Physicians

An understanding of the underlying disorder, including the mechanisms of disability, potential outcomes, and natural history of the disease being managed, is critical in planning a rehabilitation program for a patient. This expertise may be provided by the growing number of neurologists with expertise in neurorehabilitation who can bring principles from their increasing storehouse of knowledge to bear on recovery, and by rehabilitation physicians or physiatrists, who also have broad experience in musculoskeletal, orthopedic, and cardiopulmonary rehabilitation issues. Orthopedists, urologists, psychiatrists, plastic surgeons, neurosurgeons, and podiatrists often are consulted during rehabilitation and for long-term management of disabled patients.

The clinician superimposes the contributions of neurological, musculoskeletal, cardiopulmonary, and other impairments on a map of the patient’s functional abilities and disabilities. For example, does tender musculoligamentous tissue cause pain or limit movement, or does spasticity lead to loss of motor control? Does a medication or metabolic abnormality lessen concentration, the ability to learn, or endurance for exercise? Physicians tend to be the facilitators of the multidisciplinary team, especially during inpatient care. Here, the physician may conduct a weekly team conference that reviews the patient’s progress in reaching the functional goals that will permit a discharge to the home. To do this well, the physician must help build the team’s infrastructure and understand the practices of its disciplines. Rehabilitation physicians should serve as clinician-scientists as well. The physician can encourage therapists to weigh, formulate, and test strategies. Drawing on current literature and collaborating with basic and clinical researchers, the neurological rehabilitation specialist can optimally assess and develop interventions and creative solutions (Dobkin, 2003).

Physicians should explain to both patient and primary care doctor the indications for medications, measures for secondary prevention of complications, management of risk factors for recurrence or exacerbation of the disease, and the type and duration of rehabilitative interventions. Increasingly, doctors must address the risks and possible benefits of not only medications and usual rehabilitative approaches to care but also potential research interventions such as cellular transplantation (Dobkin et al., 2006b). During outpatient care, physicians must provide informed counseling about exercise and home practice for motor and cognitive retraining. The clinician reviews the details of what the patient is practicing to improve walking, the functional use of an affected upper extremity, language and memory skills, and socialization. Education should be offered about how task-specific practice may alter the brain’s representations of these activities and improve the patient’s abilities, even years after the initial neurological illness. For patients with chronic diseases that progress, such as multiple sclerosis (MS), practice is perhaps even more important because it may spur gradual neural reorganization to maintain function. Clinicians can encourage patients to increase their strength, speed, and precision of multijoint movements and to build cardiovascular fitness. The physician also should monitor outcomes with serial tests of the activities that are targeted to best determine the optimal dose of a treatment. For example, if the gait pattern is suboptimal, the clinician can test walking speed for 50 feet or the distance walked in 2 minutes to reassess progress in mobility at each visit. By documenting the effects of treatment, the physician can best advocate the continuing goals of rehabilitation to patients and insurers.

The Internet has many sites from which to develop educational materials that physicians and the therapy team can offer patients (e.g., http://www.uclahealth.org/body.cfm?id=1174), as well as lectures and articles about recovery and about experimental interventions.

Rehabilitation Nursing

Traditionally, the nursing role has been one of providing care and support during a phase of illness and doing for others the things they would normally do for themselves. Nurses have particular expertise in bowel and bladder management and have developed the post of continence advisor, particularly for teaching chronic intermittent self-catheterization (CISC) and scheduled voiding programs. They teach skin care and pressure sore management. In an inpatient unit, nurses are in constant contact with the patient undergoing rehabilitation. This extended contact with patients allows nurses to address the issue of carryover of skills from physical and occupational therapy sessions to other areas fundamental for function in the community. Each activity is integrated with others; for instance, continence management through CISC may require improvements in upper limb coordination, trunk control, mobility, lower limb tone, medications to optimize bladder and sphincter control, and strategies to facilitate problem solving. Nurses in community programs also have become involved in the management of individual chronic diseases including MS, amyotrophic lateral sclerosis (ALS), and Parkinson disease (PD), especially attending to gaps in services needed by patients. A nurse practitioner can be a valuable asset to the physician and team on a busy inpatient service, especially in a university hospital, where patients tend to have complex medical illnesses and needs. The Association of Rehabilitation Nurses has excellent resources for continuing education (www.rehabnurse.org).

