Rehab of the Trauma Patient

8/14/2019 Rehab of the Trauma Patient

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Patients suffering major trauma require an integrated

interdisciplinary approach across the continuum of care from

early injury management to later community reintegration

and beyond to achieve the best outcome for quality of life

and independence. Rehabilitation commences on the first

day of injury and requires development of a good

understanding by all members of the treating team of the

persons personality, lifestyle, interests and motivation, as

well as family situation and social support network.

Key points

Rehabilitation commences on the first day of injury

Definitions

Rehabilitation is a process of restoration to achieve

maximum physical, social, psychological, vocational and

avocational functioning following injury or illness. As well as

primary restoration, rehabilitation also places a strong

emphasis on secondary prevention through identification of

the causative or risk factors and provision of education and

appropriate interventions to maintain future health and well-

being.

Rehabilitation after traumatic injury can be divided into four

overlapping phases.

i. Acute: Stabilization of injury with surgical and medical

management, early rehabilitative measures to prevent

secondary impairments and initial remobilization. (Acute

Hospital)

ii. Subacute: Comprehensive assessment and intensive

inpatient rehabilitation to enhance level of functional

independence and psychological adjustment, prescribe

appropriate prostheses, orthoses, aids and equipment and

assess necessary home modifications in anticipation of

discharge. (Rehabilitation Centre)

iii. Community: Resettlement into a safe independent living

environment with continuation of therapeutic input as an

outpatient to achieve patients optimum recovery and

potential. Also covers further education and retraining if

required, return to work and leisure pursuits. (Day Therapy /


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Day Hospital / Outreach)

iv. Maintenance: Ongoing management of disability and

maintenance of support network. (Outpatient Clinics)

Developing a framework for rehabilitation requires an

understanding of some basic concepts (ICIDH-2 1997).

Impairment relates to the injury at the tissue level and the

body. In the case of a compound lower limb fracture a

possible impairment may be vascular insufficiency and

amputation of the limb. The resulting disability would cause a

limitation to activities at the level of the person. In this case

there would be a limitation to activities such as walking. This

limitation to activities would affect the persons participationin society. This would involve psychological aspects and

choices for work and leisure.

The team approach

The rehabilitation team must always recognize the

involvement of the patient and family as the key to

successful rehabilitation. Self implemented programs are

preferred as rehabilitation is an active rather than passive

process.

Consulting and participating members of the team include

the doctor, nurse, physiotherapist, occupational therapist,

social worker, speech pathologist, psychologist and

recreation therapist.

Key points

The rehabilitation team must always recognize the

involvement of the patient and family as the key to

successful rehabilitation.

Rehabilitation planning

A problem list is prepared and goals set as part of a

rehabilitation plan.

The goals may be medical or therapy based and must be


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locomotion, and assist the team in goal setting. They are

regularly reviewed at a case conference and provide a basis

for clinical decision making regarding treatment strategies

and care requirements. It is important to remember when

setting goals that performance may be influenced by

numerous factors other than impairment alone, including

adaptive equipment, suitable environment, social supports,

time and energy required, and safety.

A simple and reliable measure of activities of daily living is

the Barthel Index (Mahoney and Barthel 1965). Another more

sensitive ADL scale developed by the State University of

New York is the Functional Independence Measure (FIM)

(Keith et al. 1987). The FIM in addition records

communication as well as social cognition items. See

examples of data collection sheets (Tables 35.1 and 35.2).

Key points

A number of activities of daily living (ADL) scales

have become internationally accepted (The Barthel

Index and the FIM).

Physical

Serial measures of muscle strength and recording on a

muscle chart will assist in monitoring the progress of

exercise programs. Grading of muscle strength from 0 to 5

has been widely accepted. Grading movement against slight,

moderate and strong resistance as 4, -4 and +4 is

sometimes a useful variation to the original scale (MRC

1976).

0 No contraction

1 Flicker or trace of contraction

2 Active movement with gravity eliminated

3 Active movement against gravity

4 Active movement against gravity and resistance

5 Normal power


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Measures of mobility such as the motor assessment score

add extra detail to the less sensitive FIM and Barthel index in

neurological disorders. Other tests of mobility may be very

simple such as a 6 metre (20 feet) walking speed or the

timed up and go (Posiadlo and Richardson 1991) test. In

this test the patient is observed as they rise from an armchair

and walk 3 metres, turn, walk back and sit down again.

Checking and recording the range of motion (ROM) at hip for

patients in bed requires flexing of the contralateral hip and

straightening the lumbar spine (Thomas test). Assessment of

ROM at the knee and ankle should also be routine for non-

ambulant patients.

Cognitive

Traumatic head injury is often associated with impaired

cognition. This can be initially assessed on admission by the

Glasgow Coma Scale (GCS) (Teasdale and Jennett 1974)

(Table 35.3). However, patients with a GCS score of 15/15

may still have significantly impaired cognition and be

suffering Post Traumatic Amnesia (PTA) (Table 35.4).

Monitoring the period of PTA in which the injured person has

no reliable short term memory and particularly recovery from

PTA is extremely valuable in the management of a head

injured patient. Once a patient is capable of remembering

from one day to the next, then they can actively participate in

a rehabilitation program. A scale which is easily applied is the

Westmead Post Traumatic Amnesia Scale (Shores et al.

1986) (Table 35.4).

Basic screening tests of cognitive function such as the Mini-

Mental State Examination (Folstein et al. 1975) (Table 35.5)

test orientation, short and long-term memory and language.

