on promising interventions for repair of the injured spinal cord, such as cell transplant to bridge the area of injury and neurotropic agents to stimulate neuronal regrowth. Although a complete discussion of these interventions is outside the scope of this chapter, it is important that rehabilitation professionals maintain their awareness of current research so that their patients can benefit when new products and/or initiatives become available.


Concurrent diagnoses also influence rehabilitation outcome. Many trauma patients have multiple injuries, preexisting conditions, or complications of trauma that significantly impact their potential to recover. As the population ages, the incidence of trauma in the elderly will constitute a prominent proportion of trauma patients.19 Individuals are physically active well into their 80s and beyond, and thus are subject to the risks of an active adult lifestyle. The effects of normal aging and a higher likelihood of concurrent medical conditions, such as diabetes, osteoporosis, and multiple injuries, complicate healing and make rehabilitation of the elderly more difficult.20



Cognitive and Psychosocial Factors.


If physical impairment were the only factor determining rehabilitation potential, two patients with similar injuries would have comparable outcomes. Cognitive and psychosocial factors influence rehabilitation outcome as well. Cognitive factors include the patient’s ability to learn new things, solve problems, and make appropriate judgments and decisions; educational level; readiness to learn; prior experiences; and many other complex factors.21 Psychosocial factors, including income, family support, lifestyle, mood, relationships, personality, and coping ability, all affect the patient’s potential. Today, with the culturally and economically diverse backgrounds of our patients, health care providers’ responsibilities include working with interpreters and understanding the culture and financial needs of the patient to determine best interventions and expected outcomes.



Evaluating Rehabilitation Potential.


Each professional working with a trauma patient needs to evaluate the patient’s rehabilitation potential. The clinician first defines the rehabilitation outcome that is typically expected for others with the same injury as the patient. The outcome can be further analyzed by assigning a probability factor or percentage of predicted success to the estimated outcome. For example a patient who has had a traumatic below-the-knee amputation may have excellent potential to return to work and be independent in activities of daily living with the use of a prosthesis. However, when the evaluator considers that the patient is 53 years old, developmentally disabled, lives alone, and has sustained multiple infections and required numerous stump revisions, the potential for independent living and return to work becomes significantly lower. Recognizing these probability factors provides rehabilitation professionals with a clearer picture that the patient either will need significantly greater resources or may not be able to reach the standard desirable outcome. The focus of the integrated team is to work with the patient to achieve the most independent level of care no matter where the patient will be discharged. Maximizing independence optimizes quality of life.


Rehabilitation potential should not be a question of yes or no or good or poor. The important point is that the rehabilitation assessment summarizes the positive aspects that will support rehabilitative efforts and considers strategies to work with or around the negative aspects to prevent failure. Nearly every patient has some potential for improvement, but the potential must be weighed against what is both cost effective and a reasonable expectation for patient success.


From a quality-of-care perspective, an individual’s expected outcome and rate of recovery dictate the type of rehabilitation program that is best for the patient. Cost-benefit analysis is a critical element in the formulation of rehabilitation program recommendations following the evaluation of potential. The ability of the rehabilitation industry to measure its success and failure with clinical and functional outcomes will greatly influence future decisions.


Realistic goals are set for the patient, and an estimated time for achievement is established. If these goals are individualized and sensitive to the patient’s strengths and weaknesses, any patient should have good potential to achieve his or her unique rehabilitation goals.



Goal Development


The development of long-term and short-term patient goals is a collaborative process. The goals are adjusted based on the patient’s progress and should reflect the uniqueness of the patient. Long-term goals reflect a phase of the patient’s recovery after hospitalization. Short-term goals are the achievable steps toward the overall long-term goal. Goals should be functional, such as dressing or transferring, and directed toward overcoming the impairment. Goals can also be developed for the family to demonstrate knowledge about a concept or mastery of an intervention. For example, teaching about range-of-motion techniques can be done with the goal that the family will be able to perform this intervention for the patient in a persistent vegetative state after a severe brain injury. Increased range of motion alone is not a functional goal. However, the resulting improved positioning when seated in a chair benefits the patient’s quality of life and avoids complications by increasing stimulation, improving hygiene, reducing spasticity, and preventing decubiti and contractures. To establish a functional goal, the team considers the most realistic and appropriate outcomes for an individual patient. Ambulating for 20 feet is a measurable goal. The ability to get to and from the bathroom focuses on function and is measurable. All goals should be measurable and reproducible. The appropriateness of specific goals should be meaningful to the patient’s functional independence.


For successful rehabilitation, mutuality of goals between the patient and the rehabilitation specialists is essential.15 Mutuality is a concept defined as a unified acceptance and agreement by both parties of what will be achieved. It should be based on the patient’s value system, not that of the professional. Often a trauma patient begins treatment with a fairly passive position in the plan of care. The patient usually agrees to follow the regimen or to allow treatments to be conducted without much thought or question. As the crisis period subsides, the patient becomes more interested and actively involved in decision making.


The assumption that a compliant patient is an ideal patient is misleading. Even the term compliance suggests that the decision and plan are created and enforced by outside sources. It is the patient, not the staff, who has the ultimate responsibility for outcome. The patient should be included as an equal partner in the decision-making process. Values play a major role in the functional goals set by both the staff and the patient. A conflict in values should be recognized openly, and mutual goals should be sought. Education in culture and values clarification is helpful to staff members working in rehabilitation to prepare for resolution of these conflicts.

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Jul 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on REHABILITATION OF THE TRAUMA PATIENT

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