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rehabilitation

Restoration of the disabled person to self-sufficiency or maximal possible functional independence. Indications: 1) deconditioning 2) contractures, paralysis 3) *injury, trauma Procedure: === Includes === 1) physical 2) psychological 3) social 4) vocational 5) leisure 6) educational === Goals === 1) stabilize primary disorder 2) prevent secondary complication 3) treatment of functional deficits 4) adaptation a) patient to disability b) environment to patient c) family to patient === Rehabilitation settings === 1) acute medical/surgical ward 2) acute inpatient Rehab unit - long-term acute care hospital (mechanical ventilation) 3) subacute inpatient - transitional care unit (TCU) 4) nursing home - for older patients who require posthospital rehabilitation, but cannot tolerate standard rehabilitation (3 hours/day, 5 days/week) rehabilitation may be performed in a skilled nursing facility [8] - 5 days/week or rehabilitation are required in the nursing home for Medicare reimbursement [10] 5) outpatient 6) in home therapy === Rehabilitation team === 1) physical therapy 2) occupational therapy (not required in SNF for Medicare reimbursement) [10] 3) speech-language pathologist 4) therapeutic recreation therapist 5) rehab nurse 6) psychiatrist 7) social worker 8) psychologist 9) prosthetist/orthotist 10) vocational counselor === Assessment === 1) functional independence measure 2) Barthel index Management: === progressive mobilization === 1) bed position/ bed mobility a) avoid neck flexion b) avoid pillows under knees c) avoid external rotation of hip 1] stroke 2] hip fracture d) keep ankles flexed to 90 degrees e) keep arms abducted 2) range of motion (ROM) a) use functional activities for ROM b) muscles crossing 2 joints more likely to tighten - hamstrings, gastrocnemius, finger flexors 3) sitting tolerance a) end goal: out of bed 12-14 hours/day b) day 3 goal: 2.5 hours sitting tolerance c) limited by pulse & blood pressure response d) correlates with ability to strengthen e) add 15 minutes to sessions TID f) sitting balance also important 4) transfers a) bed height so feet touch floor b) put shoes on: do NOT transfer in stockings c) chair parallel to bed, on patient's stronger side with raised footplate between patient's foot & bed d) make sure chair is locked e) remove obstacles f) stand in front of patient - close g) NEVER pull on arm h) patient sits on edge of bed with slight lean forward i) have patient stand with strong hand on armrest of chair, weak hand on bed j) strong foot, then weak foot with small steps turning until in front of chair k) back legs against chair, sit 5) standing a) enables transfers & ADLs b) strengthes multiple muscles 6) stair climbing - if bad leg, use crutches, don't step on bad leg 1] up: good leg 1st, crutches & bad leg follow 2] down: crutch down 1st, bad leg down, the good leg 7) ambulation a) requires patient to sit unsupported & stand up unassisted b) stand slightly behind weak side c) place your right hand on belt & left hand on front of patient's shoulder, but give him/her freedom to move d) never hold patient just by arm or let him/her hold onto you e) always turn to good side f) turns need wide base of support g) to sit down again, walk up to chair (bed/toilet, etc), turn around, back up stepping with good foot 1st, until back of legs against chair h) let go of walker with one hand, reach back to chair armrest, ease down === exercise === 1) early gains in strength (1st days to weeks) a) little change in muscle size b) due to neural adaptations - improves coordination & muscle activation 2) exercise in elderly requires longer warm-up & cool-down period 3) complete fitness program should contain a) aerobic conditioning 1] 20-60 minutes/day 2] may be interspersed throughout day 3] minimum of 10 minute sessions b) strength training - isokinetic training better than isotonic or isometric training c) flexibility training 4) exercise tolerance testing prior to exercise program a) known coronary artery disease b) symptoms of cardiac angina c) risk factors for coronary artery disease 5) diabetics: monitor blood sugar before & after exercise === specific conditions which may require precautions === 1) osteoporosis a) protect the spine & extremities b) avoid high impact exercises 1] jogging 2] high-impact aerobics c) avoid exercise risky for falls d) avoid strenous twisting e) keep spine in proper alignment f) avoid forward flexion 2) diabetes mellitus a) watch for hypoglycemia after exercise b) increase carbohydrate intake prior to exercises - 15 g of carbohydrate for every 30 min anticipated exercise c) proper foot care d) avoid jogging/running if neuropathy or peripheral vascular disease is present e) avoid resistance training if retinopathy is present due to risk of ocular hemorrhage 3) osteoarthritis a) avoid high-impact activities b) swimming or cycling can be helpful c) goal: strong & balanced muscles with good joint range of motion 4) hypertension a) ensure blood pressure is well controlled before starting exercise program b) moderate intensity exercise is preferable c) avoid caffeine before a workout d) resistance training should use high repetitions, low weights Notes: - futile cycle beginning with hospitalization -> rehabilitation -> rehospitalization -> rehabilitation ... death without ever returning home described; C difficle colitis, delirium & falls implicated in the cycle [9] - for risk of poor outcome related to transitional care see transitional care

Related

deconditioning disability functional independence measure (FIM) handicap long-term acute care hospital (LTAC) rehabilitation hospital

Useful

comprehensive rehabilitation intense rehabilitation subacute rehabilitation

Specific

auditory rehabilitation cancer rehabilitation cardiac rehabilitation comprehensive rehabilitation intense rehabilitation neurorehabilitation peripheral arterial disease rehabilitation pulmonary rehabilitation remediation subacute rehabilitation vestibular rehabilitation vision rehabilitation

General

medical therapy; therapeutic intervention

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Genova, A, UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Brummel-Smith K in: Geriatric Medicine: An Evidence-Based Approach, 4th ed, Cassel CK et al (eds), Springer-Verlag, New York, 2003
  4. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  5. Kauppila AM, Kyllonen E, Ohtonen P et al Multidisciplinary rehabilitation after primary total knee arthroplasty: a randomized controlled study of its effects on functional capacity and quality of life. Clin Rehabil. 2010 May;24(5):398-411. PMID: 20354057
  6. Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004957. Review. PMID: 18425906
  7. Mahomed NN, Davis AM, Hawker G et al Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008 Aug;90(8):1673-80. PMID: 18676897
  8. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018
  9. Flint LA, David DJ, Smith AK Perspective. Rehabbed to Death. N Engl J Med 2019; 380:408-409, Jan 31, 2019 PMID: 30699322 https://www.nejm.org/doi/full/10.1056/NEJMp1809354
  10. Skilled nursing facility (SNF) care. 2019 https://www.medicare.gov