Settings \200 Inpatient \200\224 in a designated area or utilizing a specialized roaming team \200 DH (see b \200\230Day hospitals \200\231, p.22) \200 Outpatients \200\224 specialized clinics aimed at admission avoidance and early supported discharge, or follow-up of recently discharged patients to optimize functio nal recovery Care homes \200\224 advise on suitability of long-term placement, eg after urgent placement to avoid hospital admission Interventions CGA usually leads to several recommendations/treatments with clear goal-setti ng and often regular review of progress. Interventions might include physical therapy, chan ges in medication, environmental modi \201 ca- tion or advice about care home placement. T he tool of CGA has been adapted to disease-speci \201 c management programs (eg heart fail ure) and to assessing the suitability of older patients for cancer treatments. The patients CGA is expensive and should be targeted to those most likely to bene \201 t a nd exclude those whose prognosis is very good or very poor regardless of intervention. Evidence It is dif \201 cult to compare data from such diverse interventions and settings, and little is known about the effectiveness of individual components of the \200\230black box \200\231 of CGA. However, there is good evidence that CGA can improve important outcom es such as survival, function, and quality of life, as well as reducing length of inpatient stay and reducing admissions to hospital and nursing homes. It is not surprising that CGA is more effective when coupled with: \200 Control over implementation of advice \200 Lo ng-term follow-up/review \200 Medical management interventions Further reading Ellis G , Langhorne P . ( 2005 ). Comprehensive geriatric assessment for ol der hospital patients . Br Med Bull 71 : 45 \200\223 59 . 71 Chapter 4 Rehabilitation Introduction 72 The process of rehabilitation 74 Aims and objectives of rehabilitation 75 M easurement tools in rehabilitation 76 Measurement instruments 78 Selecting patients for inp atient rehabilitation 80 Patients unlikely to bene \201 t from rehabilitation 82 HOW TO Plan a complex discharge 83 HOW TO Conduct a MDT meeting 84 Physiotherapy 86 Walking aids 88 Occupational therapy 91 Occupational therapy assessments a nd interventions 92 Doctors in the rehabilitation team 94 Nurses in the rehabilitation team 95 Other members of the rehabilitation team 96 Social work and care management 98 Communit y nurses and health visitors 99 72 CHAPTER 4 Rehabilitation Introduction Rehabilitation (rehab) is a process of care aimed at restoring or maxi- mizing physical, mental, and social functioning. Can be used for: \200 Acute reversible insults , eg sepsis \200 Acute non-reversible or partially reversible insults, eg amputation, MI \200 Chronic or progressive conditions, eg Parkinson \200\231s disease Involves both rest oration of function and adaptation to reduced func- tion depending on how much reversibilit y there is in the pathology. Rehabilitation is an active process done by the patient not to him/her. It is hard work for the patient (akin to training for a marathon) \200\224 it is not \200\230convalescence \200\231 (akin to a holiday in the sun). Rehabilitation is the \200\230secret weapon \200\231 of the geriatrician, poorly understoo d and little respected by other clinicians. Many geriatricians feel it is what de \201 nes their specialty and it can certainly be one of the most rewarding parts of the job. The \200\230black box \200\231 of rehabilitation contains a selection of non-evidence-based, co mmon sense interventions comprising: \200 Positive attitude . Good rehabilitationalists a re optimists \200\224 this is partly because they believe all should be given a chance and partly because they have seen very frail and disabled older people do well. A positive att itude from the team and other rehabilitating patients also improves the patient \200\231s e xpectations. Rehabilitation wards should harbor an enabling culture where the whole team en courages independence: patients dressed in their own clothes, with no catheter bags on show and eating meals at a table with other patients MDT coordinated working . By sharing goals the team can ensure all team members are consistent in their approach Functionally based treatment , eg the hemoglobin level only matters if it is making the patient breathless while walking to the toilet Individualized holistic outcome goals . These incorporate social aspects which are often neglected. The team concentrates on handicap rather than impairments (see B ox 4.1 ) Settings Specialized rehabilitation wards are not the only place for rehab. If the consider ations outlined are in place then successful rehabilitation can take place in: \200 Acute wards \200 Specialist wards (eg stroke units, orthopedic wards) \200 CHs \200 DHs \200 Nursing and residential homes \200 The patient \200\231s own home These alternative sites often employ a roving rehabilitation team, which may be based in a hospital or the c ommunity. INTRODUCTION 73 Box 4.1 World Health Organization (WHO) classi \201 cation (1980) IMPAIRMENT \200\224 pathological defect in an organ or tissue, eg homonymous hemianopia du e to posterior circulation stroke DISABILITY \200\224 restriction of function due to impairment, eg inability to drive due t o visual defect HANDICAP \200\224 the social disadvantage cause by disability, eg unable to visit friends in neighboring village as unable to drive It can be seen that some impairments produce no disability or handi- caps and some handicap s are due to multiple interacting impairments. The system allows the social circumstances t o be factored in, such as in the examples given, the disability produces no handicap if a r egular bus route exists. Doctors are generally focused on impairments, poor at assessing di sability, and rarely consider handicap. Despite the attractive logic of such a classi \201 cation, it is actually rarely used in c linical practice. This is probably because geriatricians intuitively consider the wider asp ects of illness without requiring the discipline of formal terms. The word \200\230handica pped \200\231 is now avoided due to negative connotations and stigma. The WHO issued a new classi \201 cation of Functioning, Disability and Health in 1999 which is a little more co mplex but has a broadly similar structure ( M www.who.int/classi \201 cations/icf/ en/inde x.html ). 74 CHAPTER 4 Rehabilitation The process of rehabilitation 1. Selection of patients See b \200\230Selecting patients fo r inpatient rehabilitation \200\231, p.80. 2. Initial assessment This is not like a medical clerking, you need to get to know your pat ient on different levels (eg their mood, motivation and expectations, complex social factor s). Remember it is more meaningful to assess the handicap not just the impairment. 3. Goal setting See b \200\230Aims and objectives of rehabilitation \200\231, p.75. 4. Therapy \200 Medical \200\224 doctor led (see b \200\230Doctors in the rehabilitatio n team \200\231, p.94) \200 Physical \200\224 mainly physiotherapy (see b \200\230Physi otherapy \200\231, p.86) and nurse led (see b \200\230Nurses in the rehabilitation team \200\231, p.95). Mobility, bala nce, and stamina. Con \201 dence is often a key issue Self care \200\224 mainly occupational therapy (see b \200\230Occupational therapy \200 \231, p.91) and nurse led Environmental modi \201 cation \200\224 aids and adaptations \200 Carer/relative traini ng \200\224 it is too late to leave this until just prior to discharge 5. Reassessment Usually at weekly MDT meetings (see b \200\230HOW TO Conduct a MDT m eeting \200\231, p.84). Goals are adjusted and new goals are set. Points 3, 4, and 5 are re peated in a cycle until the patient is ready for discharge. 6. Discharge planning See b \200\230HOW TO Plan a complex discharge \200\231, p.83 \200\224 should be started as soon as the patient is admitted but the efforts escalate towa rds the end of the inpatient period. A home visit and family meeting are often held to clar ify issues. 7. Follow-up and maintenance Post-discharge DVs, outpatients or DH attendance. Ideally done by the same team but in reality this function often taken over by community, in which case good communication is vital. AIMS AND OBJECTIVES OF REHABILITATION 75 Aims and objectives of rehabilitation It is essential that the MDT, ideally in conjunction with the patient, states what it plans to do and to achieve, in clear terms that are shared within the team and can be worked towards. A large part of this is achieved through the ag reement and statement of targets at two hierarchical levels: aims and objectives. Aims Best set by the team, in discussion with the patient. One or two, patient- centered ta rgets that encompass the broad thrust of the team \200\231s work \200\224 a team \200\230 mission statement \200\231 for that individual, eg: \200 To achieve discharge home, with the support of spouse, at 6 weeks \200 To transfer easily with the assistance of one, thu s allowing return to existing residential home place at 4 weeks Objectives Best set by individual team members, in discussion with patient. More focused ta rgets, usually several, that re \202 ect speci \201 c disabilities and help focus the tea m \200\231s speci \201 c interventions, eg: \200 To walk 10m independently, with a singl e stick, at 3 weeks \200 To achieve night-time urinary continence at 4 weeks Both aims an d objectives should have \201 ve characteristics, summarized by the acronym \200\230SMAR T \200\231: \200 Speci \201 c , ie focused, unambiguous \200 Manageable , ie amenable to the team \200\231s in \202 uence \200 Achievable and \200 Realistic , acknowledging time and/or resource limitations. It is futile and demoralizing