rehabilitation of neurological patients

REHABILITATION OF NEUROLOGICAL DISORDER

PATIENTS

Rehabilitation Definition of neuro rehabilitaiton Principles of rehabilitation Goals of rehabilitation Types of rehabilitation Approach of rehabilitation Neurorehabilitation team Factors affecting quality of life and coping

Bobath neurodevelopmetal treatment approach

PositioningSittingMobilityTransfer Physical therapyRange of motion exerciseOther exercises

Treatment of pain and inflammationHeat therapyCold therapyElectrical stimulationTractionMassageAcupuncturebiofeedback

Sensory perceptual deficit Communication deficit Speech therapy Swallowing difficulty Bladder dysfunction and retraining Neurological disorder and its rehabilitationStrokeHead injurySpinal cord injuryParkinsonismGullaine barre syndrome Nurses role in rehabilitation

Summary Conclusion

Rehabilitation is a dynamic process throughwhich a person is assisted to achieveoptimal physical, emotional, psychological,social, and vocational potential and tomaintain dignity, self-respect, and a qualityof life that is as self-fulfilling and satisfyingas possible.

Neurorehabilitation is a complex medicalprocess which aims to aid recovery from anervous system injury, and to minimizeand/or compensate for any functionalalterations resulting from it.

Rehabilitation should begin during the

intial contact with the patient.

Restoring the patient to independence or to

regain his/ her preillness

Maximizing independence within the limits

of the disability.

Realize goals based on individual patient

assessment and to guide the rehabilitation

program

Must be an active participation

Activities of daily living are facilitated.

Motivate the patient and helps him/her to

attain social independence.

Physical independence

Mobility

Social integration

Occupational integration

Psychological support

Medical rehabilitation :restoration of structure andfunction.

Vocationalrehabilitation:

restoration of the capacityto earn a useful and decentlivelihood

Social rehabilitation: restoration of family

and social relationships

Psychological rehabilitation : restoration of personal dignityand confidence

Institution based : the services aredelivered in an institution for the disabled.

Outreach based : professional travel to the community

Community based :where resources forrehabilitation areavailable in thecommunity andservices are deliveredin community area.

Medical team Physiatrist Orthopaedic surgeon Neurologist Neurosurgeon Plastic surgeon Psychiatrist Paediatrician Obstetrician Geneticist Cardiologist Cardiac surgeon General surgeon Oncologist

Ophthalmologist Paramedical members Physiotherapist Occupational therapist Creative movement

therapist Recreation therapist Prosthetist Rehabilitation nurse

Speech pathologist Psychologist Play and drama

therapist Music therapist Social worker Vocational counsellor

Non governmental organization

Community Family members

Nature of disease

Severity of disease

Freedom to live and work

Economical stability

Access to education

Sexual dysfunction

Bobath NeurodevelopmentalTreatment Approach

Flacidity- occurs from the time of injury to 2 to 3 days after(decreased or no tendon reflexes or resistance to passive movement)

Spasticity-onset 2days to 5 wk(Hyperactive tendon reflexes and exaggerated response to minimal stimuli

Synergy – onset 2–3 wk (Simultaneousflexion of muscle groups in response toflexion of a single muscle (e.g., an attempt toflex the elbow results in contraction of thefingers, elbow, and shoulder)

Near normal, slight incoordination maybe present

Used for patients with hemiplegia caused bystroke, brain injury, and cerebral palsy.

Major goal is normalization of muscle tone,posture, movement, and function

Reintegration of function of the two sides of thebody.

Proximal to distal positioning is recommended . Weight bearing is provided on the affected side to

normalize tone. Tasks should begin from a symmetric midline

position with equal weight bearing on the affectedand unaffected sides.

Movement toward the affected side is encouraged.

Straightening of the trunk and neck isencouraged to promote symmetry andnormalization of tone and posture.

