Rehabilitation
Abstract
Rehabilitation begins as soon as the patient is admitted to the hospital. For patients with neurologic diseases or injuries, rehabilitation may include physical, occupational, and speech therapy. These services are usually provided by therapists who are specially trained in working with patients with brain and spinal cord injuries. The specific course of rehabilitation differs for each patient, but it almost always requires a multidisciplinary team that includes nurses, physicians, case managers, therapists, and family members. Given the extent of close interaction with patients with neurologic diseases or injuries, nurses are expected to play a vital role in the recovery and rehabilitation of all patients with neurologic diagnoses.
Keywords: activities of daily living (ADLs), occupational therapy, physical therapy, rehabilitation, speech therapy, therapeutic assessment
17.1 Rehabilitation
Patients who undergo neurosurgical intervention often require some form of rehabilitation. The rehabilitation team comprises many different members, and various levels of rehabilitation are available depending on each patient’s needs (▶ Table 23.1). Rehabilitation and rehabilitation services are provided, in part, by therapists (e.g., speech, occupational, and physical therapists). Therapists should be involved as early as possible; in some cases, they may work with patients while they are still in the intensive care unit (ICU). Early initiation of rehabilitation services may help decrease length of stay and has been shown to reduce complications related to prolonged bed rest (e.g., pressure sores, range of motion [ROM] limitations, and loss of muscle strength).
Complication | Discipline | Therapy intervention | Rationale |
Impaired ambulation | PT | Strength and sensory assessment Leg exercises Modify transfers Use of a gait belt Orthotics as indicated | Weakness or sensory loss affects gait and balance |
Activity intolerance or impaired endurance | PT/OT | Progressive activity Energy conservation techniques Therapeutic exercise to increase endurance Activity with light weights and increased repetitions | Inactivity and/or prolonged bed rest leads to decreased muscle mass and diminished endurance Medical issues may be exacerbated by inactivity |
Transfers | PT/OT | Thorough examination of strength and sensation prior to mobility Teach level surface transfers Use of electric lift, sliding board, and/or specialized toilet equipment Use of specific techniques, such as bracing of a paralyzed extremity Use of walkers, gait belts, and canes for stability | Limit fall risks by capitalizing on the patient’s strengths and intact skills for transfer |
Risk of immobility | PT/OT | Early mobility Elevate head of bed Lower extremity and upper extremity nonweight exercises Spend time sitting on edge of the bed | Strategies help prevent muscle atrophy, decreased respiratory function, DVT, pneumonia, urinary tract infections, and upper respiratory infections |
Cognitive impairment Disorientation Short-term memory impairments Unable to recall daily events Agitation and emotional lability | OT/SLP | Use of simple directions and helpful external memory aids Limit environmental stimuli that may distract the patient during interactions (e.g., TV, medications) | Thorough cognitive evaluation will help identify areas of deficit and determine appropriate interventions Compensatory strategies may be initiated, and the entire medical team should be encouraged to use them |
Dysphagia “Wet voice” quality Patient complains of trouble swallowing or “things not going down right” Facial weakness, coughing with oral intake | OT/SLP | Swallowing evaluation | Limit diet to food that can be swallowed safely, and teach swallowing strategies |
Impairment of visual motor skills or visual field cuts Diplopia New onset deficits in eye movement Unable to reach for items (i.e., reach falls short or overshoots) Visual neglect (i.e., patient not appreciating visual stimuli on one side) | OT | Environmental control, use of bright visual markers to help identify boundaries in a visual field, use of spot patching for diplopia | Vision impairments can affect all aspects of patient care By addressing vision deficits early, strategies can be used to accommodate for deficits |
Aphasia/dysarthria Abnormal voice Unclear speech Receptive or expressive speech problems, or both | SLP | Evaluation, use of techniques to strengthen speech quality and compensate for deficits | Ability to communicate is a cornerstone of rehabilitation after neurologic injury |
Impairment of self-care skills (affecting one or more ADLs) Unable to manage a meal tray Unable to grip hygiene items Unable to “figure out” how to use hygiene items/tools Muscle weakness Sensory loss | OT | Instruct patient on proper use of adaptive equipment to overcome these challenges | Use of adaptive equipment and rearranging the environment can increase a patient’s capacity for independence in self-care |
Abbreviations: ADLs, activities of daily living; DVT, deep vein thrombosis; OT, occupational therapy; PT, physical therapy; SLP, speech and language pathology. | |||
This chapter offers a brief description of the disciplines that may be involved with a patient at each level of care, from admission through rehabilitation (Box 17.1 Diagnoses Appropriate for Therapy Referral).
