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CHAPTER 8: PRINCIPLES OF REHABILITATION


The primary focus of rehabilitation is function. The goal may be to restore a function that you have lost, or it may involve maintaining function that you need to modify and strengthen.

    Rehabilitation can then be characterized as either a restorative or a maintenance process. Restorative rehabilitation aims to reverse a new disability and improve function and is often funded by Medicare or other payers. Examples include the short-term rehabilitation that follows a stroke or a hip fracture. Maintenance rehabilitation is less intense, with continued outpatient physical therapy or occupational therapy three times a week. This continual therapy offers the possibility of a person making further gains in function or preventing further functional loss.

    The maintenance of function is a central aspect of your general care, particularly when you experience a sudden illness or become immobilize. In these situations you would benefit from maintenance therapy that consists of exercises designed to prevent joint contractures, maintain your muscle tone, and avoid significant decline in function. Begin rehabilitation early--it will help you preserve and maintain function and can increase your chances of returning to your previous level of function.

    Usually, rehabilitation means working with a team of trained professionals. The members of the rehabilitation team will vary significantly according to the setting. The disciplines represented may include medicine, rehabilitation medicine (physiatry), nursing, physical therapy, occupational therapy, speech therapy, social work, nutrition, psychology or psychiatry (or both), and recreation therapy (see Table 3).

    Rehabilitation settings include special units in acute care hospitals, rehabilitation hospitals, nursing facilities, outpatient centers, homes, or private offices. If you have a sudden onset of a new disability and are an appropriate candidate for 4 to 12 weeks of restorative rehabilitation, you may benefit from an intensive rehabilitation program with a team effort. Such programs are usually carried out in a rehabilitation unit, whether in an acute hospital, a freestanding rehabilitation hospital, or a nursing facility with a designated rehabilitation program. If you cannot tolerate or do not need an intense therapy program, you may receive services at the nursing facility level, in your home, or as an outpatient. These programs may also be more appropriate when ongoing maintenance therapy follows the inpatient restorative rehabilitation program.

    Techniques used in rehabilitation may not be limited to specific programs such as stroke rehabilitation or hip fracture rehabilitation. People can often be evaluated when they are having difficulty performing various activities of daily living (ADL). These activities include mobility, transferring (from wheelchair to bed, toilet, chair, etc.), eating, bathing, dressing, and communication.

Assistive Devices

    Assistive devices can be used to help people with difficulties performing such activities of daily living as feeding, bathing, and dressing. Most people benefit from an evaluation by an occupational therapist to ensure that the assistive device is the appropriate one for improving the impaired capability. Several important principles need to be considered.

  1. A person must be physically and cognitively capable of using the device effectively.
  2. People tend to use aids that are not conspicuous, complicated, cumbersome, or cosmetically unappealing.
  3. A person with perceptual problems may have difficulty using a device effectively.
  4. Assistive devices may be a significant out-of-pocket expense since they are usually not funded by insurance or other payers.
  5. An evaluation of a person's home or other living situation may be necessary to determine the most appropriate and effective use of assistive devices in improving function and ensuring safety.

Table 3. Members of the Rehabilitation Team

DISCIPLINE ACTIVITY
Medicine Manages acute and chronic medical illnesses.
Nursing Assists in coping and adaptation to illness; integrates medical and nursing care plan with rehabilitation treatment plan.
Nutrition Assesses and improves nutritional status.
Occupational therapy Assesses and improves upper-extremity function; improves performance of activities of daily living; helps compensate for visual and other perceptual deficits; assists in evaluation and treatment of swallowing disorders.
Orthotics Makes and fits orthopedic appliances.
Physiatry Develops the plan for continued physical, occupational, and speech therapy.
Physical therapy Assesses and improves lower-extremity function; improves range of motion, strength, balance, and endurance; teaches use of assistive devices and provides gait training.
Psychiatry Provides psychiatric evaluation and treatment for patient; provides support for family.
Psychology Provides psychologic support and assistance to rehabilitation team.
Social work Assists in discharge planning, helps families cope with illness and disability; does financial and personal counseling.
Speech therapy Evaluates and treats communication, speech, and swallowing disorders.
Therapeutic recreation Helps plan leisure-time activities and hobbies; develops realistic goals and motivation.