to set targets that cannot be achieved. Conversely, the team (and patient) should be \200\230stretched \200\231, ie the target should not be inevitably achievable Time-bounded . Specify when the target should be achieved. Many patients are motivated and cheered by the setting of a speci \201 c date (especially for discharge). Setting dates fo r speci \201 c functional achievements prompts further actions, eg ordering of equipment f or the home Predicted date of discharge (PDD) Specifying a PDD from the point of admission is useful fo r patients, carers and MDT members. \200 Emphasizes to the patient that inpatient care is not inde \201 nite, and that a more pleasant home or care home environment is the aim Can be intrinsically motivating for patient and team \200 Prompts carers and MDT to think ahead to pre- and post-discharge phases of care 76 CHAPTER 4 Rehabilitation Measurement tools in rehabilitation Principles The most widely used standardized measuremen t instruments are struc- tured questionnaires that deliver a quantitative (numerical) outpu t. They vary in precision, simplicity, and applicability (to patient groups or clinical set tings). For each domain of assessment several tools of differing size are usually available , re \202 ecting tensions between brief assessments (speed, easy-to-use, well-tolerated) a nd a more prolonged evaluation (precision improved, give added layers of information). Measurement tools are helpful at single points (especially entry and exit to a therapy prog ram), and also in assessing progress and in guiding discussion around likely discharge dest ination. Advantages \200 Quantify \200 Widely understood, and transferable across boundaries \200 Facilitates communication between professionals and settings of care \200 Provide a synopsis \200 May permit a less biased, more objective view of the patient \200 Facili tate a structured approach to assessment and clinical audit Disadvantages \200 May be time-consuming \200 Scores may conceal considerable complexit y \200\224 patients scoring the same may be very different Intra-individual, intra-rater and inter-rater variabilities mean that a score may change wh ilst a patient remains static, eg, 3 or 4 points change in the (20-point) Barthel is needed before a team can be absolutely con \201 dent that the patient has changed There are many scales available, and some are not in general use, leading to confusion when staff or patients move between units This page intentionally left blank 78 CHAPTER 4 Rehabilitation Measurement instruments Activities of daily living (ADLs) Personal ADLs (pADLs) or basic AD Ls (bADLs). Include key personal tasks, typically transfers, mobility, continence, feeding, washing, dressing. A single scale is valid for all. \200 The commonest is the Barthel (s ee b Appendix, \200\230Bartel Index \200\231, p.688). Score range 0 (dependent) to 20 (independent). It is quick, and apparently simple t o use but is not very sensitive to change, as steps within each domain (eg transfers) are l arge. A marked ceiling effect is seen, especially for a range of impaired patients living i ndependently at home, many of whom score 20 The Function Independence Measure ( FIM ) takes longer to complete but is more sensitive to change during rehabilitation and can be useful in predicting length of stay and discharge destination Extended activities of daily living (eADLs) Also known as Instrumental ADLs (iADLs). Includ e key daily household tasks, eg housework, shopping. Useful for the more independent person . Scales are selected according to an individual patient \200\231s needs, eg Frenchay Activ ities Index, Nottingham ADL Score. Mobility For example: Elderly Mobility Scale (EMS), Tinetti Mobility Score (TMS), timed get up and go test. Cognition \200 Several screening and assessment tools are in common use \200 The 10-poi nt AMTS, see b Appendix, \200\230The abbreviated mental test score \200\231, p.690) is bri ef, and useful for screening in both outpatient and inpatient settings Clock drawing tests (see b Appendix, \200\230Clock-drawing and the Mini-Cog \204 \200\231, p.693) are alternative screening tests The 30-point MMSE provides suf \201 cient precision to be used for serial assessment \200 \224 eg tracking recovery from delirium, or therapeutic response to cholinesterase inhibito rs in dementia \200\224 but takes <10min to administer The Middlesex Elderly Assessment of Mental State assesses systematically the major cognitive domains, using a range of targeted subtests. Time-consum ing (15min), but gives more detailed information. Often used by therapists Depression For example, the GDS. Several versions of this are available, but the most commo nly used is the 15-point score (see b Appendix, \200\230Geriatric Depression Scale \200 \231, p.687), administered in 5 \200\22310min. Super \201 cially dis- tressing questions, but well