Practical Approaches To Rehabilitation

2.12.05

Physiotherapy: "The use of physical agents (eg. heat, movement) as a therapeutic intervention."

Rehabilitation:
• Process of physical rehabilitation on concept of neuroplasticity.
• Ability of central nervous system to adapt, rebuild and reorganise itself.

Plasticity of other systems:
• In response to increase/decrease in physical activity, structure of muscles, skeleton, cardiovascular and respiratory systems.

Neuroplasticity after a lesion:
• Reorganisation of blood flow.
• New synaptic connections to surviving neurones.
• New connection refined by practise and repetition of tasks.
-Restructuring of pathways to produce movement.

Neuroplasticity and rehabilitation approaches:
Therapy treatment approaches…
• Seek to guide neuroplastic reorganisation that occurs after lesion of central nervous system.
• Dependent upon understanding of normal movement.
• Use skills of movement analysis and problem solving.

Barriers to movement after stroke:
• Poorly innervated muscles.
• Loss of alignment of joints.
• Loss of normal, efficient patterns of movement.
• Loss of selective graded activity of limbs and trunk.
• Loss of sensory information (tactile, propriceptive, pressure).
• Loss of postural control (balance).
• Secondary musculoskeletal changes.

Rehabilitation approaches:
• Normal movement approach - Bobath.
• Motor relearning - Carr and Shepherd.

Most physiotherapists take an eclectic approach.
Use of knowledge of anatomy and biomechanics.

Aims of treatment in acute phase:
• Chest care - risk of respiratory complications.
• Positioning - to protect vulnerable joints.
• Maintenance of soft tissue length.
• Reduce occurrence of compensatory activity.

MAINTAIN REHABILITATION POTENTIAL.

Early intervention to provide stimulation of sensory pathways, maintain soft tissue length, facilitate muscle activity etc.

Intensive rehabilitation phase:
• May take place in rehab unit/stroke ward.
• Length of stay may be determined by:
-Unit policy.
-Follow-up available.
-Degree of dependence acceptable/manageable on discharge.

Later stroke rehabilitation:
• Refining skills, higher balance functions, more complex activities - return to occupation/leisure.
• May take place in out-patient setting, in patient's home on in leisure setting.
• Should encourage independence and self-management.

Important elements of rehabilitation:
• Patient participation.
-Learning by doing.
-Patient needs opportunities to practise skills.
-Team need to address any issues limiting patient's participation.
• Organised multidisciplinary care.
-Shared learning and skill development.
-Increased opportunities for patient to practise, refine skills - 24 hours.
• Achieving carry-over.
-Skills learnt must be transferable from rehab setting to home environment to be truly functional.
-Skills need to be practised in variety of setting.
• Goal-setting.
-Joint team goals (including patient and carer).
-Should be realistic, measurable, timebound.

Social aspects:
• Home environment.
• Carers.
-Health.
-Ability to adapt, learn new skills.
-What support will the carers get?
• Society - work and leisure opportunities.

Barriers to rehabilitation:
• Unstable medical status.
• Poor nutritional state.
• Depression.
• Pre-morbid personality.
• Co-morbidities.
• Limited pre-morbid level of function.

…Related to stroke damage.
• Communication difficulties.
• Visual field deficit.
• Perceptual problems eg. (L)/(R), poor spatial awareness.
• Reduced concentration.
• Sensory loss/neglect.
• Lack of insight.

Increased awareness of practical aspects of rehabilitation can be gained by observing and discussing therapy assessments and treatments.

Will help to:
• Discuss patient's potential realistically.
• Inform patient/carers accurately about rehabilitation process.
• Refer patients correctly to rehab.