It is essential to establish rapport and leave the patient

relaxed and comfortable. The patient must have adequate

hearing and vision to respond to questions. This is only a

screening instrument for cognitive dysfunction. A low score of


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batteries are available to examine a wide range of cognitive

abilities, including concentration, attention, planning, problem

solving, judgement and other executive functions. Tests of

learning use diagrams such as the Rey-Ostereith Complex

Figure, card sorting, mazes and trail making tests. Standard

texts contain more detailed explanations (Deutsch 1995).

Results from such tests prove most helpful when determining

issues such as a patients competency to handle financial

affairs, ability to safely drive a motor vehicle or return to work

and may assist choices for employment.

Key points

Traumatic head injury is often associated with

impaired cognition

Passive physical modalities

Heat, cold and electricity are adjuvants to active physical

therapy. There effects are only short term. A knowledge of

the risks and benefits may add substantially to the safe

design of a rehabilitation program.

Heat

Superficial heat can be applied by conduction such as a hotpack, radiant heat or paraffin bath, or by convection as

occurs in hydrotherapy or moist air (sauna). Conversion of

non-thermal to thermal energy occurs in deep heat

modalities such as microwave and ultrasound.

Contraindications to the application of heat includes:

Acute trauma, haemorrhage and oedema.

Anaesethic areas where burns may occur.

Vascular insufficiency particularly feet and hands.

Bleeding disorders.

Sepsis

Unreliable or cognitively impaired patient.

Pregnancy.

In the region of the gonads.


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Altered thermoregulation (precaution depending on

modality).

Benefits to the application of heat include:

Increase extensibility of collagen, aiding stretching

of ligaments and musculo-tendinous unit.

Decrease in joint stiffness.

Decrease pain.

Decrease muscle spasm by an effect on the muscle

spindle.

Increase of superficial blood flow through arteriolar

and capillary dilatation.

Increase tissue metabolism.

Consensual response in opposite limb or deeper

structures.

Psychological benefits.

Recommended selective heating of skin and subcutaneous

tissues should be within the therapeutic range of 40-45

degrees C for no longer than 30 minutes. Prolonged heating

should be avoided as core temperature will eventually rise.

Applications of heat that are commonly used:

Hot packs, hydrocollator and Kenny Packs. Usually

applied wrapped in towelling for ten minutes

repeated 2 - 3 times.

Infra-red lamps provide superficial heating only and

carry the risk of superficial burns.

Paraffin baths or wax baths consist of heated

melted mixtures of oil (usually one part mineral oil to

6 or 7 parts paraffin wax). It can be applied to the

skin despite the high temperature of 52 degrees C

because of the low specific heat. Application is by

dipping 3 to 4 times and wrapping in a towel, or by

brushing or immersion. Specific contraindications

are open wounds. It is specifically used for joint

stiffness and for mobilization after hand trauma.


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Contrast baths consist of alternate immersion in hot

(40-43 degrees C) and cold water (15-18 degrees

C) for 4 cycles of 4-min and 1-min durations

respectively, ending in hot water. This produces a

hyperaemia and maybe useful in regional painmanagement.

Ultrasound produces high frequency sound above

the audible range (0.8-1.0 MHz) causing heating at

the interface between tissues of differing density,

typically at fascial planes and bone. Ultrasound is

produced by a piezoelectric transducer in the

applicator or head of the machine. The intensity

may vary from 0.5-2 W/ cm2 area applied for 5-10

minutes duration. The head is applied to the skin

with a coupling medium of gel or water if the treated

part is submerged. This medium is necessary to

provide efficient energy transmission. Whilst non-

thermal effects may be beneficial in certain

situations those arising from gaseous cavitation,

caused by alternating compression and rarefaction

where gas bubbles form, may have a destructive

effect on tissues. To avoid overheating of tissues

and gaseous cavitation, ultrasound should never be

applied over large fluid filled areas such as the

eyeball, amniotic sack or larger effusions.

Ultrasound should also not be applied over nerve

roots following laminectomy, implants or devices,

and epiphysis in growing children. The transducer

head is continually moved with a stroking technique

by the operator to avoid local damage.

Hydrotherapy in heated pools and spas allows a

patient to exercise in a non or partial weight bearing

environment. This is particularly useful in the

rehabilitation of lower limb fractures. Pool

temperatures vary from around 28 degrees C for

recreational activities to 31 degrees C for

therapeutic sessions of less than 30 minutes.

Cold therapy (cryotherapy)


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Cold therapy is used for a variety of acute ligament and

muscle trauma and superficial burns and analgesia. The

benefits are:

Reduction of swelling and bleeding by

vasoconstriction.

Pain reduction by slowing nerve conduction in

peripheral nerve fibres.

Muscle relaxation by reducing muscle spindle

activity.

Contraindications to the application of cold includes:

Peripheral vascular disease, Raynauds

phenomenon/disease.

Anaesethic areas where cold burns may occur.

Severe cardiovascular disease (pressor response if

large area).

Application of ice for cooling deep tissues may be as:

crushed ice in plastic bag

ice with dry towel

ice via wet towels

immersion in iced water with or without movement

gel pack

The cooling medium should be kept in close contact with the

treated area. It is best to bandage the bag of ice or gel pack

onto the limb. The period of application will depend on the

thickness of subcutaneous fat. Ice packs are usually applied

for 15 - 20 minutes 3 - 4 times daily for the first 48 - 72 hours

following injury. If acute trauma is being treated, cold is

usually combined with compressive bandaging and elevation

using RICE regime - Rest, Ice, Compression, Elevation

(Johannsen and Langberg 1997).