Hemiplegic patients should be positionedin opposition to the spastic patterns offlexion and adduction in the upperextremity and extension in the lowerextremity

Importance of Positioning prevent development of musculoskeletal

deformities Contracture Ankylosis(stiffness and rigidty of joints) Pressure ulcers decreased vascular supply Thrombosis Edema

The unconscious patient should berepositioned every few (e.g., 2 hours) hours

If spasticity is present, frequentrepositioning is necessary. Splinting andcasting to inhibit tone may be ordered andapplied by a physical therapist.

Any restrictions of position are posted inpatient file(paper or electronic site).

A sufficient number of pillows are availableto maintain body alignment.

Trochanter rolls and other positioningdevices are useful

If an arm is weak or paralyzed, it ispositioned to approximate the joint space inthe glenoid cavity.

The affected arm is not pulled. A pillow orsmall wedge in the axillary region helpsprevent adduction of the shoulder.

Special resting hand splints may beordered to prevent contracture; removeperiodically to assess the skin for pressureulcers

Reduce edema by elevating the hand higherthan the elbow or by using elastic glove .

Foot drop- high-top sneakers or specialsplints, may be ordered.

Heels are kept off the bed to preventpressure ulcers from developing.

Pillow placed crosswise to elevate thelower legs or heel guards may be applied

Wrist support splint

Foot drop boot

Trochanter

Side-Lying Position

Favourable for unconscious patient

head of the bed elevated 10 to 30 degrees.

head should be placed in a neutral position.

soft collar or towel roll is useful to maintain the

neutral position

head turned slightly to facilitate drainage of oral

secretions and to maintain a patent airway.

The conscious patient may sit on the side of the bed,

using the over bed table and pillows for support.

For the weak, debilitated patient who cannot hold

up the head or neck, a high-back chair that extends

to the top of the head is most effective

Some patients have a neck brace; apply it for

sitting.

Pillows or rolls support the arms in the desired

position.

The feet are positioned flat on the floor. The

pressure on the bottom of the feet assists in

stretching the heel cord.

Neck brace High back chair

Transfer

Types

Two-person lift: physical transfer by at least two

staff members; no active patient participation

Mechanical lift: transfer using a lifting device that is

operated by staff members; no active patient

participation

2 person lift

Mechanical lifts

Contact guard: provision of verbal cues and

minimal physical support during the

activity, such as holding the arm or waist

during ambulation.

Supervision: provision of verbal cues only,as necessary

Transfer toward the unaffected side.

Patients should wear properly fitted, flat shoes.

Never tug on the paretic arm by pulling on the upper

arm or shoulder.

If balance is unsteady, stand on the affected side,

ready to grasp the belt around the patient’s waist.

If the patient’s knees buckle and additional

assistance is required, stand in front of the

patient and push with your knee against the

patient’s unaffected knee to lock the knee in

position and prevent buckling.

A walker or four-point cane may be used forsupport.

Transfer Activity: From Lying in Bed to a Sitting

Position Hemiplegic Patients.

Move toward or roll onto the side of the bed on which

you intend to sit.

Slip the unaffected leg under the affected leg at an angle

so that the unaffected leg becomes a transfer cradle for

the affected limb.

Place the affected arm on the abdomen or lap.

Push off the mattress with the unaffected elbow, raising your

upper body, while turning your hips toward the side of the bed

on which you intend to sit.

Swing the unaffected leg over the side of the bed, and use the

unaffected hand to push up.

Once in the sitting position, lean on the unaffected hand to

maintain an erect position.

Paraplegic or Incomplete Quadriplegic Patients.

Most transfer activities for quadriplegic and some

incomplete quadriplegic patients require direct

assistance from facility personnel.

Transfer Activity: From a Sitting Position on the

Bed to a Chair

Place the chair at a slight angle as close as possible to

the bed on the unaffected side.

With feet close together, lean forward slightly, put the

unaffected hand on the mattress edge, and push off to a

standing position, bearing weight on the unaffected

side.

Once balance has been maintained and is steady

enough for momentary release of support, move

the strong hand to the farthest arm rest of the

chair.

