Physical Medicine / Rehabilitation

KNR 365

Rehabilitation Continuum of Care

• Rehabilitation is the process of providing those comprehensive services deemed appropriate to the need of a person with a disability in a coordinated manner in a program designed to achieve objectives of improved health, welfare and the realization of the person’s maximum potential for useful and productive activity

» CARF

• Required coordinated comprehensive multidisciplinary approach

Rehab nurses TR

Physiatrists Speech & respiratory therapists

Case managers Vocational counselors

PT Social workers

OT Psychologists

Rehabilitation Continuum of Care

• These services are made available to people with traditional rehab diagnosis– CVA, TBI, SCI, hip/knee replacement, amputation, chronic

progressive and relenting neurological disorders, and multitrauma

– Decline in functioning secondary to cardiac, pulmonary, arthritic conditions

• Role of case manager is to direct patients to the most effective level of care

• Continuum of care– Subacute care units, long-term/skilled care units, day care,

rehabilitation hospitals, comprehensive outpatient care, and home health care

Rehabilitation Continuum of Care

• Subacute care is less-intense level of care than acute care provided in hospital & more that in LTC/skilled nursing facility (SNF)– Levels

• Transitional step-down unit, often in hospital• General subacute care• Chronic subacute (comatose, ventilator-dependent, little

hope of recovery or functional independence)» Harris

Rehabilitation Continuum of Care

Acute Rehab Subacute Nursing Home

Long-term Care Nursing Home

Therapy Available 5-7days/wk 3-5 days/wk 1-3 days/wk

Therapy Intensity 2-4 hrs/day 1-3 hrs/day 30 min – 1hr/day

Avg LOS 8-20 days 20-35 days 1-2 years

MD Visits 1 per day 2-3/week 1 per month

TR Services

• 1-1

• Group

• Co-treatment– Co-treatment involves more than one professional providing

treatment during the same session– Co-treatments are performed when therapeutic goals are

similar or complimentary

Disabilities in Text

Class Discussion• Amputation & Prosthesis• Back Disorders & Back Pain• Chronic Obstructive

Pulmonary Disease• Guillain-Barre Syndrome• Joint Replacement• Spinal Cord Injury• Traumatic Brain Injury

Assignments• Cardiac Conditions• Multiple Sclerosis• Fibromyalgia

Illinois Neurological Institute:Top Diagnosis on Rehab

• Stroke • Spinal Cord Injury• Traumatic Brain Injury• Critical Illness Myopathy• Guillain-Barre Syndrome

• Myasthenia Gravis• Amputation• Joint Replacement• Multiple Sclerosis• Medical Deconditioning

Critical Illness Myopathy

• What is Critical Illness Myopathy?– is not well understood– typically occurs in the intensive care unit among patients who

have been treated with multiple drugs– the most common clinical signs of the disease are diffuse

weakness and a failure to wean from mechanical ventilation• Who gets Critical Illness Myopathy?

– is a disease of limb and respiratory muscles– is observed during treatment in the intensive care unit – in addition to the critical illness (severe trauma or infection),

muscle relaxant drugs and corticosteroid medications may be contributing factors

Critical Illness Myopathy

• Deficits– Developed in critically ill patients– General muscle weakness– Decreased endurance, mobility, strength, balance– Fatigue– Lethargy

• How is Critical Illness Myopathy treated?– Early and complete recovery may occur with successful

treatment of the critical illness, and withdrawal of the medications

– RT goals:• Increase endurance, strength, balance

» http://www.aanem.org/Education/Patient-Resources/Disorders/Critical-Illness-Myopathy.aspx

Myasthenia Gravis

• Chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal (voluntary) muscles of the body

• Deficits– Decreased endurance and strength (upper & lower

extremities)– Decreased muscles that affect eye control, eyelid movement,

facial expression, chewing, talking, swallowing, breathing dysarthria (impaired speech), blurred vision, double vision (diplopia), gait

• RT goals– Increase strength and endurance

» http://www.ninds.nih.gov/disorders/myasthenia_gravis/detail_myasthenia_gravis.htm

Medical Deconditioning

• Loss of muscle tone and endurance due to chronic disease, immobility, or loss of function

• Deficits– Decreased endurance, strength, balance, mobility– Fatigue– Lethargy

• RT goals– Increase endurance, strength, balance, mobility

Amputation

• Performed because of limb disease, trauma, birth defects, frostbite– Peripheral arterial disease (complication of diabetes)– Cancer– Sudden blockage of an artery (embolus) causing lack of

blood/oxygen to tissue….gangrene• Upper: defects, trauma, tumors• Lower: 70% disease• Loss of limb requires more cardiopulmonary & muscular energy to

perform tasks• See Porter & burlingame, 2006, p. 12 for classifications

Amputation

• Secondary problems– Pain (including phantom

pain)– Infection– Skin breakdown– Deconditioning– Impaired sense of self– Lack of awareness and

knowledge

• RT interventions– Physical activity for

endurance & muscle strength

– Activity adaptation– Community problem

solving– Community mobility skills– Community reintegration

Amputation

Back Disorders & Back Pain

See text pp. 25-28

Chronic Obstructive and Pulmonary Disease (COPD)

• Chronic bronchitis, asthma, emphysema– Not reversible; damage can not be undone

• 4th leading cause of death in US• Primary cause is smoking• Secondary problems

– Poor nutrition– Poor muscle strength & endurance– Psychosocial issues (depression, anxiety, learned

helplessness, loss of internal locus of control)• RT interventions

– Stress management– Adaptive equipment– Social support

Guillain-Barre Syndrome (GBS)

• Illness in which body’s immune system attacks its own nerve cells• Affects peripheral nervous system (nerve roots that exit vertebral

column to muscles & organs) but not nerves in brain or spinal cord

• Symmetrical muscle weakness that starts in legs & rises upward (ascending paralysis)

• Weakness, loss of balance, pain• Decreased mobility, strength, endurance balance• Increased heart rate, blood pressure• Anxiety• Lack of leisure• RT Interventions: Stress management, exercise, energy

conservation training

Joint Replacement

• Removal of diseased or damaged joint and implantation of artificial joint (prosthesis)

• Hip and knee are most common (could be any joint)• Typically caused by rheumatoid arthritis, osteoarthritis, or trauma• Total hip replacement (THR)

– 2/3 are older than 65, increases up to 75, then declines– 62% are women

• Total knee replacement (TKR)• Deficits

– Decreased mobility, balance, endurance, strength– Social isolation, loss of healthy leisure lifestyle, increased

weight

Joint Replacement

• Concerns for deep vein thrombosis & pulmonary emboli– Anti-clotting medication (bleeding concerns) – Warning signs: pain in calf, tenderness or redness above or

below knee, swelling in calf, ankle, foot– Warning signs that clot has traveled to lung: sudden onset of

chest pain, localized chest pain, & coughing

• Must be cleared to resume driving