Rehabilitation

Aims to minimise disability (loss of function) and handicap (social consequences) of impairment (defect in any organ)
Epidemiology
Rehab in surgery
The Rehab Process
Amputation
Spinal Injury
Brain Injury
Elderly Surgical Pt

Epidemiology

500 million live with disability.
Increases with age in developed countries
- 1/3 adults are impaired
- 1/3 of impaired disabled
- 1/3 of disabled handicapped.
Many causes
- sensory problems in 16%
- mental problems in 10%
- congenital cause in 8%
Physical problems cause more handicap.

Rehab in Surgery

Post op
Referral appropriate when:
- post-op disability and handicap is substantial
- spontaneous resolution is unlikely
- time to recovery is likely to be prolonged.

Surgery as rehab
Eg correction of hand deformity in RA.

Principles
1. Pre-op assessment
- pre op mental, functional and physical status will influence post-op rehab programmes.
- many problems can be anticipated and prevented
- eg quad strengthening prior to knee replacement
2. Early post op mobility
-  else deconditioning and complications
3. Multidisciplinary
4. Customised to individual

Rehab Process

1.  Assessment
- assess principal impairment
- note other impairments
- note premorbid physical status
- note mental factors (cognition, mood)
- note premordbid social status / supports / money.
Generally pts either 'young / fit' or 'old / frail'.

2.  Setting Goals
Team should work toward common goeals
Team meetings help define goals
Goals should be:
- realistic, pt centred
- flexible in case not progressing
Can set short, mid long-term goals.

3.  Providing Therapy
Physio, OT, SLT, psychologists, dietitians, social work, nursing staff, medical team.
Input of each depends on pts needs

4. Aids & Appliances
From toilet seats to prosthetic limbs.
Use judiciously
- inappropriate use promotes dependence.
- and reinforces disability
OT home visits often clarify needs.

5. Monitoring Progress
Regular formal meetings
- discuss progress
- ensure goals met
- identify aspects inhibiting progress
- collectively plan further care

6. Education, 2ndry Prevention
Impairment, disability and handicap have a complex interplay.
Educate pt to minimise risk of further problem.
Prevent psychological morbidity.

7.  Discharge planning
Gains for rehab should be maintained.
Remember pts will need to be more independent at home
Remember stressors on carers.
30% of hospital discharges are delayed.
- good discharge planning improves hospital efficiency.

Limb Amputation

Epidemiology
80% are older than 60.
- most have PVD and comorbidities.
- 50% die in 3 yrs
- 25% on non-diabetics and >50% diabetics will need a second amputation within 5yrs.
Small younger group post-trauma or post-cancer.
Functional outcome depends on:
- level of amputation
- premorbid health (esp CVS)
- motivation
The majority can return home

Pre-op Conditioning
Maintain mobility and activity of other limbs
Improve general condition
Maximise cardiopulmonary reserves
Psychological support and education

Post-op cares
Desensitize stump - massage/TENs
Stabilise residual limb colume / decrease oedema / promote healing
- eg rigid/soft dressings, shrinkers, elastic bandaging.
Increase muscle strenght
Maintain mobility, prevent contractures.
Maximise independent living skills
Facilitate transfers
Facilitate wheelchair mobility

Prosthetic training focus:
Balance re-education
Ability to transfer
General conditioning / fitness
Stump cares
Fitting prostheses
Gait training
Hopping with aid
Walking on slopes

Types of amputees
Level of amputation is a clinical decision
- based on vascular status
- try to preserve the knee as greatly reduces energy reqd in walking
Preserve max possible length in arms
- allows better prosthetic control
- if taken at shoulder no prosthetis possible.
- when 60% of forearm lost, supination/pronation impossible.

Trans-tibial

Walking generally atainable in unilaterals
- bilaterals selective results
Energy redq for walking 24-40% higher.
No gait aids needed.
Can stand / walk 2hrs.
Can climb steps / work with some restrictions.

Transfemoral

Walking achieved in <80s and fit older people
Energy needs up 60-100%.
Otherwise as for trans-tibials for unilaterals
For bilaterals, energy needs >100% normal
- over 40s are often incapable.
- training is trialled in the motivated.
- standing / walking for 1hr possible.
- need an amputee wheelchair.

Transradial / Transhumeral
Teach one handed fx
Transfer dominance to other hand
Rapid return with prosthesis to bimanual use.
- only 37% of upper limb amputees use their prostheses 8hrs a day.
- a 'golden period' exists, ie fit the prosthesis in 30days and they will be more used.
If unilateral should return to near normal function with some restrictions
If bilateral acquire help gettin on prosthesis, many restrictions, but relatively normal life.

