AC - Rehabilitation

Question 1

What is rehab?

Answer 1

Process of helping person achieve fullest potential across many domains (physical, social, psychological, vocational, educational)

Maintain health and prevent secondary complications

Question 2

What are the main principles of rehab?

Answer 2

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

Question 3

What factors contribute to determining a patient’s suitability for rehab?

Answer 3

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

Question 4

What are important components of goal setting in rehab?

Answer 4

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

Question 5

How can goals/progress be monitored?

Answer 5

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

Question 6

What do you need to consider when planning a rehab program?

Answer 6

1. Patient suitability
2. Where it will take place
3. Timing of commencement
4. What it will involve and the intensity
5. Manage pt and family expectations
6. Goal setting
7. Early discharge planning and post-discharge therapy planning

Question 7

What are common cognitive issues in TBI?

Answer 7

Global impairment
Slowed processing of information
Cognitive fatigue
Cognitive overload - irritable/behavioural when overstimulated
Impaired attention & concentration - esp. divided attention

Question 8

What tools are best for assessing congnition in TBI?

Answer 8

NuCOG, CLQT, Cognistat - validated for TBI and cover good range of cognitive domains

Question 9

How can you manage cognitive deficits in TBI rehab?

Answer 9

• 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

Question 10

What are common neurological issues in TBI?

Answer 10

1. Visual changes hemianopia, diplopia, impaired accommodation
2. Anosmia
3. Balance/coordination dizziness/vertigo
4. Language deficits
   Focal neurological deficits uncommon

Question 11

What are common Medical issues in TBI?

Answer 11

1. Mood disorders - common, screen for them
2. Spasticity +/- contractures focal or generalised
3. Post-traumatic epilepsy increased risk if seizure occurs between 24 hrs – 72 hrs, high risk injury
4. Endocrine diabetes insidious, SIADH
5. Heterotrophic ossification abnormal bone deposition around joints, causes pain, limits ROM, increases spasticity, conservative Rx (NSAID) or surgery if impairs function

Question 12

What are common signs of depression in rehab patient?

Answer 12

slowed or stalled rehab progress, refusal to engage in activities, anhedonia, deteriorating cognition

Insomnia, appetite disturbance less common in this group

Question 13

What are the criteria for mild, moderate, mod-severe & severe head injury and their prediction of impairment and recovery time?

Answer 13

1. Mild injury PTA 4 weeks, expect significant disability, permanent deficits certain

Question 14

What are common long-term lifestyle issues in TBI?

Answer 14

1. Difficulty returning to work financial hardship
2. Difficulty maintaining or forming personal relationships social support, isolation
3. Minimal participation in age-appropriate recreational activities
4. Increased strain on family supports
   Difficulty living independently in the community

Question 15

What are the important acute Rx and goals for spinal cord injury?

Answer 15

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)

Question 16

What are the ASIA spinal injury categories?

Answer 16

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

Question 17

What are important issues for Rx & goals in medium-long term for spinal injury patients?

Answer 17

Bowel & Bladder

Neuropathic pain or musculoskeletal pain

Mobilisation and independence

Skin management

Sexual function & fertility

Psychosocial - coping, mood, return to work

Question 18

How can bowel & bladder be managed in spinal injury patient?

Answer 18

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)

Question 19

How can pain be managed in spinal injury patient?

Answer 19

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

Question 20

How can you optimise mobility in spinal injury patient?

Answer 20

Orthosis 
Gait retraining programs 
Wheelchair and cushions 
Commode chair for showering and bowel care 
Home modification  (access and safety)

Question 21

How can you manage spasticity and tone issues in spinal cord patient?

Answer 21

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)

Question 22

Common medical/acute and rehab goals in rehabilitation setting?

Answer 22

1. Optimise health status i.e. nutrition, BP, glycaemic control, hydration, infection, wound management
2. 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
3. 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
4. Maximise participation and facilitate reintegration across all domains (social, vocational, educational..) - physical, psychological, carer supports, skills retraining, education, driving
5. Early discharge planning and follow-up

Question 23

What are some prognostic indicators for stroke rehabilitation & recovery?

Answer 23

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

Question 24

What is the expected recovery rate in stroke rehabilitation?

Answer 24

Most rapid gains in first 3 mths, esp. first month

Usually maximally recovered by 6 mths - minimal gains thereafter

Question 25

Secondary prevention of stroke

Answer 25

1. BP, glycaemic, lipid control - drugs 2. Aspirin + dipyridamole OR clopidogrel 3. Carotid endarterectomy within 2 weeks if >70-75% stenosis 4. Anticoagulation in AF, stop clot promoting meds i.e. HRT 5. ACEI - BP control + reduces risk of stroke recurrence 6. Alcohol abstinance for 1st year and no more than 2/day thereafter

Question 26

How common is depression post-stroke?

Answer 26

Very common - ~40% become depressed | Risk of depression remains higher for significant period after stroke ~2 years

Question 27

What advice to give about driving to patient's after stroke?

Answer 27

1. Can't drive for one month after 2. Require doctor assessment thereafter - will either ok driving or refer to OT Ax to confirm 3. May be able to return to driving if deemed safe, may need some modifications to assist them if impairment or may have restricted license 4. Must inform VicRoads and insurance company of stroke event to ensure continued coverage