Key points


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It is best to bandage the bag of ice or gel pack onto

the limb.

Electrical therapy

Laser

Low intensity laser can non-destructively alter cellular

function without significant heating. It is used affects muscle

skelation and soft tissue conditioning (Basford 1993).

TENS

Direct application of electricity to the strain has been used to

relieve acute and chronic pain. Two or four electrodes are

applied in the pain related segment with a frequency of fren

75-100H3 for over 20 minutes. Narcotic analyses should be

ceased while therapy is trialled. Contraindictions include:

Cardiac pacemaker

Cardiac disease or arrythmias

Pregnancy

Larynx/Pharynx/eye

Active physical therapy

Following major injury or illness, in addition to the directly

related impairments to neurological, musculoskeletal and

cardiovascular systems, prolonged bed rest and immobility

leads to deconditioning with reduction in strength, endurance

and fitness. Physical therapy and exercise aims to increase

range of motion, muscle strength and endurance, improve

balance, motor control and coordination, teach important

functional skills and upgrade physical fitness to enhance

overall performance and independence.

Broadly, therapeutic exercise can be divided into the

following components:

Strengthening and endurance

Stretching


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Balancing, motor control and coordination

Cardiovascular fitness

Strengthening and endurance

The principle generally used in strength training of overload

is not entirely applicable to major trauma without judicious

modification of program to avoid producing further injury or

delaying healing whilst promoting progressive physiological

and psychological adaptation.

Exercise prescription entails specification of the following:

Type of exercise

Intensity

Number of repetitions and sets

Recovery interval

Traditionally, different guidelines have been used for muscle

strengthening (high resistance, low repetitions) and training

endurance (low resistance, high repetitions), although there

are crossover effects. Exercises may be performed either

concentrically or eccentrically, with the former more usual

early after traumatic injury.

The different types of exercise used for muscle strengthening

and training endurance are:

Isometric

Isotonic

Isokinetic

Isometric exercises contracting muscles without joint

movement can be used when joint motion is painful or

contraindicated, but are of limited value due to angle

specificity. A maximal contraction is held for 5-secs with 5-10

repetitions. Care must be taken with individuals with a high

resting blood pressure or underlying cardiovascular disease

due to pressor response.

Isotonic exercises are the most commonly used during


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rehabilitation after serious injury. As already mentioned, the

exercise program should be customized to the clinical

situation, carefully monitored and progressively upgraded as

possible. An arbitrary starting intensity must be chosen, for

example 3 sets of 10-15 repetitions at 40-65% of 1 repetition

maximum (RM). This endurance type of program

(low/medium resistance, low/medium repetitions) allows

patient to become familiar with exercises and provides a

stimulus to improve motor unit recruitment. The range

provided allows some flexibility and ability to progressively

upgrade program. When muscle strength in particular is a

limiting factor (e.g.. to lift body weight against gravity to

transfer independently) a predominant strength program, for

example 1 set of 6-8 reps at 85-100% of 1 RM, may be used.

Care must be taken when prescribing exercises not togenerate excessive torsional forces around injured joints and

bones.

Isokinetic exercise using a dynamometer such as Orthoton,

Cybex or Kincom allows maximum tension to be safely

exerted throughout complete range of movement, but is

generally only used for rehabilitation after traumatic injury to

larger joints, e.g. knee.

As strength and endurance improve in individual muscle

groups, the exercise program will progressively incorporate

more functional activities involving combined patterns of

movement.

Flexibility

Extended periods of bed rest and non weight bearing will

result in muscle shortening and contracture. This is most

common at the hip, knee and ankle. Maintenance stretching

regimes range from 30 to 60 seconds, 3 repetitions twice

daily. Self implemented slow stretch and techniques

progressing to the level of discomfort can be demonstrated

to the patient (Fig 35.1) (Sherry and Wilson 1998). Ballistic

(bouncing) exercises should be avoided due to the risk of

muscle tears.

In established contractures longer and more frequent

stretching is required to restore muscle length. These


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passive techniques should be administered by a

physiotherapist. Passive stretching may be combined with

the use of mechanical devices and serial splinting.

Proprioception

Ligaments, tendons and joints are involved in determining

position sense of limbs. Rehabilitation for damage to these

structures should include retraining for balance and co-

ordination. Supervised balance exercises on one or two legs

involve distractions of visual cues, e.g. blindfolding bouncing

or throwing balls. The patient progresses form static to

dynamic exercises to mobility on flat and rough or undulating

surfaces or a moving surface (wobble board). Proprioception

may be temporarily enhanced by use of taping around joints

due to increased sensory input.

Cardiovascular fitness

Exercise prescription for cardiovascular conditioning entails

specification of the following:

Type of exercise

Frequency

Intensity

Duration

Program length

Interval/rest interval (if continuous exercise not

possible)

The type of exercise prescribed (e.g.. cycling, arm

ergometry) will depend to some extent on clinical situation. A

frequency of 3-4 times/week is usually recommended.

Intensity must be adjusted to 40-70% of heart rate reserve

(HRR). HRR is calculated by subtracting resting heart rate

(HR) from age predicted or observed peak HR. Standard

formulas to determine maximum HR (e.g.. 220-age) are not

reliable when significantly impaired and deconditioned after

injury. Under these circumstances, peak HR is best

determined using a progressive stress test (e.g.. cycling, arm


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ergometry). Exercise duration should be a minimum of 20

minutes lasting up to 40 minutes. A program should run for a

minimum of 8 weeks to receive a benefit. If someone is

unable to perform continuous exercise for at least 20

minutes, then interval training can be used instead. Exercise

for a period of 5-7 minutes is undertaken followed by a rest

interval of half the exercise time or when HRR drops below

40%. Like other therapies, an individually tailored program

can be provided by consultation with an exercise specialist.