Keep the body weight well forward; pivot on the

unaffected foot, and slowly lower to a sitting

position

PHYSICAL THERAPY

Types Passive exercises Active exercises Active assistive exercises Resisted exerciseManual resisted exercisesMechanical resisted exercises Isometric or muscle strengthening

exercises

Patient is rested, comfortable, and pain free to gain

cooperation.

Position in proper body alignment, and drape, as

necessary, to avoid undue exposure.

Maintain good posture to ensure efficient body

movement

Face the patient to observe facial reaction to the

exercises.

• Movements are slow, smooth, and rhythmical.

• Move the body part to the point of Pain ,resistance

and stop.

• If the patient becomes excessively fatigued,

discontinue the exercises.

Passive exercises

Smooth rhythmical and accurate anatomical

movements performed by the therapist

within the pain limited range.

Active exercise

Exercises which are performed by the

patient himself without any assistance and

resistance by the external force except the

gravity.

Active assited exercise Range of motion to a body joint is

accomplished by the patient with theassistance of another person

Resisted exercise The activities, which are performed by

opposing the mechanical or manualresistance is called resisted exercise.

Types Manual resisted exercises Mechanical resisted exercises

Manual resisted exercises Resistance can be applied by the patient

himself or by any other person.

Mechanical resisted exercises Mechanical devices are used to oppose the

active movement of a person e.g weights, pulleys

Isometric or muscle strengthening exercises:

exercises are accomplished by alternatelytightening and relaxing the muscle withoutjoint movement

Muscle strengthening exercises Strengthen muscles enough to perform a

given function As muscle strength increases, resistance is

gradually increased

Tilt table(for orthostatic hypotension)

Mat exercise

Mirror feedback therapy with parallel bars

Co ordination exerciseFrenkel’s exercise

Task oriented exercise

Involves repeating meaningful movement that

works more than on joint and muscles.

Heat therapy Mechanism of action Increases bloodflow and the extensiblity of

connective tissue Decreases joint stiffness, pain, and muscle

spasm Reduces inflammation, oedema and

exudates resolve

Indication Sprains Myositis Arthralgia Neuralgia Muscle spasm Strains

Hot pack (containers filled with silicate gel)

Infra red ray(Applied with lamp )

Paraffin baath(Wax heated at 49 degree centigrade)

Hydrotherapy( warm water 96 to 100)

Diathermy(use of high-frequency electromagnetic current )

Cold therapy

Electrical stimulation Denervated skeletal muscle and innervated

muscle that cannot be contractedvoluntarily can be stimulated electrically tohelp alleviate or prevent disuse atrophy andmuscle spasticity.

Transcutaneous electrical nerve

stimulation(TENS)

use of electric current to stimulate the nerves

Uses

Chronic low back pain

Neuralgia

Contusion

Traction Used for extrinsic muscle spasm and to

keep bony surfaces aligned while fractureheal.

E.g cervical traction, lumbar traction

Massage

Acupuncture

Biofeedback Electromyogram

Galvanic skin response

Perception is a complex intellectualprocess of recognizing, interpreting, andintegrating sensory stimuli into meaningfulinformation from the internal and externalenvironments.

The parietal lobe is particularly importantin perception.

Perception of illness Body image Spatial relationship Agnosia Apraxia

Results from injury to the cortex of the lefthemisphere in the posterior frontal oranterior temporal lobes

Aphasia -is the loss of ability to uselanguage and to communicate thoughtsverbally or in writing.

Stimulate conversation and ask open-ended

questions.

Allow patients time to search for the words to

express themselves.

Disregard choice of incorrect words.

Assure patients that their speech will gradually

improve with time.

Provide a loose-leaf notebook with pictures of

common objects so that the patient can point

to the picture when unable to say the word.

Tell the patient that speech skills can be

relearned, given time.

Anticipate the patient’s needs

Auditory training

Lip reading

Sign board

Muscle exercise E.gMasako Maneuver (Place the tip of your

tongue between your front teeth or gums and swallow)

Swallowing is a complex process of

ingesting solid or liquid food while

protecting the airway.

four phases of swallowing:

Oral preparatory phase: food is taken into

the mouth and chewed, forming a bolus.

