Physiotherapy in a Neuro-Rehabilitation Unit

Marisa Farrugia Matthew Azzopardi 27/06/07

A neuro-rehabilitation unit (NRU) is a working model characterized by multidisciplinary teamwork, including physicians, nurses, nursing assistants, physiotherapists, occupational therapist and FAMILY MEMBERS; when required speech therapists, social workers, psychiatrists, psychologists and dieticians. A neuro-rehabilitation unit provides rehabilitation for people with complex disabilities resulting from traumatic injuries or illness affecting the brain and spine.

It provides an environment for `slow to recover` patients and for those requiring technological assessment and intervention from a multidisciplinary team specialized in treatment and management of complex neuro-disability.

Neuro-rehabilitation units involve a combined and coordinated use of medical, social, educational and vocational measures for retraining individuals to reach their maximum physical, psychological, social and vocational potential.

Each programme provided is: to optimize neurological recovery, teach compensatory strategies for residual deficits, teach ADLs and skills required for community living and provide medical and psychosocial interventions to manage depression.

All treatment programmes are designed by the multidisplinary team to meet the individual needs of each patient

OVERALL PURPOSE

To promote the best recovery possible to enhance quality of life and planning for future care needs in conjunction with the patients, carers and outside agencies.

Why have a Neuro-Rehabilitation Unit?

Extensive studies in Europe have shown that neuro-rehabilitation units are:

effective in reducing morbidity and mortality, increase the proportion of patients returning to their home, reducing the length of stay, improving the quality of life of patients suffering from neurological conditions and probably reducing the overall costs of neurological care (Indredavik B,et al 1998).

REHABILITATION
Can be defined as: a problem solving and educational process aimed at reducing the disability and handicap experienced by someone as a result of a disease, always within the limitations imposed both by available resources and by the underlying disease (Wade 1992).

Rehabilitation remains the corner stone of treatment after neurological disorders.

Physiotherapy is one of the major components of rehabilitation.

ROLE OF PHYSIOTHERAPY

Physiotherapy is about working with people and populations to maintain and restore maximum movement and functional ability throughout the lifespan. It is concerned with identifying and maximizing movement potential within the spheres of support, prevention, treatment and rehabilitation.

Steps towards rehabilitation

Early intervention in an acute setting, if possible within first 24 hrs to avoid complications. Handover to NRU of those patients that satisfy admission criteria which according to the European Stroke Initiative (1995) are the following:

Patients must be stable with the only aim of intensive rehabilitation that is with no surgical or medical complications. Adults (aged 16 and over) with neurological dysfunction who require specialist rehabilitation. Patients must be deemed to have potential for improvement in quality of life to a reasonable degree with or without support. Where able, the patient must agree with the rehabilitation plan willing to comply with the proposed programme.

Assessment

Short and long-Term goal setting by Multidisciplinary Team

What is goal-setting?

Goal setting refers to the identification of, and agreement on, a target that the patient, therapist and team will work on towards a specific period of time. Goals are determined by correct analysis of assessment done, together with discussion with all the MDT. Goal setting process may highlight the differences in expectations between the patients and therapists (Reid and Chesson 1998).

Physiotherapy Intervention
Intensity of physiotherapy after stroke?

Studies have shown that increasing amount of physiotherapy given does not have a significant effect on recovery (Kalra et. al. 1993). Implies that improved patient outcomes is dependent on the whole environment effect such as different style of nursing care and better inter-disciplinary teamwork (Parry et. al. 1999).

Physiotherapy Intervention
Prevention of complications relevant to physiotherapy
Shoulder pain in strokes

80% are affected within 1st year (Hanger et. al. 2000) Effectiveness?? Strategies include education of MDT, patients and carers in handling, correct positioning. Limited evidence of effectiveness in use of slings, supports, and exercise (Forster 1994).

Falls

Common after neurological disorders. Causes are multifactorial: include motor, sensory and visual impairments; use of drugs such as sedatives and antidepressants. Risk of falling causes further problems to rehabilitation such as increased susceptibility to further injury from which recovery is more difficult. Correct assessment needed to identify patients at most risk. Prevention strategies such as furniture, ward/cubicle layout and provision of mobility aids.

Physiotherapy Treatment Strategies

Dependent on patient characteristics, skills of physiotherapist.

Labelled approaches (e.g. Bobath used mostly in UK vs Motor Relearning Programme (Shepherd & Carr 1998) used in Australia in the case of stroke treatment).

Psychosocial approach

Patients attribute physiotherapy to physical improvement. Patients identify physiotherapists as a source of advice and information; also of providers of faith and hope (Pound et al 1994). Rehabilitation must not be focused on physical function only return of physical function might not necessarily mean a better social outcome holistic approach.

Information Provision

Service given must include provision of appropriate, accurate information and advice to the patients and carers about the debilitating neurological conditions. This is important since most people do not understand the effects that the condition will have on them and their relatives/carers

Importance of evidence-based practice content of therapy effects outcomes (Kwakkel et al 1999, Parry et al 1999).

Often it is found that diversity of approach is the most effective use of trial and error.

Transfer of care
Discharge home may present two scenarios: (A) the patient that is willing to go home and (B)the patient that is reluctant to leave. Well planned discharge including home visit by the physiotherapist and occupational therapists Patients are observed and any handicaps rather than disabilities noted. Provisions made and any further goals are planned.

Recommendations
1. Education and Training.

Emphasis to training relevant to neurological conditions to ensure better care. If possible yearly control workshops for nurses and therapists have to be provided (Jones et al 1998).

2. Education to caregivers and relatives

Maintenance of ADLs Health education via video/dvd concerning proper care. Manual information leaflet regarding the unit and services provided should be given to patients prior to admission.

3. Multidisciplinary meetings

Weekly MDT meetings with patients present.

Discharge planning participation of the whole MDT.

4. Recreational activities

e.g. Handcraft, Tombola, singing

5. Strong sense of communication between staff and the MDT

Conclusion
By the term neuro-rehabiliation unit, however, one is not simply talking about putting a sign on the wall, but talking about establishing proper staff, resources, specialist members of a MDT who are well trained and have access to, and are able to undertake a high standard of continuing professional development so as to enable them to provide the level of rehab care required (Lindley 2002)