    Older people with upper-extremity weakness, deformity, uncoordination, and limited range of arm motion frequently find assistive devices for eating very helpful. A rocker knife and fork, for example, may allow a person with paralysis on one side of the body (hemiplegia) to cut and pick up food with one hand (see Figure 6). Similar assistive devices can be used for spoons, bowls, and plates. Eating utensils can also be modified for people who have limited motion or poor grasp. For example, silverware handles can be enlarged with foam padding or other materials, and a cuff that straps around the hand to hold eating utensils in place can be used to help a person with a weak hand to hold the device.

    Because fatigue frequently aggravates uncoordination, energysaving techniques are often helpful. Foods that eliminate the need for extensive cutting, chopping, or mixing are generally recommended along with easy-to-open packages and containers. You can hold food steady by using a board with spikes, a rubber mat, or sponges. The use of blenders, coffee urns, Crock-Pots, microwave ovens, and electronic skillets all reduce the need to use the stove or oven. These need to be placed at the appropriate heights on a stationary work surface. Pizza cutters can sometimes replace knives. Oversized bowls, plate guards, and soup dishes with high rims can be used to avoid spills during the extra movements or for people with tremors. For people who have loss of manual dexterity, electric can openers and jar openers can be extremely helpful.

    In addition to raised toilet seats and tub transfer benches (see Figure 11), a variety of other devices can help with bathing and maintaining personal hygiene. Long-handled bath sponges, "soap-on-a-rope," and wash mitts can be helpful bathing aids for people who have limited motion, weakness, or difficulty with coordination. As an aid in grooming, the handles of combs and brushes can be enlarged by foam padding to help compensate for limited grasping ability. A wall mirror may be tilted downward to permit better visibility from a wheelchair.

    Assistive devices are also available to help with dressing (see Figure 7). For example, the use of a buttonhook or zipper pull can make dressing much easier, and Velcro attachments are excellent substitutes for buttons or shoelaces. A dressing stick can aid older persons to dress as they sit, allowing them to hook or pull the cuff or sleeve of a shirt or pants into position. A stockingdonning device or slip-on dressing aid can also assist in dressing the legs. This can permit older people to pull up their stockings themselves even though they cannot reach their feet. For people with limited motion of the arms or shoulders, various reaching aids (see Figure 8) can help in pulling hats off a shelf as well as paper off a floor.

Other Rehabilitation Techniques

People who are receiving either restorative or maintenance rehabilitation may benefit from electrical stimulation and thermal approaches.

Electrical Stimulation

Two kinds of electrical stimulation are generally available: (1) functional electrical stimulation and (2) transcutaneous electrical nerve stimulation (TENS). In functional electrical stimulation, an electrical current is used to produce a muscle contraction. It not only prevents atrophy in muscles that have not been used for a while but also increases the range of muscle motion and strength, helps increase the voluntary function of a previously paralyzed muscle, and reduces muscle spasticity. For older people who have severe weakness of the upper arm, functional electrical stimulation can help prevent a dislocation of the shoulder and the development of a "frozen" shoulder. (Shoulder problems are found on page 243.) Electrical stimulation has also been used to improve the strength of pelvic muscles in older women who suffer certain forms of incontinence. (See page 389 for a complete discussion of urinary incontinence.)

    Transcutaneous electrical nerve stimulation, in addition to improving muscle strength and bulk, may have a pain-relieving effect. It has been used to treat the pain that is associated with various conditions, such as rheumatoid arthritis, poor circulation, and nerve diseases. In addition, this technique may reduce the amount of pain medicine that a person may need. TENS involves the direct electrical stimulation of the spinal cord. It has been used to treat older people with shingles (herpes zoster), to reduce the spasticity of a limb after a stroke, and to relieve the nerve pain sometimes associated with diabetes or poor circulation. While TENS is sometimes used for long-standing low back pain, evidence of its efficacy is lacking.

