Rehabilitation for Specific Problems
For many problems--for example, heart disease, stroke and other brain injuries, spinal injuries, hip fracture, amputation, and loss of hearing, speech, or vision--specific rehabilitation programs are available. Rehabilitation is sometimes needed for other types of fractures (see Section 5, Chapter 62).
Heart Disease
Cardiac rehabilitation may be useful for some people who have had a recent heart attack (see Section 3, Chapter 33), a sudden onset or worsening of heart failure, or cardiac surgery. The goal is to maintain or regain independence, at least with activities of daily living, within the constraints of abnormal heart function.
Remaining in bed for longer than 2 or 3 days can lead to deconditioning and even depression. Therefore, cardiac rehabilitation is started as soon as medical care for an event such as a heart attack has been stabilized, usually while the person is still in the hospital. Rehabilitation programs typically begin with light activity, such as transferring to and sitting in a chair. When these activities can be performed comfortably, usually by the second or third day, more moderate activities, such as dressing, grooming, and walking short distances, are begun. If fatigue or discomfort occurs as a person increases his activity (for example, walking the length of the hall), the person is instructed to stop immediately and rest until symptoms disappear. The doctor then reassess the person's readiness to continue rehabilitation.
After discharge, the amount and intensity of activity is slowly increased, and a full range of normal activities can be resumed after about 6 weeks. However, most people benefit from an outpatient cardiac rehabilitation program, which is usually about 12 weeks long, because of the instruction and monitoring they receive. Cardiac rehabilitation programs include help with handling the psychologic effects of having had a heart attack or heart surgery. They also include instruction about why changes in lifestyle are necessary and how to make them--so that risk factors are modified. Quitting smoking, losing weight, controlling blood pressure, reducing blood cholesterol levels through diet or drugs, and performing daily aerobic exercises all help prevent or slow the progression of coronary artery disease and reduce the risk of another heart attack. Similarly, modification of risk factors may help slow the progression of heart failure.
Brain Injuries
Rehabilitation can help people who have had a stroke or other brain injury regain some or all of their functional abilities. Although rehabilitation helps people recover lost function, the extent of functional recovery depends heavily on the brain's natural repairing of the damaged area. Most of this natural healing process occurs during the first 6 months after the stroke or injury but may continue for as long as 2 years. The amount and rate of natural healing cannot be predicted with certainty. Because of this unpredictability, and to prevent other disabilities (such as muscle contractures) and depression, rehabilitation is begun as soon as the person is medically stable.
What part of the brain was injured affects what functions are lost. A detailed evaluation of the person, including psychologic testing, helps the rehabilitation team identify the type and severity of damage. The members of the rehabilitation team then assess which lost functions may benefit from rehabilitation therapy and create a program addressing the person's specific needs. The success of rehabilitation depends on the person's general condition, range of motion, muscle strength, bowel and bladder function, functional ability before the brain injury, social situation, learning ability, motivation, coping skills, and ability to participate in a rehabilitation program.
The damaged areas of the brain after stroke are limited to where the blocked or bleeding arteries are located in the brain. Thus, the area damaged and the symptoms of stroke are relatively well defined. The extent of brain damage due to a traumatic brain injury depends on the severity and direction of force and what part of the brain was injured. The brain can also be injured during surgery performed to remove a brain tumor. The extent and location of the surgery determine what functional problems a person will have afterward.
Some people require joint movement to prevent or relieve contractures. Others need coordination exercises. Because stroke often causes one-sided paralysis, exercise of the unaffected arm or leg is usually encouraged. The person is expected to practice other activities as well, such as moving in bed, turning, changing position, and sitting up. Regaining the ability to get out of bed and to transfer to a chair or wheelchair safely and independently is important to a person's physical and mental health.
