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 person’s 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 wellbeing. 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 patient’s optimum recovery and potential. Also covers further education and retraining if required, return to work and leisure pursuits. (Day Therapy /
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 person’s participation in 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
negotiated with the patient to be achievable within a set time frame. Regular case conferences and review of goals is essential. Rehabilitation plan checklist: •
Impairment/diagnosis
•
Functional score (e.g., functional independence measure or Barthel Index)
•
Problem list ○
Medical/surgical
○
Physical and therapeutic
○
Functional
○
Psychosocial
○
Avocational
•
Vocational
•
Educational
•
Rehabilitation goals
•
○
Problem oriented
○
Specific, achievable, time limited
○
Negotiated patient goals
Review date
Components of rehabilitation Measurement in rehabilitation Functional Rehabilitation and its progress can be monitored to assess improvement and response to treatment. Although most rehabilitation centres have developed local measures of function, a number of activities of daily living (ADL) scales have become internationally accepted. These measures provide a useful checklist of basic functions such as self-care, bladder control, bowel control, transfer,
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
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 nonambulant 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 MiniMental 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 <24 indicates a need for more detailed evaluation rather than establishing a diagnosis of permanent cognitive impairment. More detailed neuropsychological assessment must be performed by a neuropsychologist. A variety of scales and
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 patient’s 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 hot pack, 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.
•
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.
•
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 pain management.
•
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 nonthermal 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)
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
•
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
•
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
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 to generate 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
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 coordination. 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
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
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 levels reflect 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 musculotendinous portion of the gastrocnemius is tethered to the anterior distal tibia as a posterior flap. It is desirable to achieve skin closure without tension (Bowker and Michael 1992).
Key points •
Preservation of limb length has implications for prosthetic fitting
•
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 postoperatively and used continuously until a temporary or definitive prosthesis is fitted (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
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 above knee 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.
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. Postoperative 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
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 a comprehensive 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
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 seat cover 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
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 sideeffects 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.
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 15-30º extension, metacarpophalangeal (MCP) joints in 60º 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
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
generalised spasticity. Surgical techniques such as rhizotomies, myelotomies and cordotomies are rarely if ever indicated.
•
The neurogenic bladder
Overdistension of the neurogenic bladder during the acute period should be avoided until after the post-injury diuresis has occurred by indwelling urethral catheter or percutaneous suprapubic drainage (eg. "Cystocath") on continuous drainage. Catheter clamping for 2 hours twice daily may help to maintain bladder capacity and compliance. After this period, regular intermittent catheterisation by an attendant may be commenced with appropriate fluid restriction. Choice of definitive bladder management will be influenced by factors such as: •
type of bladder impairment
•
functional ability (particularly mobility, sitting balance and hand function)
•
patient’s motivation and lifestyle
The types of bladder impairment occurring after SCI may be classified as: •
suprasacral or reflex (upper motor neurone type)
•
infrasacral or acontractile (lower motor neurone type)
•
mixed (conus lesions)
It is important to remember that different underlying impairments may lead to similar outward appearance of bladder dysfunction, eg. detrusor hyperreflexia, poor bladder compliance or bladder neck insufficiency all cause storage failure, while similarly detrusor-sphincter dyssynergia (DSD), acontractile bladder or myogenic insufficiency from chronic overdistension may cause voiding failure (Wein 1981). Common clinical presentations of DSD include high residuals and recurrent urinary tract infections, autonomic dysreflexia
on voiding, increased spasticity, posture related difficulty voiding and upper tract deterioration. Urodynamic assessment (cystometry/anal sphincter EMG or x-ray videocystography) 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 (<40cm H20)
•
minimising post-void residual volumes (ideally <50mls)
•