Thermal Approaches

Various thermal approaches are used primarily to treat pain, reduce inflammation, and increase muscle tone. Heat can be applied either superficially with a heating agent such as a hot pack, or with deepheating devices such as ultrasound or diathermy. Locally applied heat can promote muscle relaxation and pain relief, help with tissue healing, and prepare stiff joints and tight muscles for exercise. Hot packs can be applied to most body surfaces, while baths of liquid paraffin are most often used for the application of heat to the hands or feet. For example, hot packs may reduce muscle spasm in older people who have arthritis involving the neck, muscular low back pain, or muscle contractions. Heated paraffin may be particularly helpful to reduce the hand stiffness and pain in people with rheumatoid or osteoarthritis.

    Ultrasound is a deep-heating technique that is capable of elevating the temperatures deep in the tissues. This can be used to relieve joint tightness and loosen scar tissue, as well as to reduce pain and muscle spasm. It has been used to treat bursitis, tendinitis, and low back pain.

    Hydrotherapy in the form of a whirlpool or other pool therapy may be helpful. It has been used to treat arthritis, joint injuries or replacements, and to promote pain relief, wound healing, and to help with various neurologic disorders. Cold treatments or cold packs have been commonly used to treat people with sudden muscle or bone injuries. They can sometimes reduce pain and muscle spasms, especially those caused by brain injury.

Who Benefits from Rehabilitation?

When evaluating a person with a disability, the health care provider concentrates on understanding the history of the progressive loss of function, its severity, and the potential for recovery. These factors are vital to determine whether a person can regain function. The present level of functioning can be evaluated both in terms of activities and of daily living.

    Knowledge of your level of functioning before a disability is essential when evaluating your potential for rehabilitation. For example, it may be very realistic for a previously healthy older person who could walk without the use of an assistive device before suffering a hip fracture to be able to walk again within several months after a program of rehabilitation. However, the same goal may be less attainable for a person of the same age whose walking ability was previously poor, limited perhaps by arthritis or poor circulation.

    Generally, a person is evaluated for coexisting medical conditions, such as heart disease, lung disease, and joint diseases, that might limit participation in an intense rehabilitation program. Although moderate to severe heart and lung disease may reduce the possibility of intensive rehabilitation, many people can improve their exercise tolerance gradually.

    Another essential factor is your commitment to ongoing rehabilitation along with the commitment to your family--or caregiver--when you return home after the rehabilitation program. The severity and type of disability often influence the decision of all involved as to whether the affected person is best off returning home. From a standpoint of function, the minimum prerequisite for people living at home is that they be able to transfer safely from a bed to a chair, and from a wheelchair to the toilet. For people who have cognitive impairment or perceptual problems, 24-hour supervision may be necessary. Often the critical factor for discharge from a rehabilitation unit is whether the person has this type of 24-hour support at home.

Settings for Rehabilitation Programs

Rehabilitation programs within hospitals or special rehabilitation hospitals utilize a multidisciplinary team approach. For a person to qualify for insurance coverage of comprehensive rehabilitation at the hospital level, Medicare and most other insurance carriers stipulate that the person must need (1) close medical supervision and care by a rehabilitation physician; (2) rehabilitation nursing on a 24-hour basis; (3) participation in more than one therapeutic discipline, such as physical therapy, occupational therapy, or speech therapy; (4) a multidisciplinary team approach to therapy, with a coordinated rehabilitation program; and (5) clear, realistic, attainable goals in rehabilitation, with the expectation and documentation of significant functional improvement during the rehabilitation program.

    In general, rehabilitation programs in these settings are shortterm. Depending upon the person's needs and anticipated gains from therapy, inpatient hospital-based rehabilitations on average require six to eight weeks for the person who has had a stroke, a longer time for those who have had a major injury, and a shorter time for those who have less complicated problems.

    Nursing facilities frequently provide rehabilitation services for older people, particularly those who have recently had a hip fracture, as well as those who have had an amputation. In contrast to the Medicare requirements for the hospital level of rehabilitation, the requirements for insurance coverage at the nursing facility level of rehabilitation do not include occupational therapy, a multidisciplinary approach, or the services of a rehabilitation physician. However, the requirements do specify that a person must need daily physical therapy and skilled nursing care and that continued, significant functional improvement be documented. Under these guidelines, a person with a hip fracture who has minimal impairment of arm function and is medically stable would be covered for rehabilitation at a nursing facility rather than at a hospital.