Rehabilitation therapists treat problems with walking, lack of coordination, spastic muscles, vision problems (including partial or complete blindness in one or both eyes), and speech problems with specific therapies. For example, an ambulation exercise program is begun for people who are having trouble walking; this program may include learning how to prevent falls. Heat or cold therapy may temporarily decrease spasticity in muscles and allow muscles to be stretched. People with one-sided blindness are given special training to avoid bumping into door frames or other obstacles. Fine motor coordination may be improved with occupational therapy.
Cognitive impairment can also occur with stroke and other brain injury, especially concussion (see Section 6, Chapter 87). Cognitive impairment can include problems with orientation, attention and concentration, perception, comprehension, learning, organization of thought, problem solving, and memory. However, not every person has all of these symptoms.
Cognitive rehabilitation is a very slow process, has to be tailor-made to each person's situation, and requires one-on-one treatment. It encourages desirable behavior and discourages undesirable action through conditioning and repetition.
Spinal Injuries
Recovery from spinal cord injury depends on the location and degree of damage. The higher up the level of injury, the greater the physical impairment. Injury at the level of the chest or below usually involves weakness or paralysis of the legs (paraplegia). Injury at the level of the neck usually involves weakness or paralysis of all four limbs (quadriplegia). If the level of injury is very high in the neck, the muscles that control breathing may be paralyzed, and a ventilator may be needed to assist breathing.
If the spinal cord is completely severed or destroyed, the body below that level becomes paralyzed. If the spinal cord is partly severed or damaged, the body below that level becomes spastic. There is little or no skin sensation in the affected area. In almost all cases of spinal cord damage, bowel and bladder control are lost (incontinence).
The two most important aspects of caring for people with quadriplegia or paraplegia are preventing bedsores and maintaining joint mobility. To prevent bedsores, the person moves or is turned frequently, and a special bed or bedding material is used (see Section 18, Chapter 205). When the person is seated in a wheelchair, a special cushion is used. To maintain joint mobility and prevent spasticity, heat, massage, and some medications are used.
A paraplegic person can live an independent life. Range-of-motion and strengthening exercises of the arms and hands enable the paraplegic person to use a wheelchair and to transfer from bed to a wheelchair and from a wheelchair to a toilet or to a car seat. A paraplegic person can be very independent in activities of daily living, and many engage in gainful employment. Some paraplegics are able to drive a car with the help of assistive devices.
A quadriplegic person can use a motorized wheelchair for independent mobility, but the person must be lifted into the wheelchair manually or mechanically. Some quadriplegics can move their hands or fingers slightly, in which case they can operate the motorized wheelchair with a hand switch. For quadriplegics whose hands and arms are completely motionless, a special device on the motorized wheelchair allows it to be controlled by chin movements or even by the person's breath, but this requires very intensive training. People with quadriplegia generally need support 24 hours a day.
Hip Fracture
Rehabilitation therapy is begun as soon as possible after hip fracture surgery, often within a day. The initial goals of therapy are to maintain the level of strength the person had before the fracture occurred by preventing loss of motion and atrophy of muscle and to prevent problems that result from bedrest. An additional goal is to restore the person's ability to walk as well as he was able to before the fracture occurred.
As soon as possible, sometimes within hours of surgery, the person is encouraged to sit in a chair, which reduces the risk of bedsores and blood clots and eases the transition to standing. The person is taught to perform daily exercises to strengthen the trunk and arm muscles and is sometimes taught exercises to strengthen the large muscles of both legs as well. Usually within the first day after surgery, the person is encouraged to stand up on the uninjured leg, often with the assistance of another person or while holding onto a chair or a bed rail. While performing these exercises, the person is directed to touch only the tips of toes of the injured leg on the floor. Full weight bearing on the injured leg is often encouraged on the second day after surgery but depends on the kind of fracture and repair.
See the figure Just the Right Height.
Ambulation (walking) exercises are started after 4 to 8 days as long as the person can bear full weight on the injured leg without discomfort and has sufficient balance. Stair-climbing exercises are started soon after walking is resumed. In addition, the person may be taught how to use a cane or other assistive device and how to reduce the risk of falls.