tolerated by most patients. Sensitive (80 % ) but only moderately speci \201 c (6 0 % ). MEASUREMENT INSTRUMENTS 79 Nutrition The Malnutrition Universal Screening Tool (MUST) (see b Appendix, \200\230Malnut rition universal screening tool (MUST) \200\231, p.695) is widely used to screen inpatients and is superior at predicting malnutrition than weight alone. Pressure area risk Prompt systematic evaluation of patients at risk, and brisk response in those at risk, is essential. Several scores are available, but the most widely used is the Waterlow Pressure Sore Prevention Score, a summary score derived from easily available clin ical data. High score indicates high risk. Note that the score does not take into account t he ability of the patient to lessen risk by changing position, the acuity of the medical co ndition, etc. Disease-speci \201 c scales All of the common diseases have dedicated scales, usually deve loped for use in research, and then introduced variably into clinical practice. They are of ten more complex than used in general clinical practice, with cor- responding disadvantages \200\224 time-consuming, less easily transferable. For example the Uni \201 ed Parkinson \200\231s Disease Rating Scale (UPDRS) quanti \201 es all the motor and behavioral aspect s of the disease as a single number. 80 CHAPTER 4 Rehabilitation Selecting patients for inpatient rehabilitation Most hospitals do not have enough rehabilit ation beds to cater for all patients who could bene \201 t, so these beds are a valuable r esource. This is often not understood by the patients, relatives, or referring service. Pat ient selection is a time-consuming, important, and complex task. Where there is no cost lim it, the approach can be more inclusive. Who should select patients? Review of referrals is often done by geriatricians, but can equ ally well be done by another experienced rehabilitation professional. In some cases, a team assessment is done and discussed in a conference. Who to choose? This is dif \201 cult. Be aware that some services will refer simply to get the patient out of one of their beds. Two factors need to be considered: \200 Which pati ents will bene \201 t most from what is a limited resource? \200 What does the MDT need to keep it positive and functioning well? In many ways the \200\230best \200\231 rehabilit ation patient is one who has had an acute event from which they are recovering (eg a fractu re), who is motivated and cognitively intact \200\224 able to participate in therapy with enthusiasm and who has a clear goal in mind. There are rapid results and fast turnover to k eep variety and interest for the team. However, consider whether this type of patient actua lly needs \200\230hard core \200\231 inpatient rehabilitation, or in fact would get better in almost any supported setting with a bit of convales- cent time (eg intermediate care wi th nursing, guidance to improve stamina and con \201 dence and perhaps a bit of social sup port on discharge). Contrast this with a frail elderly woman with multiple medical problems, moderate cognitive impairment, barely managing at home alone before a prolonged hospital inpatient stay with repeated complications, who has gone downhill physically and mentally. If asked, she wishes to go home, but this may not appear altogether realistic. Her daughter in Australia thinks she should go into a home for \200\230her own safety \200\231. It is all too easy to writ e this patient off, deny them rehabilitation, and arrange placement. This is the kind of co mplex \200\230heartsink \200\231 patient who most needs the expertise of the rehabilitatio n team. In any other specialty, the most complex cases are dealed with by the specialist; t he same applies to rehabilitation. These types of patient sometimes do remarkably well and should at least be offered a trial of rehabilitation. Even patients with no recovery potential can bene \201 t from aspects of the team \200\231 s expertise, eg learning adaptation, teaching skills to carers or arranging complex dischar ge packages. 2In general, the harder a problem seems to be, the less likely it is that it w ill be sorted out in a non-specialist setting and the more likely it is that the patient wi ll bene \201 t from the rehabilitation team. In practice it is often a balance between the two, where a broad case mix is maintained; wi th some slower-stream complex cases and some more rapidly treated simpler cases. SELECTING PATIENTS FOR INPATIENT REHABILITATION 81 Information required for patient selection Should be gleaned from all available sources (in cluding primary nurse, hospital notes \200\224 medical, nursing and therapy, family, carer s, primary care team, specialists, etc.) and may involve telephone calls and/or several vis its. Regardless of who does the assessment, the following information should be acquired. Premorbid features \200 Physical