Key points

The principle generally used in strength training of

overload is not entirely applicable to major trauma

The type of exercise prescribed (e.g.. cycling, arm

ergometry) will depend to some extent on clinical

situation

Checklist for major injury

Reflex sympathetic dystrophy (also known as complex

regional pain syndrome, type 1)

This is covered in Chapter 13(page 00)

Rehabilitation after amputation

Overview

Amputations due to trauma have been reported as

accounting for over 20% of all amputations (Goldberg 1985).

This percentage is dropping in developed countries due to

better road safety, industrial standards and advances in

replantation surgery (Ebskov 1992).

The causes for traumatic amputation in developing countries

are quite different. In India train accidents are a frequent

cause with war and unexploded landmines contributing to the

problem in Africa and South East Asia. Estimations for

traumatic amputation are as high as 1 amputee per 256

people in Cambodia and 1 per 470 in Angola. These show a


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marked contrast to 1 per 22,000 people in the USA (Staats

1992).

Lower limb trauma is a far more frequent cause for

amputation than upper limb with a ratio of approximately 11

to 1. Overall figures (from all causes) for amputation levelsreflect the trend to preservation of the knee for

proprioception input and length for biomechanical efficiency.

Published figures show: Above knee 38%, below knee 54%,

through knee/Gritti-Stokes 6%, Symes (through ankle) 1%,

forefoot 1% (Lisfranc, Pirigoff, Chopart) (Fyfe 1990).

Key points

Amputations due to trauma have been reported as

accounting for over 20% of all amputations

Key issues in the rehabilitation of the lower limb amputee

Surgery

Preservation of limb length has implications for prosthetic

fitting and the eventual energy cost of ambulation. Increased

energy costs of ambulation are reflected in the comfortable

walking speed (CWS) of amputees compared to normal. A

study of traumatic amputees demonstrated a velocity of 87%

of normal at the below knee level and 63% at the above knee

level when using a prosthesis. There is an even greater effort

required when using crutches (Waters et al. 1976).

Balance and stability of joints of the required residual limb

will result in better prosthetic outcome and activity for the

amputee in above knee transfemoral amputees. This is

achieved by myodesis of the adductor magnus to the

remaining femur. In transtibial amputation the musculo-

tendinous portion of the gastrocnemius is tethered to the

anterior distal tibia as a posterior flap. It is desirable toachieve skin closure without tension (Bowker and Michael

1992).

Key points

Preservation of limb length has implications for

prosthetic fitting


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Stump Care

Early amputation stump management is essential as a

means of hastening prosthetic rehabilitation. A variety of

methods are used post-operatively with the same intention.

Rapid resolution of stumpoedena

Prevention of stump fibrosis

Promotion of would healing

Wound protection

Desensitisation and pain management

Reduction of infection

Early mobilization and weight bearing

Muscle strengthening and stability

Anti-contracture treatment

Key points

Early amputation stump management is essential

The following techniques are currently in use:

1. The non removable rigid dressing is applied in the

operating theatre and maintained until removal of

sutures at about 2 weeks post-operative (Jones and

Burniston 1970). The advantages are early (7-14

days) weight bearing through the plaster of Paris

dressing and early mobilization with a temporary

prosthesis applied at the end of week two to three

post-operative when the dressing is removed. The

reason that this technique is used in only 8% of

centres in the USA is due to the need to access for

inspection of the surgical incision.

2. The removable rigid dressing can be applied post-

operatively and used continuously until a temporary

or definitive prosthesis is f itted (Yeongehi and Krick

1987). The advantages are that the wound may be

inspected as required and stump socks may be

applied as the stump shrinks. The additional use of


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a supporting strap allows patients to perform

quadriceps exercise, anti-contracture and

antioedema movement while sitting in a wheelchair

(Hughes et al. 1998).

3. Elastic bandaging stockingette and support

stockings (shrinkers) are the most commonly used

techniques. Stump compression may commence

within 1 to 3 days post-operatively depending on

wound condition and pain tolerance. Bandaging

techniques should provide more distal than proximal

compression. Correct bandaging and avoidance of

a tourniquet effect is essential. Stump compression

with bandaging or stocking usually continues for 12

to 18 months post-operatively at times when the

prosthesis is not in use.

Contractures

Contractures at the hip and knee form quickly with the loss of

the limb as a lever. An anticontracture program should start

within the first post-operative week. This program involves

lying prone for 30 minutes twice daily to encourage extension

at the hip. Knee exercises involve 10 second isometric

quadriceps exercises 10 repetitions every hour. An extension

stump board should be attached to the wheelchair for below

knee amputees.

Mobilization

Mobilization should occur as soon as tolerated. Partial weight

transference through a rigid dressing should be attempted

after the first post-operative week with full weight bearing as

tolerated after sutures are removed. After the third week an

interim prosthesis should be considered to commence gait

training. The choices are either a polypropylene patellor

tendon bearing socket for the below knee amputee or a

quadrelateral ischial weight bearing socket for the aboveknee amputee. Modular aluminium tubing shanks or pylons

with solid ankle cushion healed (SACH) feet are commonly

used and in the above knee amputee a single axis semi

locking safety knee may be fitted. Due to the need for socket

changes over the first weeks to months some centres use

other alternatives until fitting of the definitive prosthesis.