Arm and Leg Amputation
Most arm amputations result from accidents. A small number are performed surgically to treat a medical condition (for example, to remove a cancerous tumor). The arm can be amputated below the elbow, above the elbow, or at the shoulder.
After amputation, a person is usually fitted for an artificial arm (an upper extremity prosthesis). The prosthesis consists of a terminal device (a hook or hand), a wrist unit, an elbow unit for an above-the-elbow amputation, and a socket. Movement of the hook or hand is controlled by movement of the shoulder muscles. A hook may be more functional, although most people prefer the appearance of a hand. Control of an above-the-elbow prosthesis is more complicated than that of a below-the-elbow prosthesis. Recently, battery-operated and microcomputer-controlled prostheses have been developed, allowing a person more precisely controlled movements.
Rehabilitation after arm amputation includes general conditioning exercises, stretching of the shoulder and elbow, and strengthening of the arm muscles. Endurance exercises may also be necessary. The specific exercise program prescribed depends on whether one or both arms were amputated and whether the amputation was above or below the elbow.
Leg amputations occur almost equally as the result of an accident or as a surgical procedure performed to treat a consequence of a medical condition (for example, as the result of poor blood supply due to diabetes). The leg can be amputated below the knee, above the knee, or at the hip.
An artificial leg (a lower extremity prosthesis) consists of the terminal device (foot), a knee unit for an above-the-knee amputation, and a socket. Newer prostheses, which are battery operated or microcomputer controlled, allow a person to control movements with more precision.
Rehabilitation after leg amputation includes exercises for general conditioning, stretching of the hip and knee, and strengthening of all arm and leg muscles. The person is encouraged to begin standing and balancing exercises with parallel bars as soon as possible. Endurance exercises may be needed. The specific program prescribed depends on whether one or both legs were amputated and whether the amputation was above or below the knee.
Contracture (a shortening of muscle, producing limited range of motion) develops easily at the amputated limb, hip, or knee joint and usually results from prolonged sitting in a chair or wheelchair or improper body positioning in bed. If contracture is severe, a prosthesis may not fit properly, or the person may lose the ability to use a prosthesis. Therapists or nurses must teach methods of preventing contracture.
Therapists help people learn how to condition the stump, which promotes the natural process of stump shrinking (which must occur before a prosthesis is fitted). An elastic stump shrinker or bandages worn 24 hours a day can help taper the stump and prevent fluid buildup in the tissues. Early walking with a temporary prosthesis helps shrink the stump as well. Various temporary prostheses with adjustable sockets are available. A person with a temporary prosthesis can start ambulation exercises on parallel bars and progress to walking with crutches or a cane until a permanent prosthesis is made.
If the prosthesis is made before the stump stops shrinking, adjustments may be needed for comfort and to allow a good gait pattern. Manufacture of a permanent prosthesis is generally delayed for several weeks to allow the stump time to shrink completely.
Therapists teach amputees how to walk with a prosthesis. Strength and balance training are included in the program. Walking begins with direct assistance and progresses to walking with a walker, then with a cane. Within a few weeks, many amputees walk without a cane. The therapist teaches the amputee to use stairs, walk up and down hills, and traverse other uneven surfaces. Younger amputees may be taught to run and indeed participate in many athletic activities. Progress is slower and more limited for those who have above-the-knee amputation, for older people, and for those who are weak or poorly motivated.
The prosthesis needed for an above-the-knee amputation weighs much more than that for a below-the-knee amputation, and controlling a prosthetic knee joint requires skill. Walking requires 10 to 40% more energy after below-the-knee amputation and 60 to 100% more energy after above-the-knee amputation.
After arm or leg amputation, a sensation called "phantom limb" may be experienced, in which the person feels as if he still has the amputated limb. When this sensation occurs in the case of an amputated leg, for example, the person may stand up and thus fall back down. This kind of accident usually occurs at night when the person wakes to use the bathroom. Phantom limb can be extremely painful (phantom limb pain). Use of a prosthesis seems to accelerate the disappearance of a phantom limb. Massaging the stump also often helps.