Box 17.1 Diagnoses Appropriate for Therapy Referral
Aneurysm
Brain tumor
Hydrocephalus
Low back pain
Meniere’s disease
Meningitis
Multiple sclerosis
Myasthenia gravis
Parkinson’s disease
Scoliosis
Spinal cord injury
Spinal fracture
Spinal surgery
Stroke
Traumatic brain injury
Vascular malformation
17.2 Philosophy of Rehabilitation
The primary purposes of rehabilitation are to provide preventative care, to recover function after neurologic injury, to compensate for skill loss, and to promote independence in the least restrictive environment for the patient. To achieve these goals, the main strategies of the therapy team working with neurosurgery patients include the following:
Early mobilization
Active and passive therapeutic exercises
Positioning to optimize function
Use of adaptive equipment and techniques
Restoration of neuromuscular function
17.3 The Rehabilitation Process
The rehabilitation process begins with neurologic assessments that help therapists determine the patient’s neurologic strengths and deficits.
Clinical regulations and licensure determine which therapy discipline should perform evaluations and treatment. These regulations vary by state and institution
Therapists from each discipline are responsible for the following needs:
Evaluation of the patient’s strengths and deficits
Determination of plan of care and treatment regimen (including frequency and duration of therapeutic treatment)
Education of patients, family members, and caregivers
Recommending discharge placement and ongoing treatment (if appropriate)
Treatment plans vary by patient and should be tailored to meet individual needs
Therapists in the neurologic setting communicate with members of the nursing and rehabilitation teams and may assist with discharge recommendations
Therapy should be initiated as early as possible (Box 17.2 Early Therapy)
Each discipline of therapy is governed by state and national standards of practice.
Box 17.2 Early Therapy
Initiation of therapy services while the patient is in the ICU can do the following:
Reduce complications related to extended bed rest and/or inactivity (e.g., pressure sores, ROM limitations, loss of strength)
Reduce length of stay
Rehabilitation
Should start as early as possible, preferably at admission, given preoperative therapy may improve postoperative outcomes
Is geared toward preventive care
Increases independence
17.3.1 Therapeutic Assessments
Occupational Therapy
Despite its name, occupational therapy is not a therapy for an occupation or career. Instead, it teaches a much more essential set of abilities—skills for “the job of living.” An occupational therapist may be asked to evaluate a patient or provide therapeutic assistance in the following areas:
ADLs
Visual perceptual training
Visual hand–eye coordination
Splint or brace fabrication
Fine motor control
Upper extremity strength and ROM
Cognitive skills
Upper extremity neuromuscular reeducation
Adaptive equipment fabrication and training
Therapeutic exercise
Patient and family education
Physical Therapy
The goals of physical therapy may be described by the mantra, “Movement is life.” Physical therapists may work with patients who aspire to achieve previous levels of activity, or they may treat patients whose mobility is severely impaired. They may provide therapeutic assistance in the following areas:
Functional mobility, balance, and gait training
Lower extremity strength and ROM
Therapeutic exercise
Neuromuscular reeducation
Nonpharmacologic pain management
Patient and family education
Speech and Language Pathology
Speech and language pathologists are a critical element of rehabilitation of patients, as the ability to communicate is often viewed as the most basic element of what makes us human. Speech pathologists may evaluate a patient or provide therapeutic assistance in the following areas:
Aphasia and language deficits
Dysarthria
Motor skills related to speech
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