problems \200\224 list of medical conditions, how activ e they are and how they impact on life; list of medications Functional limitations \200\224 assess by conversation (Did you use a stick? Did you ever go out alone? Could you get up and down stairs?, etc.) Quantify with a rating scale Social set-up \200\224 who do they live with (and how \201 t and willing to help are the y); where do they live (rural or in town); what is the property like (eg \202 at or house , any stairs to access and once inside the property, whether the bedroom and bathroom are u p or downstairs); does anyone help out (formally, eg home carers, or informally, eg neighbo rs, family, friends); what did they do on a regular basis (eg walk to the pub for lunch, at tend day centers or lunch clubs, cycle into town for groceries, etc.) Cognitive state \200\224 range from mild memory problems (may predispose to delirium) to signi \201 cant dementia. Ask about any objective assessments ( eg MMSE) and the dif \201 culties the problem causes in everyday life Acute features \200 Nature of acute insult \200\224 is it reversible (compare amputation to acute confusional state) Interacting comorbidities \200 What is the expected recovery curve? \200\224 Varies with the disease: a patient with a large stroke may show very slow progress at outset and then steady but slow progress after several weeks; a patient with a fractured neck of femur by c ontrast is likely to improve rapidly after the operation and continue to make quick progres s; a septic patient is unlikely to improve at all until the acute illness has resolved and is then likely to improve steadily. If the assessor has limited knowledge of the disease, o btain information from the specialist currently caring for the patient Patient wishes \200 Do they understand about the problems they face? \200 Do they know what they wish to do when they leave hospital? (eg go home as soon as possible, return to their residential home, not go home unless they are able to function as before, etc.) 82 CHAPTER 4 Rehabilitation Patients unlikely to bene \201 t from rehabilitation \200 Patients in a steady state who are awaiting placement \200 Patients for whom the process of waiting for a rehabilitatio n bed will delay discharge (eg where expected recovery to discharge \201 tness is under a week) Patients with a single requirement for discharge (eg provision of commode) Patients who are still medically unstable, requiring frequent medical review, investigation or treatment Patients with pure nursing needs (eg unconscious patients) \200 Probably inappropriate fo r terminal care patients (palliative care teams likely to be able to support discharge planning when needed) Dementia and rehabilitation This can be frustrating and dif \201 cult (but also very rewar ding). Therapists will often prefer patients with \200\230carry over \200\231 \200\224 wh o are able to recall the last session and build on it. Nurses may \201 nd patients with b ehavioral problems disruptive to the ward. Safety issues are more dif \201 cult as awarene ss of danger and the ability to make an informed decision about risk taking are less. Relat ives \200\231 anxiety is likely to be high. However, there is still a lot that can be done. Repeated exercise can build stamina and some learning may occur. Rehabilitation settings al low more time for spontaneous recovery to occur. The more complex the discharge, the less l ikely it is that this can be managed in a non-specialist setting and the greater the need f or the MDT expertise. Patients with dementia are most at need of an advocate for their righ ts and wishes, and the expert team assessment of feasibility and risk is the best way to en sure they are respected. 2In general, dementia alone is not a reason for refusing rehabilit ation. PATIENTS UNLIKELY TO BENEFIT FROM REHABILITATION 83 HOW TO Plan a complex discharge \200 There is no such thing as a safe discharge \200\224 only a safer one. There is widespread misapprehension that hospitals and nursing h omes are \200\230safe \200\231 while home is dangerous but this is the wrong way round, eg rate of falls in institutions is higher (there is just someone there to pick you up) and t he increased exposure to infection (eg meticillin- resistant Staphylococcus aureus (MRSA), \200\230 \202 u) can be life-threatening \200 The timing of discharge is sometimes obvi ous (eg when the patient returns to premorbid functioning) but can be controversial. Some p atients want to go before the MDT feels they are ready and others (or their families) wish to stay longer (usually due to unrealistic aspirations or dislike of the chosen discharge d estination) \200\224 communication is the key to avoiding this. Patients should understand that discharge is not necessarily the end of recovery following an illness Start to plan discharge from day one, eg by obtaining background social