Oral phase: the bolus of food is centered and

moved to the posterior oropharynx.

Pharyngeal phase: the swallowing reflex

carries the bolus through the pharynx.

Esophageal phase: peristalsis carries the bolus

to the stomach.

Feed or eat in the upright, sitting position at a 90-

degree angle.

Tilt the head forward and tuck the chin in to prevent

food from moving into the posterior oropharynx

before it has been chewed

Encourage taking small bites and thorough chewing.

For patients with hemiplegia or hemiparesis, place

food on the unaffected side.

If “pocketing” of food is a problem, have thepatient sweep the mouth with his or herfinger after each bite to clear the food.

The speech therapist can be helpful by

suggesting an adaptive cup and special

techniques to ensure swallowing.

If oral feeding is contraindicated, a feeding tube

or gastrostomy tube can be considered

If cognitive deficits are present, the patient

may have poor impulse control and may stuff

the mouth hurriedly with food (manage the

behavior and controlling distractions from the

focus of eating. This patient requires mealtime

supervision and verbal and nonverbal cues)

Bladder control is an integrated function of

the brainstem, spinal, and cerebral level.

Alterations in urinary elimination patterns

can be classified generally into urinary

incontinence (UI) and urinary retention

Urinary incontinence can be associatedwith various problems, such as adiminished level of consciousness; cerebralinjury, especially to the frontal lobe; orspinal cord injury.

Four major categories

Urge incontinence: the involuntary loss of urine

associated with an abrupt and strong desire to void

(urgency).

Stress incontinence : the involuntary loss of urine

during coughing, sneezing, laughing, or other

physical activities that increase abdominal pressure.

Overflow incontinence : the involuntary

loss of urine associated with overdistension

of the bladder.

Functional incontinence : urine loss

caused by factors outside the lower urinary

tract; this category includes UI

Urinary retention is often associated with

spinal cord–injured patients.

Bladder Training. Bladder training, also called

bladder retraining, includes several variations.

Three primary components of education,

scheduled voiding, and positive reinforcement.

The patient needs to be educated to understand

the physiology,pathophysiology, technique, and

desired outcome.

A bladder retraining program assists the

patient to learn to resist or inhibit the

sensation of urgency, postpone voiding, and

urinate according to a timetable rather than

the urge to void.

The initial goal interval may be 2 to 3 hours,

although it is not followed during sleep

Prompted Voiding.

Prompted voiding is a technique used primarily with dependent

or cognitively impaired people.

Monitoring: the person is checked by caregivers on a regular

basis.

Prompting: the person is asked (prompted) to try to use the

bathroom to void.

Praising:the person is praised for maintaining continence and

attempting to use the toilet

Pelvic Muscle Exercises.

also called Kegel exercises, comprise a

behavioral technique that requires repetitive

active exercise of the pubococcygeus muscle to

improve urethral resistance and urinary

control by strengthening the periurethral and

pelvic muscles in women.

contracted to a count of 10 and then relaxed

to a count of 10.

About 50 to 100 of these exercises must be

done daily to be effective. It takes about 4 to

6 weeks to notice improvement.

Bladder-Triggering Techniques

A few bladder-triggering techniques facilitate

bladder emptying.

They include suprapubic stimulation,

Valsalva’s maneuver, and Credé’s maneuver.

Suprapubic stimulation

suprapubic stimulation

activates the sacral-lumbar dermatomes by manually tapping

the suprapubic area, pulling pubic hairs, or stroking the

medial thighs.

Valsalva’s maneuveris

straining against a closed epiglottis while contracting the

abdominal muscles and bearing down on the bladder. The

straining is sustained or the breath held until the urine flow

ceases..

Credé’s maneuver

placing the hands flat just below the

umbilical area and pressing firmly down and

inward toward the pelvic arch. The purpose

of this maneuver is to express urine from the

bladder

Catheters and Catheterizations

Intermitten catheterization

Suprapubic catheterization

indwelling catheterization

The act of bowel evacuation is called

defecation.

