Neurological Rehabilitation

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 any rehabilitation program. 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 are often consulted during rehabilitation and for the 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, limit movement, or exacerbate spasticity? 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.

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. 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 adaptive representations of these activities and improve the patient’s abilities even years after the neurological illness began. 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 should also monitor outcomes with serial tests of targeted activities 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 outline the continuing goals of rehabilitation to patients and insurers.

The internet offers access to many sites from which to develop educational materials as well as lectures and articles about recovery and experimental interventions that physicians and the therapy team can offer to patients.

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. During inpatient rehabilitation, nurses encourage greater independence in self-care, manage a bowel and bladder program that may include intermittent bladder self-catheterization, and teach skin care and pressure sore management. Their extended contact with patients allows nurses to address the carryover of skills from physical and occupational therapy sessions, teach problem solving, and recognize impending medical complications. A nurse practitioner can be a valuable asset to the physician and team on a busy inpatient service where patients have complex medical illnesses.

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 55.1 ). Newer concepts related to practice-induced neuroplasticity, motor control, and skills learning have taken greater hold, beginning in the past decade.

Occupational Therapists

Occupational therapists (OTs) facilitate the practical management of disability so that their clients can participate more fully in daily care and community activities. The philosophical foundation of OT is that purposeful activity helps prevent and remediate dysfunction and elicits maximal 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 is also concerned with improving the patient’s interaction with the environment and maximizing his or her 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.

Adaptive aids can 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). Some adaptive aids for daily living are listed in Box 55.3 . Patients with progressive cognitive or motor impairments often benefit from at least a yearly OT reassessment for additional adaptive aids. Hemicuff and Bobath slings are used to reduce shoulder subluxation and prevent pain in patients with upper limb paralytic disorders ( Fig. 55.1 ). 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.

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. 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 requiring a pragmatic solution that arise in daily living. For example, adaptive equipment and an OT educational intervention in stroke patients to remediate their lack of confidence and increase the amount of information patients have available to them has reduced the barriers to outdoor mobility and participation in the community. Controlled trials of OT strategies to improve ADLs after stroke have many methodological problems, so the efficacy of any specific approach is moot ( ).

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; they provide expertise in the investigation and management of dysphagia. These therapists treat primarily patients with dysarthria, dysphonia, aphasia, and cognitive dysfunction that interferes with daily activities.

Interventions to improve the patient’s speech intelligibility, volume, and fluency include exercises for the 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 55.4 , are commonly employed. Views on the value of speech therapy for aphasia vary. Most randomized controlled trials (RCTs) 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. With this in mind, many home computer-based programs are available to retrain planning, sequencing, memory, expression of single words and short phrases, comprehension of short phrases, and naming. Their efficacy is modest at best.

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 their 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—such as wheelchair tennis and basketball, upper extremity bicycling, and downhill skiing—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. However, these tests of aspects of memory, learning, perception, language, and executive function 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 he or she is 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 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 must also 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 and knee control during ambulation in patients with a central or peripheral lesion. Observation of gait is usually enough to determine the need for a trial with an AFO in a patient with hemiparesis or foot drop. Indications include inadequate dorsiflexion for initial heel contact or for toe clearance during early and midswing, excessive hip hiking during swing, mediolateral 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 person 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 in terms of walking velocity. Fig. 55.2 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. 55.3 shows a thermoplastic AFO with a hinged joint that enables 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 foot drop 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 allowing 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.

A metal double-upright brace offers greater rigidity for mediolateral foot instability and allows more versatility in adjustments for the amount of plantar flexion and dorsiflexion, but it 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. The lightweight knee-ankle-foot orthosis (KAFO) with locking metal knee joints shown in Video 55.1 allows the hemiplegic person to prevent snapping back of the knee in the stance phase as well as to clear the foot and enable heel strike at the end of the swing phase. Such devices can also 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. The Walkabout (Polymedic, Inc.) acts as an RGO. Short-distance ambulation for exercise can also be aided in the patient with SCI by variations on a KAFO and walker, but at high energy cost.

Video 55.1 A knee-ankle-foot orthosis (KAFO) to control snap back and toe catch. This right hemiplegic patient was able to swing from her hip to initiate a step, but her forefoot tended to catch the ground due to inadequate ankle dorsiflexion and knee flexion. Her knee tended to snap backward in the mid- and late stance phase of the gait cycle. This KAFO enabled loading the leg in stance without the instability and pain induced by hyperextension of the knee. The ankle component allowed her to clear the toes for swing and enabled a rather normal heel strike.

Static orthoses allow no motion of the primary joint. Solid wrist-hand orthoses are usually set between neutral and 30 degrees of extension. However, based on small trials after stroke, upper limb orthoses have not been shown to improve arm or hand function, increase range of motion, or lessen the incidence of pain. Dynamic orthoses use elastic, wire, or powered levers that compensate for weakness or an imbalance in strength and allow some controlled movement. Fig. 55.4 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.

Service Provision

The way in which services are organized depends to some extent on the disease being managed. The most fundamental differentiation is between acute-onset diseases with different pathophysiological characteristics such as brain and spinal cord trauma and stroke; chronic conditions such as cerebral palsy and polio, in which disability may increase with aging and overuse of muscles and joints; and progressive disorders such as MS, muscular dystrophies, ALS, and Parkinson disease (PD). Service provision should also be driven by the philosophy underlying rehabilitation: to return the patient home and optimize home and community activities as soon as possible. The speed with which this is done depends as much on the services available in the community and the capacity of the family and caregivers to look after the patient as it does on the severity of the disability. Some tension arises between inpatient services in which all of the necessary ingredients are gathered under one roof, which appeals to patients and families, and community services, which are less centralized but support patients in their own environment. Most important is the smooth interface between these two settings when patients are discharged from an inpatient service.

Complications in Patients with Stroke

Medical complications often interfere with a patient’s ability to participate in therapy ( Table 55.1 ). Medical and neurological complications occur at rates of approximately 4 and 0.6 per patient, respectively, during an average course of inpatient rehabilitation. Side effects during the adjustment of new medications are especially prevalent, including orthostatic hypotension from antihypertensives or dialysis, drowsiness from anticonvulsants and analgesics, and a statin-induced myopathy with normal serum creatine kinase. Across inpatient rehabilitation centers, 5%–15% of patients must be transferred back to an acute hospital setting.