    Outpatient rehabilitation services, also quite varied in scope, range from private practitioners' offices that offer fee-for-service care to outpatient rehabilitation facilities that provide the same comprehensive, multidisciplinary team efforts as hospital rehabilitation units. Generally, these outpatient units are appropriate for people with short-term, self-limited syndromes or illnesses, such as low back pain or minor trauma. Other services may be appropriate for people who require follow-up services after being discharged from a rehabilitation hospital or for whom an inpatient rehabilitation program is not feasible, suitable, or acceptable. Often, the availability of transportation is what determines whether the person can participate in an outpatient rehabilitation program.

    For a number of older people, home care rehabilitation programs can be an important component of follow-up care for people who have been discharged from either a hospital-based or nursing facility-based inpatient rehabilitation program. In addition, home rehabilitation services can help with the evaluation and provision of maintenance therapy or for short-term therapy for self-limiting illnesses. The Medicare criteria for in-home rehabilitation services are similar to those for outpatient or inpatient programs, with one notable addition: The person must be completely home-bound. This requirement often restricts the number of people who might benefit from therapy services at home and limits opportunities for developing a comprehensive, multidisciplinary approach to therapy in this setting.

Rehabilitation of Walking Problems

For most of us, walking difficulties frequently occur as a result of an abnormality of our nervous system, or problems with our muscles and joints. There are various assistive devices for walking, such as canes, walkers, orthotics (braces), and prostheses, designed to improve balance and support during standing and ambulation.

Canes

Canes, the simplest assistive devices for walking, provide the least amount of support and balance. While they support up to 25 percent of the body weight, they are best reserved for people whose ability to walk is limited by weakness or pain on one side. The use of canes is governed by the following principles: (1) Single-prong canes provide the least degree of support but are lighter and less conspicuous. (2) A pistol-shaped grip allows for greater comfort, better weight bearing, and more secure handling than the evenly rounded handle of the standard wooden canes. If necessary, the handle of the cane can be modified to adapt to physical impairments or deformities of the hand. (3) Quadripod canes provide greater support than the single-point cane and are usually better for people who have significant walking problems. The wider base for these canes provides greater support. (4) In general, you should hold the cane in the hand of your unaffected side. This allows you to form an arch between the affected side and the cane to help support the weight. This also permits a shorter "stance phase" of walking and a decreased period of weight bearing on the affected side when you walk. (5) The length of the cane is important for ensuring stability and comfort. When the cane is properly positioned on the ground and your hand is resting on the handle, your elbow should be flexed upward at a 20- to 30-degree angle. Another measuring method is to let the arm dangle beside the cane: A correctly sized cane will come to the crease of your wrist.

Walkers

Walkers, another common assistive device, surround you with four broadly spaced posts. Walkers can support up to 50 percent of your body weight, so you should consider them if you have problems on both sides or if you have general weakness. Among the several types of walkers in use are the standard pick-up walkers, which have four, often adjustable, posts covered by rubber tips. To use one of these walkers effectively, you must have sufficient upper-arm strength, a reasonable amount of standing balance, and the cognitive ability to walk in sequence with the walker. A person with Parkinson's disease will often have a tendency to fall backward, and would not do well with this kind of walker. People who have trouble with standing balance or who don't have enough upper-body strength can use rolling or wheeled walkers, which have either two or four wheels in place of the posts. Walkers with two wheels on the front are relatively easy to control, and can help a person maintain a forward gait--a useful feature for the person with Parkinson's disease. The four-wheeled walkers are of limited use and are probably best reserved for people with significant arm weakness who are building up enough strength to use a two-wheeled walker. Walkers can also be modified to benefit people who have significant upper-arm dysfunction or weakness. For example, if you have deformed upper extremities caused by rheumatoid arthritis, you can use a modified platform walker with arm rests. These platform walkers permit you to walk as well as to participate in active physical therapy of your lower legs despite significant upper-arm disability. Rolling walkers can be made into "auto-stop" walkers, so that when the person presses down on the front wheels the walker stops rolling.

    If you are considering using a walker, your home situation needs to be evaluated carefully. If you functioned well with a walker in a rehabilitation unit, you may find new challenges at home, including thresholds, throw rugs, narrow passages, and short stair treads.