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Sockets for interim prostheses may be fabricated in Plaster

of Paris, or a variety of resin wraps. Pneumatic weight

bearing temporary prostheses utilize an air splint inflated

around the stump and enclosed in a metal frame (Little

1971). They have been used from day 6 post-operatively and

as with other interim methods aid in reduction of oedema,

maturation and shaping of the above or below knee stump

(Redhead 1978).

Pain management

Pain management should occur post-operatively to reduce

the incidence of Phantom pain post-operatively. Post-

operative pain relief may be achieved by narcotic analgesics,

spinal anaesthesia or local anaesthetic infusions into

sensory nerves. Narcotic analgesics and other methods

usually cease by day 5 to 7 when simple analgesia i.e.

paracetamol is adequate for treating stump and wound pain.

Phantom sensation occurs in nearly all patients. Phantom

pain often commences as stump pain subsides in the second

or third post-operative week. The pain may be episodic and

stabbing or of a constant and burning nature. Adequate

stump compression bandaging, massage, physical and

diversional therapy may be useful in the daytime. Often the

pain is worse at night with the patient finding difficulty

sleeping. Simple analgesics with an adjuvant medication

may assist sleeping and reduce phantom pain. Medications

often used are tricyclic antidepressants such as Amytriptylin

and Doxepin. Sometimes an anti-epileptic medication is

added or used as an alternative e.g.. Carbamazepine

Transcutaneous electrical nerve simulation (TENS) has been

reported to reduce pain when applied to the amputation

stump or on the contralateral limb (Carabelli 1985).

Psychological adaptation

Psychological adaptation to the loss of a limb is associated

with grief and mourning (Elberlik 1980, Furst and Humphrey

1983). The phases of denial, anger, depression and

acceptance may continue over months or years following

amputation. There is a functional impairment which can be

compensated for by fitting of a prosthesis. This is not always

accompanied by an adjustment of body image. Counselling

with patients and family adjustment to disability, body image


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and roles in the family and society is integral to the

rehabilitation process. Relaxation and pain coping

techniques are useful skills.

Rehabilitation of traumatic spinal cord injury

Overview

Traumatic spinal cord injury (SCI) has an incidence of

approximately 15-30 per million population. Young males

between 16-30 years of age are at greatest risk, with motor

vehicle-related injury the most common cause, followed by

falls, sporting/recreational accidents, and violence in some

countries (Go et al. 1995). Improved survival following injury

has resulted from better roadside resuscitation, rapid

retrieval to specialized trauma centres and intensive medical

care. Likewise, advances in rehabilitation and management

of complications following SCI, as well as long-term medical

follow up by dedicated spinal cord injury specialists have

lead to improved life expectancy and quality of life for

individuals with SCI.

Key rehabilitation issues

Successful rehabilitation following severe SCI involves not

only developing as much functional independence as

possible through physical training, adaptive techniques and

specialized aids (Fig 35.1), but also adjusting to disability

and ultimately reestablishing a fulfilling lifestyle in the

community with satisfying roles and interests. Intensive,

interdisciplinary rehabilitation as an inpatient provides the

initial stepping stones for reintegration into the community,

but in many ways rehabilitation only really begins once the

person has returned home.

The purpose of this section is not to provide acomprehensive coverage of all aspects of rehabilitation after

SCI, but rather to highlight some key issues and the

importance of early rehabilitation to prevent complications

and achieve the best functional outcome.

Skin

After SCI patients are at great risk of developing skin


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complications due to factors such as immobility, loss of

protective sensation, weight loss and altered tissue viability.

The injured patient should be transferred off the spinal board

immediately on arrival in hospital and skin over entire body

including the back must be inspected for evidence of injury or

pressure as soon as possible (Mawson et al. 1988).

Nutritional status must be closely monitored with the aid of a

dietitian and enteral or parenteral nutrition considered early

to avoid later complications of altered body composition such

as decubitus ulceration secondary to poor coverage of bony

points.

Patients should be managed on an appropriate mattress,

such as a convoluted foam mattress initially and later a ripple

mattress, and must be turned or lifted and repositioned every

2 hours by a team of four trained staff with the skin checked.

Sheep skins may also prove helpful. Particular attention must

be given to areas at greater risk overlying any bony

prominence, such as the sacrum and heels when lying

supine or greater trochanter, medial aspect of knee and

lateral malleolus if on side.

Essential to avoid pressure problems in the longer term

include the following:

Appropriate prescription of equipment such as

mattress overlay, commode chair or toilet seatcover and pressure relieving cushion for wheelchair

(such as air floatation, gel or cut-out foam design)

Regular pressure relief when sitting by lifting,

leaning forward or to one side, or tilting motorised

wheelchair in space for 15-30 seconds 2-3

times/hour

Self-inspection of skin (with assistance if necessary)

using a mirror to monitor for pressure marks twice

daily

Key points

After SCI patients are at great risk of developing

skin complications

Pain


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Pain frequently accompanies SCI and can significantly

impact upon a person's functional ability, ability to return to

work, psychological well-being and quality of life. At present

there are no clear links between acute pain management

and longer term outcomes. However, there is some evidence

emerging from studies in other areas such as phantom limb

pain after amputation to suggest that early treatment may be

helpful for preventing later development of chronic pain. Pain

should therefore be vigorously treated during the acute

period. Patients are more likely to be actively involved in

rehabilitation when pain is adequately controlled.

The most important issue in the treatment of pain is to

correctly classify the type of pain, which most commonly is

either musculoskeletal or neuropathic (Siddall et al. 1997).

