AC - Rehabilitation Flashcards
What is rehab?
Process of helping person achieve fullest potential across many domains (physical, social, psychological, vocational, educational)
Maintain health and prevent secondary complications
What are the main principles of rehab?
Consistent with the person’s life goals, environmental limitations and impairment
Holistic approach - significant inter-disciplinary and multi-disciplinary contribution
Addresses patient issues in all domains – communication, mobility, self-care, cognition, behaviour, social supports, community access
Patient needs to be suitable for a rehabilitation program
SMART goals - tailored, monitored, reviewed and revised
What factors contribute to determining a patient’s suitability for rehab?
Medically stable
Appropriate supports available (social, family, carers)
Cognition adequate memory & problem-solving skills to allow them to learn new skills
Motivation & mood
Expect performance gains within a timely manner
What are important components of goal setting in rehab?
SMART - specific, measurable, achievable, relevant and timely
Monitored and reviewed regularly
Include current issues as well as predicted issues and prevention of further possible impairments or their complications
How can goals/progress be monitored?
Barthel, FIM, ICF scales
Assess patient performance across various domains
Measure and quantify performance gains and rehab progress + determine level of funding and care needs
Barthel mainly used in aged care - Dressing, continence and ambulation
FIM specific to rehab setting - Barthel + communication, problem-solving, memory, social behaviour
ICF body functions & structure, environmental factors (barriers & facilitators), activities & participation
What do you need to consider when planning a rehab program?
- Patient suitability
- Where it will take place
- Timing of commencement
- What it will involve and the intensity
- Manage pt and family expectations
- Goal setting
- Early discharge planning and post-discharge therapy planning
What are common cognitive issues in TBI?
Global impairment
Slowed processing of information
Cognitive fatigue
Cognitive overload - irritable/behavioural when overstimulated
Impaired attention & concentration - esp. divided attention
What tools are best for assessing congnition in TBI?
NuCOG, CLQT, Cognistat - validated for TBI and cover good range of cognitive domains
How can you manage cognitive deficits in TBI rehab?
- Education to patient and family about fatigue, behaviour, cognitive deficits, effects of alcohol and drug intake, good sleep hygiene
- Education about driving +/- occupational driving test
- Vocational rehabilitation provider promote return to work or new work opportunities
- Social reengagement
What are common neurological issues in TBI?
- Visual changes hemianopia, diplopia, impaired accommodation
- Anosmia
- Balance/coordination dizziness/vertigo
- Language deficits
Focal neurological deficits uncommon
What are common Medical issues in TBI?
- Mood disorders - common, screen for them
- Spasticity +/- contractures focal or generalised
- Post-traumatic epilepsy increased risk if seizure occurs between 24 hrs – 72 hrs, high risk injury
- Endocrine diabetes insidious, SIADH
- Heterotrophic ossification abnormal bone deposition around joints, causes pain, limits ROM, increases spasticity, conservative Rx (NSAID) or surgery if impairs function
What are common signs of depression in rehab patient?
slowed or stalled rehab progress, refusal to engage in activities, anhedonia, deteriorating cognition
Insomnia, appetite disturbance less common in this group
What are the criteria for mild, moderate, mod-severe & severe head injury and their prediction of impairment and recovery time?
- Mild injury PTA 4 weeks, expect significant disability, permanent deficits certain
What are common long-term lifestyle issues in TBI?
- Difficulty returning to work financial hardship
- Difficulty maintaining or forming personal relationships social support, isolation
- Minimal participation in age-appropriate recreational activities
- Increased strain on family supports
Difficulty living independently in the community
What are the important acute Rx and goals for spinal cord injury?
Prevention of secondary cord damage (if vertebral #) - Careful movement stabilising aids, team, surgical, Halo vest or collar to prevent hyperextension injuries
Neurological assessment and classification of patient to ASIA (American spinal injury association)
Optimise health status and prevent complications associated with immobility
(DVT, Wound Rx, Pressure area monitoring, Nutrition and fluids, bowel and bladder - IDC or acute suprapubic catheter (SPC), diet & fluids and aperients, monitoring & Rx of labile BP, adequate analgesia
Optimise psychosocial status and minimise secondary mood disorder
(Early psychiatry and social work consultation, Monitor mood, early management strategies)
What are the ASIA spinal injury categories?