Orthotics or Braces

Orthotics (from the Greek, meaning "straight") are another category of assistive devices. They are braces that are designed to modify the support and functional characteristics of the musculoskeletal system. The goals of these braces include (1) relieving pain by limiting motion or weight bearing; (2) immobilization and protection of weak, painful, or healing body parts; (3) reduction of weight on that body part; (4) prevention and correction of deformity; and (5) improvement of function.

    Orthotics can be applied to the arms, legs, and spine. Orthotics are usually referred to by an acronym formed from the first letter of the joints braced by the device or an orthosis. For example, WHO signifies wrist-hand orthosis, and AFO signifies ankle-foot orthosis.

    Common reasons for using an orthosis on your legs include weakness, deformity, increased muscle tone (spasticity), ankle or knee instability, or pain on weight bearing such as that which sometimes occurs after surgery or with inflammatory arthritis. These orthotics not only help with your walking but also encourage more energy-efficient walking. An ankle-foot orthosis can improve the efficiency and speed of walking as well as decrease your body sway.

    A foot orthosis can be as simple as a modified shoe in which a wedge, lift, bar, or other device has been inserted. These are sometimes used for people whose legs are different lengths, a condition called leg length discrepancy. Foot orthoses outside the shoe sometimes provide additional rigidity to align a malformity of the foot caused by severe joint deformity, reconstruction after surgery, or severe muscle contraction.

    Ankle-foot orthoses, which are normally used for limited weight bearing or to preserve joint alignment, are commonly used in older people with mild to moderate leg weakness due to a stroke or some process affecting the nerves. These devices are designed to provide support for unstable joints, particularly the ankle. Some are as simple as a plastic shell that fits into your shoe and extends up the back of your calf to prevent the foot from dropping. This device can offer short-term benefit for the person whose foot drop is caused by a stroke or a nerve problem.

    Knee-ankle-foot orthoses (KAFOs) are essentially ankle-foot orthoses with additional support surrounding the knee. These are sometimes used to provide knee support during weight bearing in cases of severe weakness of the lower leg, such as severe paralysis of one side of the body (hemiplegia) following a stroke. These devices can be made more sophisticated by the addition of a knee joint hinge.

    Orthoses are not appropriate for everyone who has a leg disability. For example, if you have poor balance, strength, or coordination, a lower-extremity orthosis may aggravate rather than improve your walking. In addition, if you have considerable loss of sensation as well as muscle control of the leg, you may be vulnerable to skin breakdown because of the direct pressure and force produced by the orthotic device. The presence of a poorly fitting device, underlying skin disease, impaired circulation, or swelling increases the likelihood of skin breakdown.

    Spinal braces are sometimes worn by people who have compression fractures of the spine or disk disease in the neck. For the majority of people with mild compression fractures, the most important principles of treatment are adequate pain relief and temporary limitation of movement. Abdominal binders or corsets are not routinely recommended for rib or spinal fractures.

    Rigid braces can be valuable for people who have significant spinal injuries resulting in a need for stability of the spine. The use of rigid metal supports, however, makes it important to monitor carefully the areas where pressure ulcers and skin breakdown might develop.

    If you have neck problems, whether caused by muscle strain, a narrowing of the spinal canal, or arthritis, you can sometimes benefit from the use of a cervical collar. Soft, foam collars or molded plastic collars are often used but various collars all provide similar levels of support to the neck, spine, and muscles. Keep the following important principles in mind when using neck supports: (1) As with most spinal devices, you should only use neck braces for a very short time to avoid psychological dependency. (2) The prolonged use of these collars may actually reduce your neck muscle strength and result in atrophy of the neck muscles. Therefore, use them very conservatively.

    The principles that apply to the use of orthoses for the arms are similar to those that apply to the legs. Arm braces may be appropriate for neurologic problems, severe arthritis, or burns. Like other devices, arm braces provide immobilization, improve alignment, and assist or restore function. For stroke victims, a hand or forearm splint helps maintain the optimal position and can improve the function of the weak limb. In people with lower nerve problems, such as carpal tunnel syndrome where a nerve may be pinched, a special splint can reduce nerve entrapment. In people whose arthritis involves the joints of the hand and wrist, a wrist-hand splint may help prevent joint deformity.