Classification is crucial in terms of determining the

appropriate treatment. As with other types of acute

musculoskeletal pain, opioids are effective. In contrast, the

management of neuropathic pain remains difficult. There are

currently no available treatments that consistently and

effectively alleviate this problem. However, there are a

number of treatments in current use (Siddall et al. 1998).

In the acute phase, local anaesthetics such as lignocaine

administered subcutaneously or intravenously may be useful

and if effective followed by mexiletine orally. Anecdotally,

ketamine infusion has also been described, although side-

effects may be limiting. With chronic pain, a tricyclic

antidepressant such as amitriptyline alone or in combination

with an anticonvulsant such as carbamazepine or sodium

valproate are commonly used. More recently, anecdotal

reports suggest the effectiveness of Gabapentin in treating

intractable neuropathic pain.

Other techniques which have proved helpful in some cases

include anaesthetic blockade at various levels, namely

sympathetic, epidural or spinal blockades, and intrathecal

administration of baclofen, clonidine and morphine via an

implanted pump.

Physical treatments including exercise and hydrotherapy

programmes, postural reeducation, wheelchair and seating

adjustments and possibly other physical modalities are often

helpful in managing pain resulting from a mechanical cause.


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It should never be forgotten that pain is a complex

phenomenon and that emotional, behavioural and

environmental factors may contribute to the experience of

pain. Therefore, attention should always be paid to

psychological factors and the use of cognitive-behavioural

techniques and strategies such as relaxation and distraction.

Key points

Correctly classify the type of pain

Positioning and contracture prevention

Contractures may develop as the result of immobilization and

poor positioning, spasticity, or muscle imbalance around a

joint and interfere with later rehabilitation. During the acute

phase, it is important to ensure that all joints are correctly

positioned, rested in mid-position of function and regularly

moved passively through a full range of motion at least once

daily.

Problems due to shortening of shoulder capsule can be

prevented by daily positioning of shoulders in abduction and

external rotation, the crucifix position. Foot drop can be

prevented with a pillow or bolster at the foot of bed

maintaining ankle in neutral position.

In the individual with C5 or partial C6 tetraplegia without

antigravity strength wrist extension, splinting of fingers and

hand at rest with a long opponens wrist-hand orthosis is

used to maintain wrist in 15-30 extension, metacarpo-

phalangeal (MCP) joints in 60 and thumb in abduction.

Particular attention in the tetraplegic hand must be given to

prevention of clawing (intrinsic-minus hand posture) and

MCP joint, proximal interphalangeal joint (apart from

functional finger flexor tightness for tenodesis) and thumb

adduction contractures. Presence of such contractures can

ultimately limit effectiveness of tenodesis grasp (natural

finger flexion with wrist extension), use of a wrist-driven

flexor-hinge splint and potential for later tendon-transfer

surgery (Keith and Lacey 1991).

Spasticity

Spasticity is a common problem in SCI patients with upper


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motor neurone lesions after spinal shock and tends to

increase in severity during the first few months after injury.

Severe spasticity during the early phase after injury may

exacerbate pain, predispose to pressure sores and

contribute to development of contractures. Spasticity which is

evident early and very pronounced or not symmetrical may

indicate an incomplete lesion.

Treatment should usually be instituted if spasticity interferes

with functional independence, endangers safety when

transferring, causes pain or places skin at risk from shearing.

Management is normally approached using a hierarchical

model of care, beginning with the simplest and least invasive

measures and progressing to more invasive methods as

required (Merritt 1981).

When the degree of spasticity increases significantly without

obvious explanation, consideration must always be given to

looking for aggravating factors such as:

urinary tract infection

renal or bladder calculi

constipation

skin ulceration

ingrown toe nails

less commonly, intra-abdominal or pelvic problems.

Key points

Spasticity is a common problem in SCI patients

Regular stretching is important to maintain muscle length,

particularly hip flexes and plantar flexes. Medications

commonly used include baclofen (10-25mg qid) and

diazepam (5-7.5mg tds or qid). Other medications used less

commonly include dantrolene sodium and clonidine. Motor

point injections with botulinum toxin, phenol or alcohol or

more definitive surgical approaches such as tendon

lengthening, tenotomy and/or neurectomy may be used for

localised spasticity, whilst intrathecal management (Penn et

al. 1989) with baclofen may be used for more difficult


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on voiding, increased spasticity, posture related difficulty

voiding and upper tract deterioration. Urodynamic

assessment (cystometry/anal sphincter EMG or x-ray video-

cystography) is performed after passage of spinal shock to

help to classify bladder type (Watanabe et al. 1996).

Goals for bladder management include:

protecting upper urinary tracts from sustained high

pressure (


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be suspected when difficulty clearing or recurrent urinary

tract infections with the same or different organisms,

particularly urea-splitting Proteus. These will require removal

by lithopaxy, lithotripsy or rarely open methods.

Regular follow-up by ultrasound examination or intravenouspyelogram every 2 years unless indicated more frequently

because of previous abnormal study is recommended,

particularly in those patients using reflex voiding/expression

techniques to monitor for early signs of

hydroureter/hydronephrosis (Staskin 1991).