history and patient aspirations. Set a target that patient and team are aware of \200\224 it is better to rev ise a predicted discharge date or destination than to have none at all because it helps to focus goal planning Involve relatives early \200\224 family meetings will ensure effective two way communicati on. It will also reduce the chance of \200\230the daughter from America syndrome \200\231 where a relative comes out of the woodwork just before a carefully planned discharge to blo ck or alter the plans The MDT members should prompt you but the following are common pitfalls which can cause a d ischarge to fail: \200 Care availability (especially night times) \200\224 check well in advance with the care manager that the care package you plan is available Modi \201 cations and equipment \200\224 ideally any environmental modi \201 cations should be in place before your patient is ready for discharge otherwise there can be lengthy delays. It is amazing how long it can take for simple measures such as a bed to be moved downstairs. For more complex interventions (eg stairlifts, walk in showe rs, deep cleaning) get an realistic estimate of time \200\224 sometimes the patient may ne ed alternative accommodation while these works are completed Appropriate transportation available (relative, ambulance) \200\224 check not just for patient but also for their equipment Keys \200\224 who has got them? Who needs keys/door entry codes? \200 Night times \200 \224 discharge plans often fail because the patient who looks good by day has unanticipated needs at night. Check with the nurses that they are not incontinent, immobile, or confused at night 84 CHAPTER 4 Rehabilitation HOW TO Conduct a MDT meeting This is a ward or team-based meeting with the primary fu nctions of communication, goal setting, reviewing progress and discharge planning. There are also wider aims of: Team building. There is usually a chance for discussion over tea and biscuits. This is not time wasting, it is vital for team bonding \200 Education. Sharing knowledge and insight into each other \200\231s jobs Usually weekly for inpatient settings but can be less frequent in com- munity or outpatients. Most commonly the team meets in a r oom away from patients/relatives \200\224 sometimes involving the patient by bringing them into the room. Any member of the team can \200\230run \200\231/chair the meeting but in practice where a doctor attends they usually take this role. The chair is respon- sible for: \200 Timing \200\224 the last few patients discussed should not be rushed. Some patients take a lot lon ger than others but this should be a function of need not just where they happen to appear on the list. Don \200\231t use the same order each week Involving all team members \200\224 ensure each member has an unimpeded opportunity to comment on each patient \200\224 some may need prompting. Don \200\231t allow assumptions that everyone knows certain information or that it is unimporta nt. A well-established team may automatically take turns \200\224 others may need you to f orce an order. Ask members to clarify jargon or code that may not be universally understood Ensuring decisions are made/goals are set . Without good leadership a long discussion can occur without a positive action plan. Prompt with \200 \230So what are we going to do about this? \200\231 \200\230Who is going to take that on? \200\231 \200\230When will that actually happen? \200\231. If discussion is going in circl es or there is dispute it can be helpful to summarize what has been said so far to allow th ings to move on. Where there is agreement on goals make sure they are SMART (see b \200 \230Objectives \200\231, p.75) Maintaining morale \200\224 remember case conferences can be stressful. Keep discussions p rofessional and good humored. Careful use of humor and frequent reminders that individuals and the team have done well are very important Encourage feedback \200\224 it is interesting and educational to hear follow-up on discharged patients. Ensure thank you letters, etc. are shared as well as news on deaths, readmissions, etc. Continued PATIENTS UNLIKELY TO BENEFIT FROM REHABILITATION 85 The conventional order of presentation is: 1. Doctor \200\224 diagnosis, current managemen t and changes planned, prognosis \200\224 particularly if symptoms are limiting therapy 2. Nurse \200\224 nursing requirements, mood and behavior, continence, sleeping, relatives/visitors comments 3. Physiotherapist \200\224 mobility, equipment, progress and potential 4. Occupational th erapist \200\224 functional assessments (eg dressing, kitchen), cognition, and DVs 5. Social worker/care manager \200\224 background, discharge discussions, external liaison (eg with council, funding panels, etc.) This order allows discussions to \202 ow naturally from medical back- ground to current f unction (therapists) to goal planning and discharge plans (social worker). There is no reas on why the order should not be different but beware one person dominating and avoid discuss ing endpoints (eg discharge) before going through the logical steps or you will miss someth ing. Notes of the meeting are vital \200\224 ideally they should be written once somewhere that all team members have access to. As a minimum record date, current status, notes about the content of discussion (even if solutions not found), goals, and plans. You have failed if you summarize a 20min important discussion as \200\230continue \200\231 or \200\230aim ho me next week \200\231. 