Amputations and Prostheses

Seventy-five percent of all amputations occur in people older than 65. The leg is the site of 90 percent of amputations, with two-thirds of these occurring below the knee. Fortunately, fewer than 15 percent of people with below-the-knee amputations eventually need above-the-knee amputations. However, 30 percent of people who require amputation because of poor circulation require an amputation on the other side within five years. For people whose poor circulation has been worsened by diabetes mellitus, the amputation rate affecting the opposite side is about 30 percent within two years and about 50 percent within five years. While this information suggests significant potential disability, 70 to 80 percent of older people can regain their ability to walk with or without assistive devices if they undergo the proper rehabilitation program before and after they acquire a prosthesis.

    The energy expenditure required for walking is related to the length of the residual limb. An amputation just above the ankle requires only a 10 to 15 percent additional energy expenditure. The standard below-the-knee amputation, however, requires expenditures of 25 percent of additional energy. Below-the-knee amputation of both legs requires a 40 to 45 percent increased energy expenditure, and an above-the-knee amputation of one leg requires 65 percent more energy.

    The use of prostheses is governed by the following principles: Age alone is never a reason to avoid use of a prosthesis. In general, the weight of the prosthesis should be minimized, and the attachment chosen should be the one that is easiest and most appropriate. You should be trained to perform simple transfer movements without the prosthesis. For example, transferring from a bed to a wheelchair or to the toilet in the middle of the night should not necessarily be delayed for the attachment of a prosthesis. People expecting amputation should be reassured of the fact that 70 to 80 percent of older people who have had an amputation are able to walk with a prosthesis and that many below-the-knee amputations result in the ability to walk independently without an assistive device such as a cane or walker. Often, meeting with a person who has successfully completed a rehabilitation program and who walks independently can be informative and can improve your motivation if you are faced with a choice of amputation. Depression after an amputation is common. Emotional support, treatment of severe depression with antidepressants, and the involvement of caregivers and families are critical in reversing the depression. Often, your functional state before the amputation is one of the most reliable predictors of your success. This occurs both in short- and long-term prosthetic training.

The Use of Wheelchairs

Wheelchairs become an easy and frequently used (if not overused) way to move about for some older people. However, there are important factors to be considered in wheelchair use, whether it is used during the rehabilitation process or on a long-term basis.

    You must be properly fitted and measured to your wheelchair, because if this is not done correctly, a wheelchair might actually impair rather than aid your mobility. Ideally, your weight, strength, skin condition, heart function, mental capacity, and vision should all be evaluated. In the process, you need to balance your concerns about seating comfort with those for mobility and your general functional needs.

    For most people, a chair with the large rear wheel is adequate (see Figure 9). While sitting in the chair with your feet on the floor, you should be able to raise your feet off the floor, if necessary. The chair should be as narrow as possible, with a clearance of at least two inches on each side for entering doorways. A seat that is too narrow can hinder transferring and can increase your risk of pressure ulcers. If the seat is too wide, you may become unsteady while sitting and have difficulty in propelling the wheelchair and overcoming various architectural barriers, such as narrow doors. Armrest height is also important, because if the armrests are too high, your shoulder muscles can become fatigued. If the armrest height is too low you may develop poor posture as a result of leaning forward, and your balance within the wheelchair may become impaired. Homes may need to be modified to accommodate a ramp for an entrance. Doorways, for example, need to be 30 to 36 inches wide, and bathrooms at least 5 to 6 feet wide to permit the turning of the wheelchair.

    Footrests need to be properly positioned, because if they are too low, they may increase the pressure under the thigh and may allow the foot to drag. If the footrest is too high, this can create greater pressure on both the foot and calf, thus increasing the risk of pressure ulcers and blood clots in the legs.

    The seating can be modified to reduce the risk of pressure ulcers by using low-pressure cushions made of foam or gel, which transmit the body weight over a broader surface. A wheelchair can adjust to accommodate a person who can only use one limb and can be modified so that the arms can be raised up, down, or folded back on each other to facilitate transferring.