Key points

Overdistension of the neurogenic bladder during the

acute period should be avoided

The neurogenic bowel

Patients should be kept nil by mouth initially until bowel

sounds return. A nasogastric tube is required to decompress

the stomach and reduce abdominal distension until ileus

resolves to prevent vomiting and risk of aspiration as well as

respiratory compromise due to diaphragmatic splinting. H2

receptor antagonists should be used to combat low pH and

stress ulceration. Initially, the neurogenic bowel is emptied

with assistance by an attendant, usually daily. Later bowel

management (Banwell et al. 1993, Steins et al. 1997) will

involve:

developing a regular bowel routine (daily or 2nd

daily)

adequate fluid intake (approx. 2000mls/day)

healthy eating habits with a well balanced diet high

in fibre, such as from whole grain breads, cereals,

fruits and vegetables

stool bulking agents such as psyllium and softening

agents such as dioctyl sodium sulphosuccinate

(commonly used to increase water content and

volume of stool, soften and regulate stool

consistency, and promote intestinal evacuation)

avoidance of irritant laxatives such as senna and

bisacodyl if possible (these may be used in the


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short-term to help establish a satisfactory bowel

program, but are best avoided in the longer term

due to unpredictability of results, tolerance and

potential long-term side effects)

bowel emptying timed 20-30 minutes after a meal

(to utilise gastrocolic reflex)

rectal emptying achieved using an enema,

suppositories, digital stimulation and/or manual

evacuation; the latter being particularly helpful in

lower motor neurone type bowel dysfunction.

Psychological issues

The reality of a sudden traumatic SCI with the inherent

disbelief, fear, sadness and uncertainty about the future

places enormous stress both on the injured individual and

family. In this setting, anxiety and depression are common

following SCI (Craig et al. 1994). Post-traumatic stress

disorder may also occur early after injury in which the injured

individual re-experiences the traumatic event with distressing

flashbacks or nightmares often associated with a variety of

physical symptoms and increased arousal (APA 1994).

Whilst in the past perhaps insufficient attention has been

paid to psycho-social assessment and adjustment following

injury, their importance to the overall success of rehabilitation(Trieschmann 1988) and the value of specific interventions

such as cognitive-behavioural therapy are now well

recognized (Craig 1997). The very specialized area of

psycho-social rehabilitation following SCI requires intensive

and coordinated input from an experienced psychologist and

social worker.

Key points

The reality of a sudden traumatic SCI with theinherent disbelief, fear, sadness and uncertainty

about the future places enormous stress both on

the injured individual and family

Fertility


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Infertility is common in males following SCI due to

anejaculation and/or poor semen quality. Since the majority

of spinal injuries occur to young, single males this is an

important issue. Two methods of semen retrieval are

commonly used, namely vibroejaculation and

electroejaculation (Linsenmeyer 1993). Vibroejaculation is

the most frequently used method in patients with lesions

above T11 level. However, electroejaculation may be used in

acute phase for collection of semen, when vibroejaculation

will be unsuccessful in the presence of spinal shock (Mallidis

et al. 1994). When this technique is performed within 7-10

days after injury, semen quality is usually normal and can be

cryopreserved for future use. Problems with reduced sperm

quality later can be overcome using assisted reproductive

technologies, such as in vitro fertilisation (IVF) andmicromanipulation techniques (Linsenmeyer 1993).

Key points

Infertility is common in males following SCI

Autonomic dysreflexia (hyperreflexia)

This condition is peculiar to individuals with SCI above the

splanchnic outflow (lesion generally above the T6 level) and

is the result of dissociation from higher centres. A triggering

sensory stimulus initiates excessive reflex activity of the

sympathetic nervous system below the level of injury,

causing vasoconstriction and a rapid rise in blood pressure,

which is uncontrolled due to isolation from the normal

regulatory response of vasomotor centres in the brain.

Parasympathetic activity occurs when the rise in blood

pressure is sensed by baroreceptors in the aortic arch and

carotid bodies resulting in compensatory slowing of the heart

and dilatation of blood vessels above the level of injury. If not

recognized or treated promptly the blood pressure may rise

to dangerously high levels and precipitate intracranial

haemorrhage, seizures or a cardiac arrhythmia (Colachis

1992, Braddom and Rocco 1991).

Common symptoms and signs are:

Sudden Hypertension

(Remember BP for these individuals is usually around 90/60-


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100/60 mmHg lying down and possibly lower whilst sitting,

therefore patients may become symptomatic with BP in the

normal range for population. If untreated this can rapidly rise

to dangerously high levels).

Pounding headache

Bradycardia

Flushing / blotching of the skin

Sweating above spinal injury level

Goose bumps

Chills without fever

Nasal stuffiness

Blurred vision (dilatation of pupils)

Shortness of breath and associated anxiety

Common causes include:

Bladder distended or severely spastic bladder,

urinary tract infection, urological procedure or even

inserting a catheter.

Bowel distended rectum, enema irritation.

Skin pressure sores, burns, ingrown toenails, tight

clothing.

Other any irritating stimulus, including fracture,

renal stones, epididymo-orchitis, distended

stomach, labour, severe menstrual cramping.

It is vitally important to remember that autonomic dysreflexia

is a medical emergency requiring urgent treatment (detailed

in Fig. 35.2).

Key points

Autonomic dysreflexia (hyperreflexia) is a medical

emergency

Rehabilitation after traumatic brain injury


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product of the brain stem reticular system interaction with the

cerebral cortex. Loss of consciousness occurs with

dysfunction either of upper brainstem structures or diffusely

of the cortex. The upper brainstem and cortical connections

seem particularly liable to injury where the head is free to

move on the trunk (Gennarelli et al. 1982).