preventing urinary tract infections
•
ensuring social continence
In both male and female patients with paraplegia or males with tetraplegia and sufficient hand function, clean intermittent self-catheterisation (CISC) every 4-6 hours with anticholinergic medication such as oxybutynin hydrochloride (5mg tds) or propantheline bromide (15-30mg tds or qid) to relax bladder is the preferred method. In males with tetraplegia and insufficient hand to perform CISC, drainage by reflex voiding with tapping, Valsalva or Crede manoeuvre using an external collection device or indwelling urethral or suprapubic catheter is possible. If employing bladder training to achieve balanced reflex voiding, use of short-term cholinergic medication such as bethanecol (10-20mg tds) to enhance detrusor tone with an alpha adrenergic blocker such as phenoxybenzamine (10mg tds) to reduce internal sphincter spasm is frequently required. In addition, a sphincterotomy or urethral wall stent may also be required to help manage DSD. Urinary antiseptic medications to lower pH of urine such as hippuric acid and vitamin C or cranberry juice/tablets, which in addition appears to inhibit bacterial adhesion, are often prescribed particularly in patients using reflex emptying or CISC. In female tetraplegic patients due to greater difficulty, either suprapubic or indwelling urethral catheter is most common. Urinary tract calculi are a common complication that should
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 intravenous pyelogram 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
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 the inherent disbelief, fear, sadness and uncertainty about the future places enormous stress both on the injured individual and family
•
Fertility
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) and micromanipulation 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-
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
Overview Traumatic Brain Injury (TBI) affects predominantly males under 40 years of age (Lyle et al. 1986, Jennett 1996). Long term disability and handicap issues relate to cognitive and behavioural impact on social role, with little correlation with physical disability (Jennet et al. 1981, Oddy 1984, Oddy et al. 1985, Tate et a. 1989) In particular, disrupted families and social contacts and poor work return are prevalent. These are significant issues even for people who have made a good recovery and require long term strategies implemented by a team working with the patient and their family. Most recovery and most rapid changes in terms of Glasgow Outcome Score (Table 35.6) occurs in the first 6 months (Jennett et al. 1981, Multi-Society Task Force on PVS 1994). Of those who have Good recovery or are Moderately disabled at 12 months, almost 2/3rds are already at that level at 3 months and 90% at 6 months. However, recovery significant to the individual can be seen over 3 to 4 years after accident, particularly in people with more Severely disability (Powell 1984). This highlights the requirement for adequate follow-up.
Key points •
Traumatic Brain Injury (TBI) affects predominantly males under 40 years of age
•
Pathology & outcomes
Poorer prognosis is associated with older age (Vollmer 1991); forces of injury; evidence of hypoxia or hypotension; acute subdural haematoma; widespread contusions; Raised intracranial pressure; low GCS in the first 24 hours (Rimel 1983, Jennett 1979) post resuscitation and longer duration of Post-Traumatic Amnesia. Diffuse axonal injury is usual and may have few changes on acute CT scan. Low Glasgow Coma Score and duration of Post-traumatic amnesia may be better indications. The characteristic Frontal & Temporal distribution of contusions (Courville 1997) are associated with planning, organising & executive impairments, personality & behaviour control
changes, and memory impairments (Oddy et al. 1985). These deficits have been associated with unemployment levels (Brooks et al. 1987, Crepeau and Scherzer 1993). Penetrating injury, haematomas and infarction superimpose focal syndromes on the diffuse and polar injuries. Hypoxia, subdural haematoma, vascular spasm with subarachnoid haemorrhage, cerebral oedema & hydrocephalus may all complicate the presentation. The multiple pathologies overlap to cause individual clinical presentation and may place significant caveats to functional prognostication for the individual (Choi et al. 1988). Mild Head injury (GCS 13-15 or PTA < 1 hour), 70 to 90% of admitted TBI, can have an appreciable incidence of sequelae including headaches, memory changes and unemployment after several months (Rimel et al. 1981). Key points
•
Poorer prognosis is associated with older age
•
Coma and poor responsiveness
•
Plum and Posner characterised coma by (Plum and Posner 1980):
•
unarousable psychological unresponsiveness
•
eyes closed
•
no psychologically understandable response to external stimulus or inner need
•
producing neither ..understandable words nor accurately localise noxious stimuli with discrete defensive movements
This is a feature of acute injury and is self limiting, rarely lasting longer than four weeks. Duration of coma is associated with outcome, with only one third or less of those in coma longer than 2 weeks or more making a Good to Moderate recovery (on GOS), in comparison with 80 to 90% of those with coma less than two weeks (Lyle et al. 1986). Pathophysiology: The content of conscious behaviour is a reflection of arousal and cognitive behaviour. Arousal is a
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
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 person’s 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
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 PTA scale. 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)
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
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
•
Most medications are associated with negative effects on cognition and perhaps recovery of function, with the exception of adrenergic agonists.
•