Physical Medicine & Rehabilitation Flashcards
WHO ICF (international classification of functioning, disability, & health) defines rehabilitation as
The ability of an individual to participate in “living”
Medical diagnosis vs. rehabilitation diagnosis
Medical -> focus on disease process (e.g. 65 yo w/ stroke)
Rehabilitation -> focus on functional consequences of disease (e.g. unable to walk)
Functional assessment requires an understanding of
- Disease
- Impairment
- Disability
- Handicap
Impairment definition
Any loss or abnormality of psychological, physical, or anatomical structure or function (e.g. lower extremity paralysis)
Disability definition
Any restrictions or lack of an ability to perform an activity in the manner or range considered normal for a human being (e.g. inability to operate foot pedals in vehicle)
Handicap definition
A disadvantage for a given individual that limits or prevents the fulfillment of a role that is normal for that person - depending on age, sex, social and cultural factors (e.g. pt. can’t drive for his job)
Sites of rehabilitative care - inpatient
Rehab hospital, SNF
Sites of rehabilitative care - outpatient
Hospital-based clinic, independent clinic, day hospital, home
Who is admitted for inpatient rehab?
Must have at least one of 13 conditions (e.g. neurologic, MSK, etc.)
Must receive 3 hours of therapy 5d/wk
All pt. in inpatient rehab must….
Have 24h availability of a physician with expertise in rehabilitation & nursing care
Be managed by an interdisciplinary team of skilled nurses & therapists
Have a reasonable expectation if improvement
SNF
24h nursing care
Dietary, pharm, dental, social services
Supervised by a physician
Goal: maintain function
How often should services be prescribed & recertified by a physician for home-based care?
60 days
Who is eligible for home-based services
Pt. requires intermittent or part0time skilled nursing care/therapy (<7 days per week or <8 hours per day)
Pt. is homebound (considerable effort to leave their home)
Medicare coverage for SNF
Per diem rates regardless of problem
Medicare coverage for home-based care
Rates based in OASIS (outcome & assessment information set)
- Lengthy assessment for reimbursement
What providers should consider choosing site of care
- Severity of impairments
- Functional status, ability to withstand active therapy
- Social support, need for full-time caregiver
- Insurance plan
Goal of interdisciplinary team management
Ensure pt receives comprehensive assessments & interventions for
- The disabling illness and comorbid conditions
- The specific impairments and environmental factors that may affect activities and participation
Impact of cormorbid conditions on rehabilitative care
- Interrupt ot delay tx
- Require adaptations in the care plan
Reducing the impact of comorbidities: Delirium
- Screen for toxic or metabolic contributors (e.g. meds, electrolyte disturbance)
- Sensory aids
- Planned reassessment for improvement if confusion limits rehabilitation potential
Reducing the impact of comorbidities: DVT, PE
- Mobilization
- Compression stockings
- Warfarin or LMWH
- Intermittent pneumatic compression
Reducing the impact of comorbidities: Depression, apathy
- Screening for depression
- Medication, counseling, support group
Reducing the impact of comorbidities: Kidney or bladder infection
- Avoidance, removal of indwelling catheter
- Check of postvoid residual
- Frequent toileting
- Prophylactic abx RARELY helpful
Reducing the impact of comorbidities: PNA
- Mobilization
- Tx of COPD prn
- Flu & penumococcal vaccine
- IS
- Screening, precautions for aspiration risk
Reducing the impact of comorbidities: Skin breakdown
- Mobilization & positioning
- Monitor pressure & wt.-bearing areas
- Pressure-relieving mattresses, cushions
- Early care with dressings
Goals of rehabilitation
- Restore function
- Compensate for & adapt to functional losses
- Prevent secondary complications
- Maximize potential for participation in social, leisure, or work roles
Examples of rehab interventions
- Therapeutic exercises (flexibility, strength, motor control, CV endurance)
- Speech & language therapy
- Cognitive rehab
- Pain mgmt
- Fitting of mobility aids, orthotics, prosthetics
- Practice of task-specific activities (e.g. transfers)
- Retraining activities (e.g. grip)
- Balance training
- Retraining in ADLs (e.g. cooking)
- Massage, heat, cold, US to decrease pain & muscle spasm
What is the Harris Hip Score?
Measures outcomes after hip surgery
People >__years are at highest risk for morbidity & mortality from stroke
55
> __% are likely to survive from a stroke, but with many neurological deficits
80
Stroke-related deficits are severe in about ___% of survivors
33
Recovery is most dramatic in the first ___ days post-stroke
30
Stroke severity should be assessed using the
NIHSS
After hip fx, __% of pt. require transient long-term care, and about __% of those remain in long-term care 1 year later
50; 25
__% mortality in the year following hip fx
25
After hip fx, __% recover to prior level of function, but up to __% require assistive devices
75; 50
Two key factors to hip fx rehab
- Early mobilization
- Frequent initial therapy
Acute rehabilitation after hospital D/C results in….
Results in superior outcomes
Preventing recurrent hip fx
- Diagnose & tx osteoporosis, balance problems
- Encourage safety awareness
- Assistive devices prn
- Consider calcium, vitamin D supplementation
What is the most common elective procedure in the US?
Joint arthroplasty
- Provides pain relief & improved functioning!
Most common reason for failure of joint arthroplasty
Implant loosening
Rehab after total hip arthroplasty (modifications, goal)
- Avoid bending over to tie shoes, crossing legs
- Raised toilet seat during rehab period
- Rehab focus: muscle strengthening (esp. abductors)
Rehab after total knee arthroplasty (modifications, goal)
- Key to return of fcn -> recovery of ROM
- Continuous passive motion machine (CPM) + PT -> increases ROM, decreases length of stay
- Compression stockings, CPM, cryotherapy to reduce swelling
How do you use a cane
In hand contralateral to affected limb (reduces wt. bearing on opposite leg)
What is the most important factor for stability with the use of a cane
Proper length (distance from distal wrist crease to the ground in erect pt.)
Two types of canes:
Straight, quad
Purpose of a walker
Completely support one lower extremity (NOT full body wt.)
Two types of walkers:
Stationary “pick-up”, wheeled/rolling/rollator
Use of pick-up walker requires
Strength + cognitive ability
Benefit of pick-up walker
Very stable, allows for non-weight bearing movements
Benefit of wheeled walkers
Allow smoother, more coordinated, faster gait
Which type of walker provides more stability?
Pick-up
Which type of walker is easier to advance?
Wheeled
Who uses wheelchairs & scooters?
Patients who cannot safely use or are unable to ambulate with other mobility aids
Motorized wheelchairs are good for these two populations
- Bilateral arm weakness (lack ability to operate wheelchair)
- Severe cardiopulm disease (lack endurance)
Purpose of orthotics
Designed to assist, resist, align and stimulate function
How are orthotics named
By the use of letters for each joint involved
e.g. AFO = ankle & foot orthotic device
Adaptations to facilitate dressing
- Shirts that fit overhead
- Hooks, loops, velcro
- Long, loose socks
- Long-handled shoehorn (the fuuuuu is this)
- Elastic shoelaces
Environmental modifications
- Assistive devices (e.g. reachers)
- Bars installed near tub/shower, toilet
- Raised toilet seat, bathtub bench
- Long-handled bath brushes, hand-held shower faucet, & “soap on a rope”