86 CHAPTER 4 Rehabilitation Physiotherapy Training BSc(Hons) Physiotherapy is a 3 \200\2234 years \200\231 full-time co urse. MSc Physiotherapy can be done as a 2-year accelerated postgraduate course. After prim ary training physiotherapists usually sub-specialize in one area such as care of the elderl y. See UK Chartered Society of Physiotherapists website, M www.csp.org.uk . The role of the physiotherapist \200 Aimed at improving physical functioning by exercise, reducing pain and providing appropriate aids May be for recovery, adaptation, or prevention, eg falls \200 Patient needs suf \201 cie nt motivation, muscle strength, and energy to participate \200\224 it is not a passive process Duration of therapy may be short initially, but increase as patient tolerates more Cognitive impairment may limit learning and \200\230carry-over \200\231 of skills from session to session, but stamina may be improved with repeated sessions; dementia is no t a reason to withhold physiotherapy \200 Physiotherapists are the experts who plan and s upervise physical therapy but rehearsal of skills is often delivered by other members of the MDT or patients are given exercises to do alone (often with written instructions). Physiotherapy assistants , nursing staff, and relatives can all assist in this rehearsal process Involved in training others to move dependent patients safely (eg carers) Range of interventions Increasing range of movement \200 Active or passive exercises \200 Use after stroke or prolonged bed rest to increase joint mobility and prevent pain and contractures Increasing strength of muscles \200 Usually general strengthening to improve stamina \200 Can be targeted at speci \201 c areas of weakness and enhanced by the use of resistance and weights Important part of falls prevention Improve coordination \200 Usually after stroke \200 Repeated movements rehearse skills and improve coordination \200 Improve sitting balance Transfers (ie the ability to get from one place (bed) to another (chair)) \200 Strategy d epends on patient ability \200 Totally dependent patients are hoisted \200 Once there i s sitting balance then transfers with assistance of two people and a sliding board can be attempted Once there is standing ability, then standing transfers with one person, then a frame can be worked on PHYSIOTHERAPY 87 Ambulation \200 Exercises aimed at improving independence in mobilizing \200 Realistic goals should be set \200\224 ideally premorbid state should be achieved, but 10m may be adequate for discharge home if this is the distance from chair to kitchen Balance aided by bars then walking aids Heat treatment Using packs, hydrotherapy pools, ult rasound etc. to treat pain and imp-rove joint mobility. Other treatments For example, cold treatments, electrical stimulation for pain relief (eg t ranscutaneous nerve stimulation (TENS) machine). Provision of aids Usually ambulatory aids. 88 CHAPTER 4 Rehabilitation Walking aids These increase stability, leading to improved con \201 dence and function, an d decreased falls. In general, identifying the need for an aid should prompt consideration of: the cause of functional decline (is it reversible?); provi- sion of a physiotherapy ass essment for prescription (correct aid, correct size); education (use of the aid, how to get up after falls); and treatment (strength/balance training). All walking aids without wheels should be \201 tted with rubber ferrules to optimize grip and then checked for wear regularly (Fig. 4.1 ). Stick (or cane (USA)) \200 May be single-ended ( \200\230straight \200\231), double-ended ( \200\230hemi- \200\231 or \200\230bipod \200\231), three-ended ( \200\230tripod \200 \231) or four-ended (delta-, quadrupod).The latter offer modest additional stability compar ed to the straight stick Held in the hand opposite the most impaired leg, thus unweighting the impaired limb The level of hand placement should be at the greater trochanter, permitting 20 \200\22330 of elbow \202 exion \200\224 the most ef \201 cient elbow m uscular function The choice of handle is important, eg Contoured : improve grip, reduce pressure, in permanent users or those with deformities Swan neck : weight is centered over the base of the stick, providing a little more stability