Physical Therapists

Physical therapists (PTs), or physiotherapists relate voluntary motor control and patterns of multijoint movements, sensory appreciation, range of motion of joints, strength, balance, and endurance to the training needs for bed and wheelchair mobility, standing up, walking, and functional mobility during activities. PTs bring expertise to the team in wheelchair design, assistive devices, and orthoses. They manage compensatory strategies for carrying out activities of daily living (ADLs) such as the use of a walker and offer interventions to lessen specific impairments. PTs play a primary role in managing musculoskeletal and radicular pain, contractures, spasticity, and deconditioning.

Two broad categories of physical therapy, therapeutic exercise and the so-called neurophysiological and neurodevelopmental techniques, were the bulwark of the approaches used by therapists in the past (Box 48.1). Newer concepts related to practice-induced neuroplasticity, motor control, and skills learning have taken greater hold beginning in the past decade.

Neurophysiological Schools

Many schools of physical therapy have developed approaches that focus on enhancing the movement of paretic limbs affected by UMN lesions. These approaches may be especially valuable when initiating motor therapies in patients with profound weakness. Techniques include using sensory stimuli and reflexes to facilitate or inhibit muscle tone and single- and whole-limb muscle movements in and out of mass actions called synergies. Most approaches try to sequence therapy in a progression reminiscent of the neurodevelopmental evolution in infants from reflexive to more complex movements. The emphasis is on normal postural alignment before any movement. Some techniques permit mass movement patterns early in treatment; others inhibit spastic overflow synergistic movements. For example, mobility activities may proceed in a developmental pattern from rolling onto the side with arm and leg flexion on the same side, followed by extension of the neck and legs while prone, then lying prone while supported by the elbows, and then doing static and weight-shifting movements while crawling on all four extremities. These mat activities are followed by efforts for sitting, standing, and finally walking. This progression is used most often in children with cerebral palsy, but some therapists also apply it to stroke and TBI rehabilitation.

Different schools vary in their attempts to activate or minimize reflexive movements and how they train the functional movements needed for ordinary activities. These schools have not emphasized strengthening exercises. Their use of reflexive movements, vibration to stimulate a muscle contraction, cutaneous stimulation to facilitate a voluntary contraction, and loading a joint to increase extension is reasonable from a physiological point of view, but any carryover of responses into functional or volitional movement is uncertain.

Neurodevelopmental practitioners believe that the optimal facilitation of movement requires normal postural responses, that abnormal motor behaviors are compensatory, and that the quality of motor experiences and the integration of whole-body somatosensory information will train patients for more normalized movements. The Bobath hands-on approach is a particularly popular neurodevelopmental technique. It aims to facilitate normal movement and desired automatic reactions and to restore postural control while inhibiting abnormal tone and reflex activity using specific motor patterns. Bobath therapists avoid provoking mass flexor synergies from the shoulder, elbow, and wrist or extensor synergies at the knee and ankle. The coordination of patterns of muscle group activity is viewed as more important than the actions of individual muscles. Most practitioners take a problem-solving and task-oriented approach with patients. A typical exercise routine may work on stance and trunk control with a large ball and careful hand placement by the therapist to evoke movements out of synergy (Fig. 48.2). These methods originally were developed for children with cerebral palsy but have been adapted for stroke and other neurological disorders. In comparison with other neurophysiological approaches and task-oriented motor learning for gait, upper extremity function, and overall level of functional independence, use of Bobath techniques has led to equivalent outcomes or, in several small trials, modestly inferior outcomes (van Vliet et al., 2005). Given the underlying theory of Bobath, however, outcome measures ought to examine the quality of task-related movements as much as functional gains.

Fig. 48.2 Gymnastic ball used to facilitate standing and postural adjustments for standing up (A) and flexion and extension of the trunk and reaching (B).

Occupational Therapists

Occupational therapists (OTs) facilitate the practical management of disability. The philosophical foundation of OT is that purposeful activity helps prevent and remediate dysfunction and elicits maximum adaptation. Goal-oriented tasks are meant to be culturally meaningful and important to the needs of clients and their families. Activities include daily life and work skills, exercise, recreation, and crafts. Occupational therapy also is concerned with improving the patient’s interaction with the environment and maximizing the patient’s role in society in terms of relationships, occupation, and personal standing. The OT implements a program to enable patients to learn or relearn specific activities, develop new or compensatory skills, adapt their behavior to what is feasible, make adjustments to increase the accessibility of their environment, and perform leisure activities.