A complete injury
B incomplete (sensory but no motor preservation below injury level)
C incomplete (motor function preserved, 50% key muscle groups 3 power)
E normal
What are important issues for Rx & goals in medium-long term for spinal injury patients?
Bowel & Bladder
Neuropathic pain or musculoskeletal pain
Mobilisation and independence
Skin management
Sexual function & fertility
Psychosocial - coping, mood, return to work
How can bowel & bladder be managed in spinal injury patient?
Secondary complications (i.e. constipation, incontinence, acute retention, UTI, psychological distress)
Education and counselling on long term changes and management
Baseline imaging IVP, CUG
SPC, reflex condom drainage (men) or intermittent clean self-catheterisation
Consider urinary antiseptics
Optimise dietary intake of fibre and fluids & apperients (UMN bowel is reflexic)
Consider ileostomy or colostomy for LMN bowels (LMN bowel requires increased abdominal pressure to empty)
How can pain be managed in spinal injury patient?
Psychosocial strategies to enhance ability to cope with ongoing musculoskeletal or neuropathic pain
Optimise analgesia medications gabapentin, Pregabalin most effective (Amitriptyline also useful)
Increase physical activity
How can you optimise mobility in spinal injury patient?
Orthosis Gait retraining programs Wheelchair and cushions Commode chair for showering and bowel care Home modification (access and safety)
How can you manage spasticity and tone issues in spinal cord patient?
Regular movement and repositioning of patient
Regular movement of joints and complete stretching of muscles to full length (physio)
Baclofen +/- diazepam, intrathecal baclofen (generalised spasticity/increased tone), botulinum injection (specific muscle group effected)
Common medical/acute and rehab goals in rehabilitation setting?
- Optimise health status i.e. nutrition, BP, glycaemic control, hydration, infection, wound management
- Prevent complications and reoccurrence - falls risk identification/reduction strategies/injury prevention, VTE prophylaxis, pressure monitoring, mood monitoring, mobilisation, secondary prevention of stroke/CVD, prevent contractures
- Promote return to pre-morbid function - assess baseline & current function, optimise current abilities, compensatory and modifications, mobility, confidence, nutrition, pain and mood not limiting function
- Maximise participation and facilitate reintegration across all domains (social, vocational, educational..) - physical, psychological, carer supports, skills retraining, education, driving
- Early discharge planning and follow-up
What are some prognostic indicators for stroke rehabilitation & recovery?
Severity of stroke - shrug shoulders at 2 weeks, fine movement within 6 weeks, early attention deficits, behavioural or executive dysfunction, LOC at time, size and site of stroke, sitting balance, visuospatial deficits
Age
Social situation, presence of carer
Premorbid function and mobility
Comorbidities
What is the expected recovery rate in stroke rehabilitation?
Most rapid gains in first 3 mths, esp. first month
Usually maximally recovered by 6 mths - minimal gains thereafter
Secondary prevention of stroke
- BP, glycaemic, lipid control - drugs
- Aspirin + dipyridamole OR clopidogrel
- Carotid endarterectomy within 2 weeks if >70-75% stenosis
- Anticoagulation in AF, stop clot promoting meds i.e. HRT
- ACEI - BP control + reduces risk of stroke recurrence
- Alcohol abstinance for 1st year and no more than 2/day thereafter
How common is depression post-stroke?
Very common - ~40% become depressed
Risk of depression remains higher for significant period after stroke ~2 years
What advice to give about driving to patient’s after stroke?
- Can’t drive for one month after
- Require doctor assessment thereafter - will either ok driving or refer to OT Ax to confirm
- May be able to return to driving if deemed safe, may need some modifications to assist them if impairment or may have restricted license
- Must inform VicRoads and insurance company of stroke event to ensure continued coverage