The anus, the terminal end of the large bowel,

is controlled by two sphincters: the

involuntary proximal anal sphincter (smooth

muscle) and the voluntary distal anal sphincter

(striated muscle).

Defecation is a coordinated reflex involving

sacral segments S-3, S-4, and S-5, which is

initiated by stimulated stretch receptors

located in the anus that initiate peristaltic

waves.

Types of Altered Bowel Function Patterns Constipation Diarrhea Incontinence

Constipation: fluid restriction, prolongedimmobility, nothing by mouth status as a resultof swallowing deficits or unconsciousness,decreased bulk in diet, drugs known todecrease peristalsis (e.g., codeine), spinalnerve compression, paralytic ileus, lack ofsensation, lack of privacy, interruption of usualbowel routine, and failure to respond todefecation stimuli

Diarrhea: intolerance to tube feeding,antibiotic therapy, and fecal impaction .

Incontinence: altered consciousness, cognitive

deficits (e.g., social disinhibition, lack of impulse

control, inability to recognize and respond to

defecation impulses), impaired communication, and

neurogenic bowel without sensation or control

(related to spinal cord injury above T-11 or

involving sacral reflex arc S-2 to S-4)

Make sure the lower bowel is empty; an enema may

be necessary before beginning the training program.

Establish a time of day for a bowel movement based

on the patient’s previous pattern; adhere to this

designated time of day rigidly.

Encourage a diet high in roughage (whole-grain

bread and cereal, fresh fruits, and vegetables).

Unless contraindicated by a fluid

restriction, increase fluid intake to 2000 to

2500 mL/d.

Insert a suppository on the first day. If it

does not work, you may wait until the next

day.

The patient should be seated on the commode or

taken into the bathroom to defecate.

Administer medications and collaborate with patient

and health team members to adjust regimen

individualized to the patient

Neurological disorders and its rehabilitation

Stroke is when poor blood flow to the brainresults in cell death.

There are two main types of stroke:ischemic, due to lack of blood flow, andhemorrhagic, due to bleeding.

They result in part of the brain notfunctioning properly

Positioning Mobilization and stretching Weight bearing activities Chest physiotherapy Pain relief Speech therapy Bowel and bladder care

Title -A randomized controlled trial on the immediate and long-term

effects of arm slings on shoulder subluxation in stroke patients

Author : VAN Bladel A, Lambrecht G, Oostra KM, Vanderstraeten

Year of publication:2017,jan

Objectives To determine both the immediate and long-term effect on

acromiohumeral distance using the Actimove® sling and Shoulderlift

(V!GO, Belgium) and to determine the effect of slings on pain and

passive range of motion of the shoulder in stroke patients with

glenohumeral subluxation

METHODS:

28 stroke patients, with severe upper limb impairments, were

randomly allocated to 3 groups (Actimove, Shoulderlift, No sling).

Patients wore their supportive device for 6 weeks and no sling in

the control group. Immediate and post-interventional effect on

acromiohumeral distance was measured using sonography. Pain

(VAS), ROM (goniometry), spasticity (Modified Ashworth Scale),

Fugl-Meyer Assessment and trunk stability (TIS) were also

assessed before and after the intervention.

RESULTS:

The level of immediate correction of both slings was different at baseline and

after 6 weeks (0 weeks: Shoulderlift 63%, Actimove 36%; 6 weeks: Shoulderlift

28%, Actimove 24%). Comparing the level of subluxation over time shows a

distinct decrease in subluxation but only for the control group (-37.59% or

3.30 mm). Subluxation remained the same in the Actimove group (- 2.77 % or

0.27mm) but increased in the Shoulderlift group (+ 12.44% or 1.03 mm).

After 6 weeks, the Actimove group reported more pain at rest (p = 0.036). ROM

for abduction and external rotation decreased in 2 groups and remained un-

altered in the Shoulderlift group

CONCLUSIONS: Results of immediate correction varied.

Subluxation seemed to reduce in patientsthat did not wear a sling.

