The rehabilitation medicine prescription is a communication tool between the referring physician and the rehabilitation team in both the inpatient and outpatient settings. This instrument is critical in both directing a course of treatment as well as minimizing risk to the patient during the treatment sessions. The goal of this article is to provide an overview of the rehabilitation prescription with an emphasis on safety.
The rehabilitation medicine prescription is a communication tool between the referring physician and the rehabilitation team in both the inpatient and outpatient settings. This instrument is critical in both directing a course of treatment as well as minimizing risk to the patient during the treatment sessions. The goal of this article is to provide an overview of the rehabilitation prescription with an emphasis on safety.
Medical history
A thorough review of the patient’s medical history is the foundation for the rehabilitation medicine prescription. Information is typically obtained from the patient, family members, clinicians with knowledge about the patient’s medical condition, and the patient’s medical record.
In the body of the history of present illness, the details of the chief complaint for which the patient is seeking medical attention should be emphasized. Here the physiatrist should allow the patient or if possible a family member to express the history and symptoms in his or her own words. A review of the chart should also be done to summarize all of the important medical or surgical information needed for treatment. It should be organized in a chronologic narrative manner, including onset, location, duration, severity, modifying factors, associating symptoms, treatment, and functional status.
Precautions—general considerations
Patients referred for rehabilitation often have several comorbid medical conditions. It is important to think systematically about these conditions and their potential impact on the patient during his or her rehabilitation treatments. For example, if a lower extremity amputee with diabetes, coronary artery disease, peripheral vascular disease, and neuropathy is referred for rehabilitation, what are the specific risks posed to the patient while undergoing rehabilitation, and how can they be minimized? The rehabilitation medicine prescription should address the risks associated with each of these medical conditions in the context of rehabilitation. In addition, one should also take into consideration the main condition for which the patient is being referred and its own risks to the patient’s safety.
Precautions in the general prescription should take into consideration the various interventions that are commonly used by members of the rehabilitation team such as modalities and exercise.
Modalities are of added benefit to many therapy programs. In prescribing modalities, it is important to take into consideration various patient specific factors such as:
Sensory deficits
Decreased vascular supply
Underlying scars
Underlying malignancy
The patient’s ability to communicate
Cognitive impairments
Presence of metal objects in the body (eg, joint replacements, bullets, shrapnel)
Presence of implanted electronic devices (ie, pacemakers, baclofen pumps, spinal cord stimulators
Pregnant uterus
Presence of superficial infections
Active joint diseases (ie, rheumatoid arthritis).
The choice of modality should also be carefully considered (ie, heat, cold, electrical stimulation), as well as the frequency, intensity, duration, and type of modalities.
Cold Therapy
General precautions to the use of cold modalities include history of cold intolerance, arterial insufficiency, impaired sensation, Raynaud disease, cryoglobulinemia, and cognitive and communication deficits.
Heat Therapy
When applying a heat modality, care must be taken not to apply it over: areas of acute trauma or sites of active inflammation, areas with impaired sensation, edema, scars, areas that are poorly vascularized, or areas that are malignant. Additionally, it should not be used in people with impaired communication or cognition. Similar general heat precautions apply to use of ultrasound as well with additional precautions.Ultrasound should not be applied over the brain, eyes, reproductive organs, the pregnant uterus, the spine or laminectomy sites, and areas with skeletal immaturity. Shortwave diathermy should not be used in patients with metallic devices such as pacemakers, intrauterine devices, deep brain stimulators, or surgical implants, near contact lenses, or with skeletal immaturity. Patients using hot packs should never lie on the pack. Since transcutaneous electrical nerve stimulation can cause skin irritation, stimulus areas should be rotated. The duration for most modalities is 20 the 30 minutes except for ultrasound, which is 5 to 10 minutes per site.
Exercise
The choice of exercises should also be carefully considered in the rehabilitation medicine prescription, since different types of exercises carry their own specific risks. Commonly prescribed exercises include resistive, endurance, and balance training exercises. Strengthening exercises including isometric, isotonic, and isokinetic exercises should be rhythmic, performed at low-to-moderate speed, and done through a full range of motion. The patient should maintain full breathing, since heavy resistance training associated with a patient holding his or her breath can result in dramatic rises in systolic and diastolic blood pressure. Recommended guidelines for strength training include; performing a minimum of 8 to 10 exercises that train the major muscle groups, 1 set of 8 to 12 repetitions resulting in volitional fatigue for each exercise, and exercise for no more than 1 hour. Exercises should be performed at least 2 days per week. Isometric exercises should be used with caution in individuals with hypertensive and cardiac disease. Isotonic exercises can be performed with free weights or an exercise machine. Proper lifting techniques should be used to avoid injury. The equipment used should be maintained in good condition to prevent injury. Exercise machines are safer to use when compared with free weights. They require less training and stabilize the body. Additionally, it is easier to control the exercise throughout the range of motion. Patients should also be instructed to perform the exercise in a pain-free range.