Pain
Phantom sensations (70%)
Become more prox when pts walking
Then tend to disappear.
Massage, vibration, TENS help
Stump pains (25%)
Ischaemia, infection, neuroma.
?poorly fitting prosthesis.
Phantom limb pain
Burning, knife-like.
Pathophysiology unclear.
Massage, TENS, walking, psychological interventions (eg biofeedback, relaxation) help.
- if lasts >6mo, difficult.
Neuralgic pain meds, eg carbamazepine, tricyclics.
Incidence related to pre-op limb pain extent
- hence reduce by aggressive pre-op pain control with epidural blocks.

Spinal Cord Injury

Aim is max independence compatable with injury.
Inpatient to begin with
- paraplegics need at least 3mo
- tetraplegics at least twice this

Focuses on:
Neurogenic bladder/bowel control
Spasticity management
Skin care
Aids
Sexuality, fertility
Psychological adaptation
Outcomes are often predictable:
Level
Key Muscles
Muscle Fuction
Feeding
Bladder &Bowel
Weight shifts
Chair transfers
Locomotion
Driving
>=C4
SCM, trapezius
Neck control
Possible
Dep
Dep
Dep
Dep
Unable
C5
deltoid bicep
Partial sh/elbow
Indep (aids)
Dep
Dep
Assisted
Indep w wheelchair
Unable
C6
ECRL&B
Pro Teres
Wrist ext/pron
Indep
Indep w bowel
Indep
Indep w board
Indep w wheelchair
Able (aids)
C7
Triceps
Lat Dorsi
Sh/Elbow
Indep
Indep
Indep
Indep
Indep w chair
Able (aids)
C8
FDP
Hand fx
Indep
Indep
Indep
Indep
Indep
Able (aids
Individuals w C7 injuries may live alone - triceps facilitates transfers.

Common problems:
DVTs (10-64%)
LMWH for 8 wks
- then risk decreases
- higher risk for tetraplegics
Orthostatic hypoT
More likely w high injuries
- tilt on table
- stockings
- poss fludrocortisone
Autonomic dysreflexia
Sudden sympathetic surges.
Remove noxious stimuli eg fecal impaction, blocked catheter.
Elevate head of bed
Give GTN.
- nifedipine if reqd.
Heterotopic ossification
1-3mo after injury
Formation of bone in soft tissue
- usually below injury in large jts
- physio maintains movement
- NSAIDs for pain.
- serial bone scans

Traumatic Brain Injury

Prognostic factors
Severity / duration of coma
Duration of post-trauma amnesia
Over 40s do worse
Early specialised care helps
Branstem dysfunction is bad.
2/3 of survivors of severe TBI have significant residual physical, emotional and cognitive problems.

Rehab Focus
Maximising natural recovery
Compensatory techniques
Aids
Education of pt and family

Problems

Post-TBI syndromes
behavioural excess
disinhibition
emotional lability
akathisia
- reduce stimulation
- minimise injury risk
- educate

Spasticity
Painful spasms and fx disturbance
- positional techniques
- stretching
- orthoses / casting
- dantrolene baclofen, nerve blocks, intrathecal pumps, tendon transfers

Cognitive deficit
Attention, concentration, initiation, judgement, communication, learning and memory affected.
- self-talk to enhance skills
- repetition, association, categorisation, imaging
- external strategies (lists, alarms)
- task analysis (breaking down tasks)

Epilepsy
5% closed, 35-50% open injuries
Rx not needed if do not occur beyond 2 wks.

Elderly Surgical Pts

Elderly pts are increasing
- aging population
- high surgical burden in the elderly
- better risk-benefit ratio in modern practice
- increasing health expectations

Rehab and elderly
- multiple problems
- reserves become attenuateed
- rapid deconditioning.
Perhaps more to offer in rehab for elderly as spontaneous recovery less likely.
- cost effective (reduces stay length)
- less institutional demands
Shd have close liason with AT&R services
Falls a major issue (-->90% of #s in elderly)
- balance and strength training
- reduce postural hypotension risk
- revew environmental hazards
- reduce meds if possible.

Problems
Delerium
Often an exacerbation of underlying dementia.
Precipitating factors should be sourght
- infection
- drugs
- electrolytes
- stroke, MI etc.
Avoid psychotropics as exacerbate and prolong delerium.

Pain
Older people get more side effects from meds
Constipation is common, esp when mobility poor.
- always prescribe aperients with them.
NSAIDs cause GI upset
Dextropropoxyphene causes confusion.

Constipation +/- urinary retention
Often atypical
High index of suspicion, get XR / USS if reqd

Undernutrition
Common in the elderly surgical pt
- eat less, need more.
- even obese may be undernourished.
Routine dietetic advice helpful.