Coma should be distinguished from brainstem death,

persistent vegetative state, locked in syndrome and severe

disability with minimal responsiveness

Management

Progress is monitored clinically, including the GCS, to identify

complications. Exacerbating factors are excluded,

particularly Hydrocephalus or Intracranial Space occupying

lesion; Electrolyte disorders; Sepsis; Drug toxicity; Seizures

(see acute Ch. 00). Medications are critically reviewed,

minimizing those associated with adverse central nervous

system affects or negative effects on recovery, particularly

sedatives, anticonvulsants, anticholinergic and sympatholytic

agents.

Nutrition: Energy requirements are usually underestimated

by calculation of the Harris-Benedict equation (Wilson and

Tyburski 1998), because of the significant catabolic state

associated with TBI. Management requires regular review of

nutrition parameters and adjustment of intake. Gastrostomy

feeding may not necessarily prevent aspiration, being

associated with an appreciable risk of reflux aspiration

(Finucane and Bynum 1996). Indication for gastrostomy

feeding include agitation and risk of inappropriate removal in

post-coma recovery.

Bowel care: Regular enema and aperient regimen with the

aim of establishing predictable evacuation, promoting good

nursing care, hygiene and skin care.

Bladder: Early removal of urinary catheter & management

with a collection device is preferable to minimize the risk of

infection and bladder dysfunction. Monitoring for urinary

retention is required initially.

Immobility: Skin management, management of hypertonia &

maintenance of joint range of movement require appropriate


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bed, seating system, splinting materials, pharmacotherapy

and staff expertise. A programme of positioning, maintained

stretching, seating and splinting needs to be managed

Respiratory: Clinical monitoring, tracheostomy and airway

management require attention to chest physiotherapy,posturing and oral care.

Family knowledge & education are addressed and as are

issues such as emotional support, income support and

access to community assistance.

After the period of coma (rarely more than 4 weeks after

onset), the person establishes a new state in recovery. The

key issues after emergence from coma are the need to

identify the degree of the persons ability to interact with their

surroundings and the setting up of programs to promote their

participation and skills acquisition.

For people thought to be suffering from the vegetative state,

it is important to distinguish this from severe disability with

minimal responsiveness (Table 35.7). Misdiagnosis remains

a risk. Recent reviews of referrals to two specialty units,

showed 30 to 40% or more of people incorrectly diagnosed

as having persistent vegetative state. Visual impairment was

common.

Post traumatic amnesia

Post Traumatic Amnesia (PTA) is a self limited confusional

syndrome characteristically following closed head injury in

which new memories are unable to be reliably established,

often associated with agitation. It is distinct from Retrograde

Amnesia in which memory is lost for events occurring prior to

the incident. Inasmuch as it is defined by being self-limiting, it

is can only be confirmed retrospectively.

The patient is inattentive and distractible, unable to orientate

to the environment or recent events. They are unable to

learn to compensate for other sensory, language or cognitive

deficits related to injury and unable to recall explanations for

injuries. Agitation, confabulation, disinhibition or

uncharacteristic behaviour may occur. Patient safety and

avoidance of elopement may be prominent management

problems, with lack of insight into safety or requirements for


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injury healing.

Problems of retrospective assessment of PTA duration lead

to development of prospective measures such as the

Galveston Orientation and Amnesia Test (Levin et al. 1979),

Westmead PTA Scale (Shores et al. 1986) & the Oxford PTAscale. The latter provide a hierarchy of orientation and recent

memory tasks.

Key points

Post Traumatic Amnesia (PTA) is a self limited

confusional syndrome

Russell (Russell and Nathan 1946) related PTA to return to

full duty by military servicemen (Table 35.8)

Jennett and Teasdale (1981) noted the relationship between

PTA and outcome in terms of GOS for a group of patients

admitted with severe head injuries (GCS 8 or less), adding a

category extremely severe for PTA > 4 weeks duration (Table

35.9)

Management

Monitoring progress of PTA helps identify those in whom

exacerbating factors should be sought, and identifying when

resolution of PTA allows benefit from education and

strategies in rehabilitation.

Careful clinical survey is required to avoid additional

morbidity from mismanagement of associated injuries,

particularly when agitation is a prominent feature. Particular

attention is required to managing sources of pain and

impairments of vision & hearing, often needing serial

evaluation and observation over time

Other causes of delirium need excluding (Table 35.10)


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Key elements in orientation in a suitable environment

include:

Limit

conflicting sensory stimulation and

noise

Provide clear

cues to time and place including

items of personal relevance, familiar

photographs and possessions

Train family

and staff to consistently deal with

the person. Consistency in

communication may be enhanced

by use of a communication log book

& timetable

Limit visitor

numbers at any one time

Recognise

the patients inability to incorporate

strategies


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Agitation is best managed without use of

restraints. Environment modification and

problem solving triggering factors are a

priority. Monitoring and control of the

environment requires appropriate ward

design with sensitivity to noise, patient

interactions and safety. Nursing on

mattresses on the floor or a modified, low

bed may be best for the markedly agitated

patient with impaired balance. Formal

behaviour control programs are not

indicated.

Where agitation is unable to be managed by

other means, physical restraint may be

required (Table 35.11).

Key points

Agitation is best managed without

use of restraints

Communication and support of family and

staff requires regular review. Medication

management needs to observe the following

principles:

Medication in

management of extreme or

persistent agitation may be needed

to avoid unacceptable morbidity


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muscle bulk over pressure prone areas

(especially buttocks); facilitating transfers;

allowing ambulation.

Negative effects may include: pain/spasm;

mobility/function; posture; hygiene; decubitusulceration

Management (Table 35.13) requires a focus

on the goals of the intervention. Combination

therapy is usually required.

Rehab of the Trauma Patient

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