Right-angled : more comfortable, but not easily secured when not in use Crook handle : hooked over the arm when not in use Frame \200 A structure of lightweight alloy metal that is self-stabilizing (usually based around four points in contact with the \202 oor), providing unweighting of the lower lim bs and greater stability than a stick Various heights, depths and widths are available \200 Bulky, and dif \201 cult to transp ortation. Some folding versions (often only three legs) are available \200 May be used indoors or out \200 The handgrips should be at wrist level, with the elbows slightly (15 ) \202 exed. Shorter frames are used in patients who fall backwards To use a non-wheeled frame , lift it and move it 10 \200\22330cm in front of the body; then lean forwards a little, taking some weight through the arms before taking two equal steps towards the center of the frame A weighted frame has weights low on the frame structure to provide additional counter-balance against falls A wheeled frame has wheels at the front, permitting faster walking and an improved gait pat tern, but it provides a slightly less stable base. Small-wheeled frames are suitable only f or smooth surfaces \200 A gutter frame has forearm rests, enabling weightbearing through forearms rather than hands alone, providing additional support in the early stages of mobil ization, or when hands/wrists are impaired WALKING AIDS 89 Crutches A full assessment by a therapist is needed before selecting crutches. Crutches may be of the axilla- or elbow- type. Both are available with various features that should be individually prescribed, eg closed elbow cuffs provide added security and enable the user t o let go of the handgrip to open a door without the crutch falling to the \202 oor. Walkers or rollators \200 A frame that has three or four wheels and often hand-operated b rakes (for added stability while static) Three-wheeled versions usually fold, permitting stowage in a car \200 Rollators with addi tional features such as bigger wheels (for uneven ground), a seat or attached basket for sh opping or other house/ garden tasks are larger than most standard frames and are usually us ed outdoors A trolley walker combines walking support with a means of transporting items from room to room. One or two shelves. The lower shelf is recessed at th e back so that it doesn t interfere with walking Early walking aids (EWA) For example post-amputation mobility aid (PAM-aid). Used early (us ually from 7day 7) following amputation, in patients in whom a permanent pros- thesis is pl anned or being considered. 90 CHAPTER 4 Rehabilitation Quadrupod stick Gutter frame Wheeled frame Non-wheeled frame Wheeled trolley (indoors) Three-wheeled rollator (in and outdoors) Fig. 4.1 Different types of walking aid. OCCUPATIONAL THERAPY 91 Occupational therapy Training BSc Occupational Therapy a is 3 \200\2234 years \200\231 full -time course or can be done as a 2-year accelerated postgraduate course. The courses are 2/ 3 academic and 1/3 \201 eld work. After primary training OTs usually subspecialize in one area such as care of the elderly. See (for UK) the British Association of Occupational The rapists and College of Occupational Therapists website, M www.cot.org.uk . Role of the OT College of Occupational Therapy de \201 nition: \200\230OT enables people to achieve health, well-being and life satisfaction through part icipation in occupation (ie daily activities that re \202 ect cultural values, provide str ucture to living and meaning to individuals; these activities meet human needs for self car e, enjoyment and participation in society) \200\231. OTs achieve this by assessing both functional status and the environment then advising how to adapt. Skills versus habits \200 A skill is having the ability to start, carry out, and complete a task effectively (eg making a cup of tea) A habit is those tasks that are actually carried out (eg a person may be able to make a mea l, but does not do so when alone as they do not feel hungry) Components of personal ability Assessed by direct observation during tasks, formal testing, and informa- tion taken from carers, relatives, and other professionals. \200 Cognition \200\224 to understand the task and why it needs doing. May be limited by dementia, poor concentration span, poor problem-solving skills, etc. Assessed wi th cognitive tests such as Middlesex Elderly Assessment of Mental State (MEAMS) Psychology \200\224 wanting to do and complete the task. Limited by depression, apathy, impaired coping skills, etc. \200 Sensorimotor ability \200\224 espe cially in the upper limb 92 CHAPTER 4 Rehabilitation Occupational therapy assessments and interventions Assessments \200 Washing and dressing \200\224 aim to be done in the morning, when the patient would normally be carrying out these tasks Kitchen \200\224 looking at competence and safety for required tasks