Precautions—general considerations
Patients referred for rehabilitation often have several comorbid medical conditions. It is important to think systematically about these conditions and their potential impact on the patient during his or her rehabilitation treatments. For example, if a lower extremity amputee with diabetes, coronary artery disease, peripheral vascular disease, and neuropathy is referred for rehabilitation, what are the specific risks posed to the patient while undergoing rehabilitation, and how can they be minimized? The rehabilitation medicine prescription should address the risks associated with each of these medical conditions in the context of rehabilitation. In addition, one should also take into consideration the main condition for which the patient is being referred and its own risks to the patient’s safety.
Precautions in the general prescription should take into consideration the various interventions that are commonly used by members of the rehabilitation team such as modalities and exercise.
Modalities are of added benefit to many therapy programs. In prescribing modalities, it is important to take into consideration various patient specific factors such as:
Sensory deficits
Decreased vascular supply
Underlying scars
Underlying malignancy
The patient’s ability to communicate
Cognitive impairments
Presence of metal objects in the body (eg, joint replacements, bullets, shrapnel)
Presence of implanted electronic devices (ie, pacemakers, baclofen pumps, spinal cord stimulators
Pregnant uterus
Presence of superficial infections
Active joint diseases (ie, rheumatoid arthritis).
The choice of modality should also be carefully considered (ie, heat, cold, electrical stimulation), as well as the frequency, intensity, duration, and type of modalities.
Cold Therapy
General precautions to the use of cold modalities include history of cold intolerance, arterial insufficiency, impaired sensation, Raynaud disease, cryoglobulinemia, and cognitive and communication deficits.
Heat Therapy
When applying a heat modality, care must be taken not to apply it over: areas of acute trauma or sites of active inflammation, areas with impaired sensation, edema, scars, areas that are poorly vascularized, or areas that are malignant. Additionally, it should not be used in people with impaired communication or cognition. Similar general heat precautions apply to use of ultrasound as well with additional precautions.Ultrasound should not be applied over the brain, eyes, reproductive organs, the pregnant uterus, the spine or laminectomy sites, and areas with skeletal immaturity. Shortwave diathermy should not be used in patients with metallic devices such as pacemakers, intrauterine devices, deep brain stimulators, or surgical implants, near contact lenses, or with skeletal immaturity. Patients using hot packs should never lie on the pack. Since transcutaneous electrical nerve stimulation can cause skin irritation, stimulus areas should be rotated. The duration for most modalities is 20 the 30 minutes except for ultrasound, which is 5 to 10 minutes per site.
Exercise
The choice of exercises should also be carefully considered in the rehabilitation medicine prescription, since different types of exercises carry their own specific risks. Commonly prescribed exercises include resistive, endurance, and balance training exercises. Strengthening exercises including isometric, isotonic, and isokinetic exercises should be rhythmic, performed at low-to-moderate speed, and done through a full range of motion. The patient should maintain full breathing, since heavy resistance training associated with a patient holding his or her breath can result in dramatic rises in systolic and diastolic blood pressure. Recommended guidelines for strength training include; performing a minimum of 8 to 10 exercises that train the major muscle groups, 1 set of 8 to 12 repetitions resulting in volitional fatigue for each exercise, and exercise for no more than 1 hour. Exercises should be performed at least 2 days per week. Isometric exercises should be used with caution in individuals with hypertensive and cardiac disease. Isotonic exercises can be performed with free weights or an exercise machine. Proper lifting techniques should be used to avoid injury. The equipment used should be maintained in good condition to prevent injury. Exercise machines are safer to use when compared with free weights. They require less training and stabilize the body. Additionally, it is easier to control the exercise throughout the range of motion. Patients should also be instructed to perform the exercise in a pain-free range.
Related posts:
Patient Safety and Quality Improvement in Rehabilitation Medicine
Patient Safety Considerations in the Rehabilitation of the Individual with Cognitive Impairment
Patient Safety in Rehabilitation Medicine: Traumatic Brain Injury
Falls in the Inpatient Rehabilitation Facility
Safety Considerations During Cardiac and Pulmonary Rehabilitation Program
Patient Safety in the Rehabilitation of Children with Spinal Cord Injuries, Spina Bifida, Neuromuscular Disorders, and Amputations
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