A program may include the use of appliances to improve independence, ranging from simple devices (e.g., a thickened grip to better grasp cutlery or a pen) to complex ones (e.g., use of an environmental control unit). Such adaptive aids for daily living are listed in (Box 48.3). Hemicuff and Bobath slings are used to reduce shoulder subluxation and prevent pain in patients with upper limb paralytic disorders (Fig. 48.3). A balanced forearm orthosis can support the upper arm and allow a modest biceps and triceps contraction to swing the arm over a table, which may be especially effective for the patient with a level C5 SCI. For patients with stroke and brain injury, OTs work closely with the neuropsychologist to address visuospatial inattention, memory loss, apraxia, difficulties in problem solving, and the skills needed for return to school or employment. Some OTs manage dysphagia and interpret modified barium swallow (MBS) studies.

Fig. 48.3 A cuff support to prevent pain and lessen the subluxation of the glenohumeral shoulder joint in a patient with left hemiplegia after stroke.

Task-oriented and motor learning strategies have gained attention in formal occupational therapy research. Using this approach, the OT presents activities in a way that elicits the retention and transfer of particular skills for use in a functional setting. For example, in one study, limb kinematics improved in normal and hemiparetic subjects when training included purposeful goals with relevant items used daily. Thus, practice in object-related tasks, rather than simple repetition of reaching and grasping of items that have no significance for the client, may provide more concrete sensory information and offer rewards that motivate performance. In many instances, OT strategies evolve from problems that arise in daily living that require a solution. For example, adaptive equipment and an OT educational intervention in stroke patients to remediate the lack of confidence and increase the amount of information patients had available to them reduced the barriers to outdoor mobility and participation in the community (Logan et al., 2004).

Speech and Cognitive Therapists

Speech and language therapists are trained in many aspects of communication and cognition, including phonetics and linguistics, attention and memory, audiology, and developmental psychology, and provide expertise in the investigation and management of dysphagia. These therapists treat primarily patients with dysarthria, aphasia, and cognitive dysfunction that interferes with daily activities.

Interventions to improve the patient’s speech intelligibility, volume, and fluency include exercises of affected oromotor structures. For example, patients may be trained to slow their articulation, use shorter sentences, maximize breath support, extend jaw motion, adjust placement of the tongue, and exaggerate articulatory movements. Communication aids include voice amplification and computer assistive and voice recognition devices. These therapists also provide guidance for persons with swallowing difficulties; assessment may include the MBS study during videofluoroscopy.

Treatment for aphasia generally is based on clinical evaluation of the patient’s cognitive and linguistic assets and deficits. The therapy plan is fine-tuned according to standardized language and neuropsychological test results, knowledge of the cortical and subcortical structures damaged, and the ongoing response to specific therapies. Speech therapists attempt to circumvent, deblock, or help the patient compensate for defective language behaviors. Stimulation-facilitation approaches, listed in (Box 48.4), are commonly employed. Views on the value of speech therapy for aphasia vary. Most randomized controlled trials demonstrate a significant benefit for aspects of expression and comprehension in moderately impaired subjects. The amount of practice is a key variable for enhancing outcomes for any particular approach.

Recreational Therapists

Recreational therapists involve patients on an inpatient unit in group games, crafts, cooking, playing with pets, and other activities to help them socialize, practice skills, and enjoy the physical and emotional value of recreation despite new disabilities. In addition, the recreational therapist joins with the PT and the OT to teach patients how to reintegrate into the home and community. Outpatient recreational activities carried out in a wheelchair or with one hand also foster socialization and fitness. More than 200 local, national, and international organizations have developed rules and equipment for at least 75 sports and recreational activities that take into account a range of functional abilities.

Psychologists

Neuropsychologists with skills in clinical psychology help define and manage cognitive impairments and mood and behavioral disorders. Detailed psychometric testing is fundamental to establishing a rehabilitation program for a patient with cognitive impairment. These tests of aspects of memory, learning, perception, language, and executive function, however, do not represent the range of cognitive skills needed for real-world activities. The neuropsychologist often takes the lead in the management of mild to severe brain injury resulting from trauma or stroke and plays an important role in counseling patients, caregivers, and staff. When working with amnestic patients after TBI, the neuropsychologist may design operant conditioning paradigms or a token economy to reinforce appropriate social interactions, awareness of deficits, and learning. The neuropsychologist also develops relaxation techniques for anxiety states and behavioral approaches for the management of chronic pain.