A brain injury is any injury occurring in

the brain of a living organism. Brain injuries

can be classified along several dimensions

Positioning, transfer Supportive eating and standing Rehabilitation of motor control Bowel and bladder care Pain Training balance Aids to improve memory

A spinal cord injury (SCI) is damage to the

spinal cord that causes changes in its function,

either temporary or permanent.

These changes translate into loss of muscle

function, sensation, or autonomic function in

parts of the body served by the spinal cord

below the level of the lesion

Safe transportation Traction Positioning Active and passive ROM Mat work Orthoses (spinal corsets, crutches) Gait trainning Mobility training

Title -Spinal cord injury rehabilitation in Riyadh, Saudi

Arabia: time to rehabilitation admission, length of stay and

functional independence.

Authors: Mahmoud H, Qannam H, Zbogar D

Year of publication:2017,jan

Objectives -To describe functional status, length of stay

(LOS) and time to rehabilitation admission trends.

To identify independent predictors of motor function

following rehabilitation

METHODS:

From chart review of 312 traumatic and 106

nontraumatic adult patients with spinal cord injury

(SCI) we extracted information on time from injury to

rehabilitation admission, rehabilitation LOS, Functional

Independence Measure (FIM) motor score (admission

and discharge), American Spinal Injury Association

Impairment Scale (AIS) grade and demographics..

RESULTS: Mean±s.d., median days from injury to

rehabilitation admission were 377±855, 150 daysfor traumatic SCI and 288±403, 176 days fornontraumatic SCI. For individuals with traumaticSCI, after accounting for admission FIM motorscore, tetraplegia and time from injury torehabilitation admission had a significant butsmall negative association with discharge FIMmotor score.

Parkinsonism is a clinical syndromecharacterized by tremor, bradykinesia,rigidity, and postural instability.

Reduction of rigidity and maintaining flexibility

Balance training Coordination exercises Breathing and chest expansion exercises Improvement in psychological well being

Guillain–Barré syndrome (GBS) is a rapid-

onset muscle weakness caused by the

immune system damaging the peripheral

nervous system

Chest physiotherapy Maintenance of range of motion of all joints Psychological support Prevention of postural hypotension Strengthening Gait training

Coordinates various aspects of patient care in

hands on manner, identifying day to day problems

and monitoring progress.

Liaises between various team members of the

rehabilitation team and looks after critical

executive function like positioning, splinting,

hygiene

Acts as spokes person for the patient to highlight

their problems and needs to the team.

Provide psychological support.

Create awareness of the problem in the

community.

SUMMARY

Rehabilitation is a combination of methods

that are focused in restoring the patient’s

useful life.

Rehabilitation could help one body achieve

the normal daily functions by different kinds

of recovery techniques.

Books

Clement. Textbook on neurological and neurosurgical nursing.1sted. Newdelhi.Japee

brothers medical publishers.p553-58

Sundar S. Textbook of rehabilitation.3rd ed. Newdelhi . Jaypee brothers medical

publisher.p.13-40

Narayanan S lakshmi. Textbook of therapeutic exercises.6th ed. New delhi. . Jaypee

brothers medical publisher.p.13-40.

Hickey J. the clinical practice of neurological and neurosurgical nursing. 7thed.

Wolters and kluwer.p. 224-56

Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. Textbook of

medical surgical nursing, 12th ed. Newdelhi: Lippincot wolter’s kluwer; p.113-

114(vol-1).

Journals

Mahmoud H, Qannam H, Zbogar D.Spinal cord injury rehabilitation in Riyadh,

Saudi Arabia: time to rehabilitation admission, length of stay and functional

independence. Spinal cord.2015 jan. 4(1)

VAN Bladel A, Lambrecht G, Oostra KM, Vanderstraeten. A randomized controlled

trial on the immediate and long-term effects of arm slings on shoulder

subluxation in stroke patients.eur j physrehab med.2017 jan.6(2).

Internet

https://en.wikipedia.org/wiki/Pain_management

https://en.wikipedia.org/wiki/Rehabilitation

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