Rehabilitation for Other Disorders

Patients with arthritis can benefit from activities and exercises to increase joint range of motion and strength and from strategies to protect the joints. For example, patients may be advised to

• Slide a pot of boiling water containing pasta rather than carry it from the stove to the sink (to avoid undue pain and strain to joints)

• Get in and out of the bathtub safely by following specific steps

• Get a raised toilet seat, a bathtub bench, or both (to reduce pain and stress on the lower-extremity joints)

• Wrap foam, cloth, or tape around the handles of objects (eg, knives, cooking pots and pans) to cushion the grip

• Use splints to protect inflamed, unstable, or painful joints

• Use tools with larger, ergonomically designed handles

Such instruction may occur in outpatient settings, in the home via a home health care agency, or in private practice.

Patients who are blind are taught to rely more on the other senses, to develop specific skills, and to use specific devices (eg, Braille, cane, reading machine). Therapy aims to help patients function to their maximum and become independent, to restore psychologic security, and to help patients deal with and influence the attitudes of other people. Therapy varies depending on the way vision was lost (suddenly or slowly and progressively), extent of vision loss, the patient’s functional needs, and coexisting deficits. For example, patients with peripheral neuropathy and diminished tactile sensation in the fingers may have difficulty reading Braille. Many people who are blind need psychologic counseling (usually cognitive-behavioral therapy) to help them better cope with their condition.

For ambulation, therapy may involve learning to use a cane; canes used by people who are blind are usually white and longer and thinner than ordinary canes. People who use a wheelchair are taught to use one arm to operate the wheelchair and the other to use a cane. People who prefer to use a trained dog instead of a cane are taught to handle and care for the dog. When walking with a person with sight, a person who is blind can hold onto the bent elbow of that person, rather than use an ambulation aid. A person who is blind should not be led by the hand because this action could be perceived as dominant and controlling.

The term head injury is often used interchangeably with traumatic brain injury (TBI). Abnormalities vary and may include muscle weakness, spasticity, incoordination, and ataxia; cognitive dysfunction (eg, memory loss, loss of problem-solving skills, language and visual disturbances) is common.

Early intervention by rehabilitation specialists is indispensable for maximal functional recovery. Such intervention includes prevention of secondary disabilities (eg, pressure injuries, joint contractures), prevention of pneumonia, and family education. As early as possible, rehabilitation specialists should evaluate patients to establish baseline findings. Later, before starting rehabilitation therapy, patients should be reevaluated; these findings are compared with baseline findings to help prioritize treatment. Patients with severe cognitive dysfunction require extensive cognitive therapy, which is often begun immediately after injury and continued for months or years.

Chronic pain from conditions such as low back pain is one of the most common causes of chronic disability. A physiatrist or pain management specialist typically manages the care of patients with chronic pain, which is a complex condition that benefits from the use of a biopsychosocial model to guide treatment. Thus, a rehabilitation program may involve a combination of the following:

• Supervised exercises for trunk and postural conditioning

• General exercises (in individual or group fitness classes)

• Manipulative therapy or chiropractic manipulation

• Massage therapy

• Physical modalities

• Acupuncture

• Pain neuroscience education

• Cognitive therapies (eg, cognitive behavioral therapy, pain reprocessing therapy)

• Mindfulness meditation

• Pharmacologic measures

• Injection procedures

• Surgical referral when appropriate

Patients with COPD can benefit from exercises to increase endurance and from strategies to simplify activities and thus conserve energy. Activities and exercises that encourage use of the upper and lower extremities are used to increase muscle aerobic capacity, which decreases overall oxygen requirement and eases breathing. Supervising patients while they engage in activity helps motivate them and makes them feel more secure. Such instruction may occur in medical facilities or in the patient’s home.

Critical illness polyneuropathy can present as failure to wean from mechanical ventilation. In multisystem organ failure secondary to sepsis, the systemic inflammatory response syndrome, presumably resulting from cytokine and free radical release, impairs peripheral nerve microcirculation, resulting in polyneuropathy of mixed or motor nerves. Noninflammatory axonal degeneration and resulting neurogenic muscle atrophy may cause weakness of the diaphragm, limbs, and facial and paraspinal muscles. Sensory fibers are minimally affected. Serial serum creatinine kinase levels and serial electrodiagnostic studies are helpful in monitoring the disease course in some patients. Recovery time ranges from 3 weeks to 6 months.

Rehabilitation focuses on prevention of pressure ulcers, contractures, and compression neuropathies and return to normal function. Strengthening exercises, mobility and ADL (activities of daily living) retraining, as well as appropriate orthotics and adaptive equipment, should be provided at appropriate stages of recovery.

Differential diagnosis of foot drop includes common peroneal nerve (fibular) neuropathy, diffuse peripheral polyneuropathy (eg, caused by diabetes), L4 and/or L5 radiculopathy, tumor, stroke, multiple sclerosis, spinal cord injury, and other causes. Patients may present with weakness of ankle dorsiflexors, ankle evertors, and/or toe extensors, as well as possible foot slap and steppage gait (compensatory excessive hip and knee flexion).

Treatment of foot drop includes treatment of the underlying cause when possible; training in the use of ankle-foot orthosis (AFO); strengthening of weak ankle dorsiflexors, ankle evertors, and/or toe extensors; stretching of ankle plantar flexors; and gait training. Functional electrical stimulation (FES) is currently used in patients with multiple sclerosis to produce fibular nerve stimulation during the gait swing phase to help with foot clearance.

Specific rehabilitation therapy varies depending on the patient’s abnormalities, which depend on the level and extent (partial or complete) of the spinal cord injury (see Spinal Trauma, particularly see table Effects of Spinal Cord Injury by Location). A patient’s functional capacity depends on the level of injury (see Overview of Spinal Cord Disorders: Symptoms and Signs) and the development of complications (eg, joint contractures, pressure ulcers, pneumonia, and bowel/bladder incontinence).

The affected area must be immobilized surgically or nonsurgically as soon as possible and throughout the acute phase. During the acute phase, daily routine care should include measures to prevent contractures, pressure ulcers, and pneumonia; all measures needed to prevent other complications (eg, orthostatic hypotension, atelectasis, deep venous thrombosis, pulmonary embolism) should also be taken. Placing patients on a tilt table and increasing the angle gradually toward the upright position may help reestablish hemodynamic balance. Compression stockings, an elastic bandage, or an abdominal binder may prevent orthostatic hypotension.