Social Workers

Social workers deal with the psychosocial aspects of disability and provide counseling and often brief psychotherapy. Their concerns extend to the ability of the patient and family to cope with disability in and out of the hospital. They play a key role in apprising the rehabilitation team about family issues, supports needed for best management of the disabled patient, and appropriate care services in the community. The close interactions of social workers and patients or caregivers during inpatient rehabilitation often provide valuable insight into the dynamics of family involvement and the adequacy of resources. Social workers serve as liaisons to private and government agencies and to case managers from insurance companies. Smooth discharge planning from an inpatient service requires their assistance.

Orthotists and Bracing

Expertise in the manufacture, selection, and application of orthotic devices is another key component of a rehabilitation service. The PT or the OT works with an orthotist to select external devices that modulate directional forces from the body and joints in a controlled manner. Although many orthotic devices are mass-produced, the expertise of a trained orthotist is invaluable in choosing and constructing orthoses and supervising their fitting and adjustment. Orthoses include ankle and ankle-knee braces, finger-wrist and shoulder splints, spinal braces, collars, and corsets. The material most often used in manufacture of these devices is a malleable type of plastic, but light metals may be used when large biomechanical forces have to be managed. The effects of pressure, shear forces, and heat retention with sweating also must be considered during fitting to protect the skin.

With shortened inpatient rehabilitation stays, especially after stroke, ankle-foot orthoses (AFOs) that fit inside a shoe tend to be used early to more quickly assist foot clearance during ambulation in patients with a central or peripheral lesion. Observation of gait usually is enough to determine the need for a trial with an AFO in a patient with hemiparesis or footdrop. Indications include inadequate dorsiflexion for initial heel contact or for toe clearance during early and mid-swing, excessive hip-hiking during swing, medial-lateral subtalar instability during stance, tibial instability during stance, and uncontrolled foot placement caused by sensory loss. An orthosis also may be needed after operative heel cord lengthening. If the knee of the hemiplegic buckles during stance, angling the AFO in slight plantar flexion will extend the knee earlier. Dorsiflexing the AFO by 5 degrees can decrease knee hyperextension and help prevent the snapping back that causes instability and pain in midstance. Ankle inversion may necessitate greater rigidity and longer anterior foot trim. The AFO worn in a shoe ought to improve weight-bearing on the affected leg, increase single-limb stance time, and perhaps lessen postural sway. This may improve safety, especially on uneven surfaces, and walking velocity. Fig. 48.4 shows a thermoplastic AFO that fits in a shoe to limit plantar flexion and rotation and help control the knee. Orthoses may be static, such as a rest splint worn at night, or dynamic, with joints that may be lockable or free moving. Fig. 48.5 shows a thermoplastic AFO with a hinged joint that allows flexibility on rising to stand and at heel strike to start the stance phase of the gait cycle. Toe clawing can be managed with a metatarsal pad that spreads the toes. Some patients who have footdrop from a neuropathy such as Charcot-Marie-Tooth disease or diabetes may find that a fashionable boot with a flat heel that fits snugly above the ankle can improve gait by lessening its steppage quality, yet allow toe clearance. An orthotist can assess the potential for shoe modifications and inserts to improve balance and pressure points. Multiple small trials in patients with hemiplegic stroke show that walking activity increases and impairments in walking and balance decrease with the use of an AFO (Tyson and Kent, 2009). Functional electrical stimulation of the peroneal nerve timed to the gait cycle has equivalent or somewhat better effects on walking speed.

Fig. 48.4 This fabricated ankle-foot orthosis is designed for ankle and knee control of a hemiparetic patient who has minimal hypertonicity. A wider lateral flange and hook-and-loop straps across the front of the ankle would provide greater ankle control.

Fig. 48.5 This thermoplastic orthotic includes a hinged ankle with a stop to allow approximately 5 degrees of dorsiflexion when the subject goes from sitting to standing and in portions of the stance phase.

A metal double-upright brace offers greater rigidity for mediolateral foot instability and allows more versatility in adjustments for the amount of plantar and dorsiflexion but can be expensive, heavy, and cosmetically unappealing to the hemiplegic patient. Metal bracing systems are used more often by selected subjects with paraplegia from spinal injuries and in those with polio. Lightweight plastic knee-ankle-foot orthoses (KAFOs) with locking metal knee joints also can assist patients with severe polyneuropathy, muscular dystrophy, meningomyelocele, or SCI. Reciprocal gait orthoses (RGOs) with wire cables that link flexion of one hip to extension of the opposite hip are available for paraplegics. Short-distance ambulation for exercise also can be aided in the patient with SCI by variations on a KAFO or other devices. Bracing in persons with SCI has been combined with functional electrical stimulation to improve stepping and decrease its energy cost.