Speech Disorders
Aphasia: Aphasia is a defect or loss in the ability to comprehend or express words, often resulting from a stroke or another type of brain injury that affects the language center in the brain (see Section 6, Chapter 82).
The goal of therapy for people with aphasia is to establish the most effective means of communication. For people with mild impairment, the speech therapist uses an approach that emphasizes ideas and thoughts rather than words. Pointing to an object or picture, gesturing, nodding, and relying on facial expressions are often sufficient for rudimentary communication. For people with more severe impairment, a stimulation approach (in which words are repeatedly spoken to the person) and a programmed stimulation approach (in which words are spoken and objects are presented that can be touched and seen) help the person reacquire language ability. Caregivers of an aphasic person need to be very patient and appreciate the person's frustration. Caregivers must also realize that an aphasic person is not demented and should not be spoken to in baby language, which is insulting. Instead, the caregiver must speak normally and, if necessary, use gestures or point to objects.
Dysarthria: Dysarthria is an inability to articulate words properly because of problems in muscular control caused by damage to the nervous system. Rehabilitation goals depend on the cause of the dysarthria.
If the cause of dysarthria is stroke, head trauma, or brain surgery, the goal is to restore and preserve speech. For mild cases of dysarthria, repetition of words or sentences may sufficiently allow the person to relearn how to use facial muscles and the tongue for proper pronunciation. For severe cases of dysarthria, a letter or picture board or electronic communication device may be helpful.
If the dysarthria is caused by a progressive problem with the nervous system, such as amyotrophic lateral sclerosis (Lou Gehrig's disease) or multiple sclerosis, the goal of therapy is to maintain speech function for as long as possible. The person exercises to increase control of the mouth, tongue, and lips and is taught more appropriate speech rate and proper phrase length. Poor control of breathing muscles may force the person to take a breath in the middle of a sentence. Breathing exercises and planning punctuation within a sentence are helpful.
Verbal Apraxia: A person with verbal apraxia cannot produce the basic sound units of speech because of an abnormality in initiating, coordinating, or sequencing the muscle movements needed to talk. Verbal apraxia is often caused by brain injury, such as occurs with stroke or head trauma. In one therapeutic approach, the therapist has the person practice making sound patterns over and over again. In another approach, the therapist teaches the person to use natural melodic patterns for common phrases. Every phrase has its own melodic rhythm depending on the mood of the speaker. For example, "Good morning! How are you?" can be said in a flat melodic patter if the speaker is not up in the mood. However, when these phrases are said in a very cheerful manner, there is almost musical melodic rhythm. In treatment of verbal apraxia, the practitioner encourages the patient to repeat very exaggerated natural melody and rhythm patter. As the patient progresses, melody and rhythm cues are gradually faded.
Blindness
For rehabilitative purposes, blindness is classified into two groups: blindness present at birth (congenital) or at a very young age and blindness that develops later in life. Children who are born blind or who become blind at a very young age usually receive special education and become well adjusted. People who become blind later in life, however, must learn new ways of dealing with daily living. One activity of daily living, feeding oneself, is commonly taught to blind people with use of the clock method, in which, for example, the dinner plate is located at 6 o'clock, the salad plate at 3 o'clock, and the beverage at 9 o'clock. The person also has to learn how to use a cane, and family members and other caregivers must learn how to walk with the blind person. The family is also instructed not to change the location of furniture or other objects without telling the blind person. Use of a seeing eye dog and learning Braille come much later. In the interim, audio books help the blind participate in reading.
Hearing Loss
Aural rehabilitation is used for people who became deaf in adulthood. Those deaf at a young age receive training in school. Rehabilitation teaches lip reading and how to optimally use a hearing aid (see Section 19, Chapter 218). Training also teaches the deaf person how to modulate his speaking volume, since without training a deaf person tends to speak loudly. Therapists can also recommend other assistive devices, such as door bells, phones, and alarms that display a flashing light when they ring.
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