    Powered or motorized wheelchairs are generally reserved for people who have been unable to achieve sufficient functional mobility with a manual wheelchair. In general, these people suffer from increasing disability as a result of a progressive disease.

    Powered wheelchairs are made in three-wheeled and four-wheeled versions. They vary substantially in terms of their quality, adjustability, and durability. Powered wheelchairs are very expensive and should be used for people who have seen a physiatrist in collaboration with a physical therapist.

Transferring from One Place to Another

A transfer refers to a pattern of movement that involves shifting from one surface to another. It can occur in the sitting, standing, or lying positions, and may be accomplished with or without the help of another person, or an adaptive device (see Figure 10).

    Safe and efficient transfers require a combination of physical and perceptual capacities, proper equipment, and training and techniques that are tailored to your special abilities. The achievement of sitting balance is a prerequisite for safe and comfortable transfers. To perform standing transfers, you must have good sitting balance and be able to stand evenly without assistance. In addition to lower-leg stability, you also need a reasonable degree of upper-arm strength to accomplish a transfer safely in the standing position.

    A bed-to-wheelchair transfer can be initiated from a sitting position. The person locks the brakes on both sides of the wheelchair, grasps the side rails of the bed to come to a sitting position, and then while grasping the front arm of the wheelchair with the unaffected arm (in the case of a person who is paralyzed on one body side--the hemiplegic person) sits down in the wheelchair. This type of transfer is also known as a stand-pivot transfer. Early in the course of therapy, or if the person cannot stand, a board can be used to bridge the space between the bed and the wheelchair.

    Wheelchair-to-toilet transferring is similar to the bed-to-chair transfer. However, you must be able to manage clothing and undergarments for this maneuver. Special adaptive equipment may be used to help make these transfers more independent (see Figure 11). For example, toilet seats should be approximately 20 inches from the floor. If necessary, raised toilet seats can be attached to the standard height toilet bowl. Handrails can be attached to the wall if it is close enough, or they can be freestanding. They should be placed on your unaffected side if you have a paralysis or on both sides of the toilet if you have weakness on both sides.

    Transfers in and out of the bathtub (see Figure 11) are especially important because this is a potentially dangerous procedure. Unlike most transfers, which should be made normally from your strongest side, a tub transfer usually makes use of your weaker side, depending on which is easier for you. Adaptive equipment, such as a tub transfer bench, which bridges the tub side by having one leg in the tub and one leg on the other side of the tub, can be helpful to move you safely along the bench to the tub. In doing this, a person with hemiplegia may first move the affected leg into the tub and then the unaffected leg. To help with bathing, a hand-held shower hose can be attached to the faucet. Safety-tread tape will secure a bath mat to the tub surface. There are also a number of bed aids that are useful for the transferring of positions and for exercising.

Stroke Rehabilitation

Most stroke therapy programs take place in a rehabilitation hospital, a rehabilitation unit in an acute hospital, or a nursing facility. The physical therapy plan in these programs is targeted at obtaining safe ambulation, usually with the use of an assistive device. Generally, occupational therapists address problems with upper-extremity function in terms of upper-muscle weakness and coordination, as well as perceptual and cognitive difficulties. For people with speaking or language problems, speech therapists develop specific treatment programs, both to try to restore some language and, if necessary, to develop alternative communication systems.

    Since swallowing difficulty is a common but frequently under-recognized complication of strokes, an evaluation of swallowing function by a speech or occupational therapist should be done. The involvement and education of family or caregivers during the stroke rehabilitation program is crucial to the entire rehabilitation process. This is important in establishing the appropriate goals for rehabilitation and in planning for discharge. Before discharge, physical and occupational therapists generally visit the home to evaluate it for safety and the need for any adaptive equipment. Depression after a stroke is common and may also seriously affect rehabilitation. (Depression is covered on page 192.)

Hip Fracture Rehabilitation

The goal of rehabilitation for people who have had a hip fracture is the return to full ambulation. The focus is physical therapy that strengthens the leg muscles. This approach is intended to prepare the person for walking and to prevent any displacement of a hip prosthesis or the destabilization of a hip fracture that has been fixed by a pin or screw. Arm muscles are strengthened to help people in using assistive devices such as walkers. Arm strength and function are also important for bathing and dressing, which may be affected by the lower-extremity disability. Generally, people progress from using a walker to using a wide-based four-prong cane, to walking with a handheld single-point cane.

