Rehab Intro + SCI Flashcards
What is rehabilitation?
Process of returning a person to maximal physical, psychological, social and vocational functions with their physiologic or anatomic impairment, environmental limitations and desires or life plans.
What is the role of rehabilitation medicine?
Delivers medical management and multidisciplinary therapy to address impairments, limitation in ADLs (disability) and participation restrictions in the person’s social role (handicap)
How does medical model view disability?
Problem of the person, caused by disease / trauma / health condition which requires medical care in treatment by professionals.
- Mx aimed at cure or individual’s adjustment of behaviour if cure not possible
- medical care viewed as main issue
What is the social model of disability?
- Main issue is socially created problem and matter of fully integrating individual within society
- Disability attribute of social environment not individual
- Solution = environmental modifications required for full participation of people with disabilities
What is the FIM score?
Functional Independence Measure: preferred tool in rehab settings. More sensitive development of Barthel scale (adds communication, social behaviour, memory and problem solving to basic domains assessed by Barthel).
What is ICF?
International Classification of Functioning, Disability and Health.
Framework for conceptualisation, classification and measurement of disablity.
What are impairments?
Problems in body function or structure such as significant deviation or loss
What are activity limitations?
- Activity = execution of task or action by an individual
- Activity limitation = difficulties an individual may experience executing activities
What are participation restrictions?
- Participation = involvement in a life situation
- Participation restrictions = problems an individual may experience in involvement in life situations
What are environment factors in the context of rehab?
Physical, social, attitudinal environment in which people live and conduct their lives. Either barriers to or facilitators of the person’s functioning
Example of impairment without limitation?
Disfigurement in leprosy has no effect on person’s capacity
Performance and activity limitation without evident physical impairment?
Reduced performance in ADLs associated with many diseases
Example of Participation restrictions without impairments or activity limitations
e.g. HIV +ve person, ex-patient recovered from mental illness; may face stigma or discrimination
Activity limitations without assistance but no performance problems in current environment - example?
an individual with mobility limitations may be provided assistive technology by society to move around
What are the criteria for suitability for a rehab program?
- Medical stability i.e. pt with untreated CHF cannot participate in exercise program
- Reasonable cognition, or expectation that cognition will improve
- Motivation to attend therapy and participate
- Expectation that program will result in performance gains within a reasonable amount of time
- Availability of supportive family / carers
What are the considerations in starting rehab?
- Who - appropriate v inappropriate
- What: intensity, content
- When: early intervention v post acute
- Where: inpatient, OP, home based, proximity to home, centre of excellence
- Why: realistic expectations (pt and family)
Group most affected by traumatic spinal cord injury?
Males (80%); 15-30y.
Small peak age 65+
Major cause of spinal cord injury?
Road traffic accidents
Aim of early management of traumatic spinal cord injury?
-Preventing secondary cord damage OR preventing cord damage at all in those with vert # w/o cord damage
Where and why are pts with spinal cord damage best managed?
- Specialised acute comprehensive spinal cord service
- Minimise complications e.g. respiratory, bladder, bowel and skin problems
What must be addressed in rehab following spinal cord injury?
- Psychosocial management
- Bladder management
- Skin care
- Bowel care
- Sexual function
- Spasticity
- Autonomic dysfunction
- Pain
- Gait
- Respiratory function
Psychosocial aspects of rehab following traumatic spinal cord injury?
- Mx psychosocial distress
- Review by psych and SW after admission
- Restoration personal and social structures
Bladder management SCI rehab?
- Initially IDC / SPC (removed 3-6/52 post injury)
- condom drainage reflex emptying (for some males)
- intermittent self catheterisation
What baseline tests should be undertaken in bladder management post SCI?
- IVP
- CUG
- Most pts: video urodynamics
Bladder Mx options for pts with LMN lesion?
Usually mobile and can void by increasing intra abdominal pressures:. If incontinent:
- M: condom drainage
- F: artificial external urethral sphincter and intermittent catheterisation
What is required in pts with long term IDC or SPC?
Yearly cystoscopies after 10y of catheterisation.
When does reflex bladder usually occur?
Injuries T12 or above
When does flaccid bladder usually occur?
The flaccid bladder usually occurs below spinal cord injuries of T12 to L1, where the spinal cord injury is in the cauda equina area of the spinal cord.
Why is skin care important in Mx SCI?
- Pt has no awareness of need to relieve pressure on anaesthetic skin / cannot do so
- W/o pressure relief, skin, S/C tissue and muscle become anoxic and die
- Other skin problems from scolds, burns, grazes, shear stresses
What must pt do post SCI regarding skin?
Twice daily skin checks using mirror to visualise areas not in direct sight
How can UMN bowel be managed?
Reflexic; can be regulated with
- good diet with high fibre content
- adequate fluid intake
- aperients and stool softeners
When are aperients given?
~12h before bowel action intended
What is the role of aperients in SCI UMN?
Stimulate bowel function to remove colonic contents into the rectum
How can the patient stimulate rectal emptying (SCI, UMN)?
-Increasing intra abdominal pressure
-gentle digital dilation of sphincter
-+/- suppository
~12h after using aperient
LMN SCI bowel management?
- Empty bowel with abdominal pressure
- To prevent incontinence when rising from chair / car etc, may have colostomy
What are reflex spasms in SCI?
- Reflex spasticity often presents as spasms precipitated by movement after being in one position too long
- Hypertonia may precipitate formation of contractures
How is spasticity managed in SCI?
- Movement of joints and stretching of muscles to full length
- Treat irritatants (e. UTI) that might precipitate spasticity
- When no precipitant and full stretches as often as practical, consider Rx baclofen +/- diazepam
Which patients are disposed to autonomic dysfunction?
High spinal cord injury patients predisposed to unstable BP, esp above T6 lesion
What is autonomic dysreflexia?
Massive rise in BP in SCI pts with autonomic dysfunction. Occurs when noxious stimuli applied below level of injury. Medical emergency
Aids for low spinal cord / incomplete SCI patients?
Aids e.g. Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO)
Return to work post SCI?
- Aided by OT and SW
- Aim to return to same position or different position with same company
- Some may require retraining
What are major late complications of SCI?
- Severe osteoporosis. Not uncommon to break a long bone with relatively minor trauma.
- Post traumatic syrinx: SC may heal with small cyst. 2% cases expand, cause further neuro damage. Emergency.