The thoracolumbar support shown in Fig. 48.6 was molded to the patient to lessen neck motion after a high thoracic vertebral injury and surgical stabilization. Static orthoses allow no motion of the primary joint. Solid wrist-hand orthoses usually are set between neutral and 30 degrees of extension. Upper limb orthoses, however, have not been shown to improve arm or hand function, increase range of motion or lessen the incidence of pain, based on small trials after stroke. Dynamic orthoses use elastic, wire, or powered levers that compensate for weakness or an imbalance in strength and allow some controlled movement. Fig. 48.7 shows the paretic left hand of a patient with a level C6 SCI holding a playing card with the aid of a thumb opposition splint. The weaker right hand needs wrist extension to mechanically oppose the thumb to the second and third digits. Such custom-made devices can be produced with lightweight metals and plastics. Functional neuromuscular electrical stimulation electrodes can be embedded in a wrist splint to enable grasp and release or over the peroneal nerve to trigger ankle dorsiflexion at appropriate times during the stepping cycle.

Fig. 48.6 This thoracolumbar support orthotic was molded to the patient’s chest to limit upper thoracic vertebral motion after a high spinal cord injury and surgical fusion. The chin brace and stiffness of the jacket limit early progress in mobility tasks for transfers. The riser grips that the patient holds make it easier to practice pushing down into the mat to raise the buttocks.

Fig. 48.7 This card-playing patient with a C6 spinal cord injury uses a molded thumb-opposition splint to pinch better with the right hand, and a lightweight metal tenodesis orthotic that pinches the thumb to the next two fingers when he dorsiflexes his wrist.

Measures

Neurorehabilitation employs measurement tools to characterize the impairments, disabilities, activities, and psychosocial needs of patients, as well as to monitor interventions, assess outcomes, and document services. To provide a comprehensive assessment of the impact of disease, outcomes may be considered at four levels: pathophysiology and related impairments, disability and level of functional activity, handicap and ability to participate, and health-related quality of life. The design and applications of these scales across diseases are described in Table 48.1.

What to measure depends on the clinical setting and must be based on the anticipated effect of the intervention. Quantitative clinical end points such as death and presence or absence of paralysis are important in evaluating early neuroprotective interventions in acute SCI, TBI, and stroke but tell little about disability and quality of life in survivors.

Each outcome level addresses distinct aspects of the disease process. The relationships among them are complex. The first two levels entail physician-oriented outcomes, whereas those at the third and fourth levels are more accurately called patient-based outcomes, although only the fourth incorporates the patient’s perspective. Rehabilitation is especially interested in measures of the impact of disease, which is contained within the World Health Organization (WHO) International Classification of Impairments, Disabilities, and Handicaps. As shown in Table 48.1, the focus is on the consequences of the disease or health condition rather than the disease alone (i.e., a classification of disablements and functioning). A classification available on the WHO website (www.who.int/icidh/) emphasizes whether people actually perform the tasks, especially those that require a lot of time and energy. The dimensions of the WHO classification also include personal and environmental factors that affect functioning. The emphasis on activities, participation, and contextual factors interacting with impairments and disabilities may influence the design of new measurement tools.

Two types of measures exist for each of these domains: measures that are specific to a given disease and generic ones that may, with caution, be applied across a range of diseases (see Table 48.1). The former may be more sensitive in detecting changes particular to the effects of an individual disease, whereas the latter may allow comparisons across different diseases and serve as an off-the-shelf tool. Two generic measures of disability are the 10-item Barthel Index (BI), which can be totaled to a maximum score of 20 or 100 (Table 48.2), and the 18-item Functional Independence Measure (FIM) (Box 48.5), which includes a modestly responsive cognitive component for a total of 126 points (Box 48.6). The FIM is used more often in the United States, especially for studies with large numbers of subjects, than in Europe or Asia, where its applicability for clinical trials has been questioned. The FIM, the BI, and two other scales—the Glasgow Outcome Scale for Recovery of Consciousness and Function and the Rankin Disability Scale (Tables 48.3 and 48.4