    Several factors influence both the course and outcome of hip-fracture rehabilitation. For example, the person's weight-bearing status depends upon the type and severity of the fracture and the resulting repair. The capacity for early full weight bearing increases the intensity and shortens the duration of therapy services that are needed. Not surprisingly, the risk of institutionalization for people with a hip fracture increases in the presence of dementia and with significant functional impairment.

Rehabilitation if You Need an Amputation

Ordinarily, the rehabilitation process takes longer for an amputation than for either a stroke or hip fracture. The program begins before surgery and involves not only the evaluation of the site for the amputation but also a comprehensive evaluation of your medical condition and an evaluation of your motivation to participate in the program. Whenever possible, the preoperative management should include stabilization of any medical problems, especially heart and lung disease. The surgeon, primary care physician, physiatrist, and you and your family should discuss the care plan for postoperative management as well as preprosthetic conditioning and training, and to prepare you for the phenomenon of "phantom limb" sensation, in which you feel as if the amputated limb were still present.

    The initial postoperative efforts are directed to proper care of the stump to promote healing, the initiation of an exercise program to strengthen the muscles above the site of the amputation, and the maintenance of proper positioning as well as exercise to prevent contractures of the knee or hip. Shrinking of the stump to accommodate the socket of a temporary prosthesis is usually accomplished by either using tight elastic cuffs or by frequent wraps with tight elastic bandages. Usually, people are measured for a temporary prosthesis 4 to 8 weeks after surgery and for a permanent prosthesis 8 to 12 weeks after surgery.

    In preparation for an amputation, the therapy program initially involves training in transfer techniques, such as from bed to wheelchair or from chair to toilet. After amputation, you will progress to practicing weight bearing on a temporary prosthesis, first on parallel bars and eventually using a walker, then crutches, then a cane for assistance. By the time you complete the rehabilitation program, you will probably be capable of walking without any assistance. People with amputation of both limbs may progress to needing, at most, a walker for ambulation.

Common Medical Problems During Rehabilitation

During the course of rehabilitation, you may need ongoing medical evaluation and intervention to treat or prevent significant illness and disability. If you have had a stroke or have suffered a hip fracture, you are at increased risk for blood clots and the complication of pulmonary embolus. This refers to the situation where a blood clot breaks away from its origin in the veins in the legs and travels up to the lungs. Generally, people are given blood thinners during the rehabilitation process to keep blood clots from forming.

    Most physical therapy programs do not require a high level of physical activity. It may come as a surprise that occupational therapy results in greater cardiovascular stress than physical therapy. This is because exercise of the arms causes a greater increase in blood pressure and pulse rate than does leg exercise. Therapy activities for people with known heart disease are generally modified, especially if they induce chest pain, shortness of breath, light-headedness, or fatigue. The blood pressure and pulse rate are frequently monitored to avoid undue stress. Sometimes a physician will recommend that other tests be performed to assess cardiac risk.

    People with preexisting arthritis may experience a worsening of their disease during rehabilitation as a result of progressive weight bearing and stress during therapy. Other people may develop bursitis around the shoulder, or especially around the hip. Some of this is due to the increased physical activity in their rehabilitation program. Treatment approaches for these individuals, however, are generally the same as those for people with arthritis who are not in a rehabilitation program.

    For people who have moderately severe lung disease and who become short of breath while participating in a physical therapy or occupational therapy program, a reevaluation of their lung status is necessary. Sometimes the amount of oxygen in the blood is measured during therapy to see if any abnormalities are present. In some rehabilitation sites, it may be possible to include a lung rehabilitation program within the person's disease-specific rehabilitation program. Usually, pulmonary rehabilitation programs emphasize instruction in breathing techniques, pacing of physical activities, and exercises and relaxation techniques to assist in activities of daily living.

    The goal of rehabilitation is to improve function, which is usually attained through the efforts of the multidisciplinary team of health professionals working together to identify and address potential barriers to effective function. Factors that have an important bearing on the outcome of rehabilitation are the nature and extent of the limitation, the person's motivation, and the presence of adequate daily supervision.




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