Enable patients to function optimally within the limits placed upon them by disease processes which may not be reversible.


spinal cord injury, brain injury, stroke, neuromuscular disease, and musculoskeletal injury, as well as the performance of electrodiagnostic studies and the assessment of neuromusculoskeletal impairment.

Determine why a patient is weak, distinguishing between critical illness neuromyopathy, steroid myopathy, and other causes of debility. They can evaluate patients with specific impairments and recommend orthoses, bracing, or other assistive devices to improve mobility, and provide recommendations for formal physical or occupational therapy, as well as weight-bearing and fall precautions. Physiatrists work closely with PTs, OTs, speech-language pathologists, and allied providers in the coordinated delivery of multidisciplinary care. They often oversee the rehabilitation process, and work with hospitalists to ensure that care is appropriate for the medical context (Table 69-3).


Rehabilitation facilitates recovery from loss of function.

Loss may be due to fracture, amputation, stroke or another neurologic disorder, arthritis, cardiac impairment, or prolonged deconditioning (eg, after some disorders and surgical procedures).

Rehabilitation involves physical, surgical, occupational, and speech therapy; psychologic counseling; and social services.

Rehabilitation involves increasing muscle strength, maximizing motor control, training individuals to make the most effective use of residual function, and providing adaptive equipment to minimize limb deformities.


The most successful model for rehabilitation addresses all the needs of the patient, including physical and emotional needs, and is based on a team approach. Among those frequently included in the team are physicians and nurses from various medical specialties, physical and occupational therapists, speech therapists, psychologists, orthotists, and social workers as well as the patient and members of the patient's family. The shared goal of team members is to prevent barriers to rehabilitation by (1) diagnosing all current problems, (2) treating the problems adequately, (3) establishing adequate nutrition, (4) monitoring the patient for any complications that might impede progress in recovery, (5) mobilizing the patient as soon as possible, and (6) restoring function or helping the patient adjust to an altered lifestyle.




For some patients, the goal is complete recovery with full, unrestricted function. For others, it is recovery of the ability to do as many activities of daily living (ADLs) as possible. ADLs include caring for self (eg, grooming, bathing, dressing, feeding, toileting), cooking, cleaning, shopping, managing drugs, managing finances, using the telephone, and traveling. Results of rehabilitation depend on the nature of the loss and the patient's motivation. Progress may be slow for elderly patients and for patients who lack muscle strength or motivation.

The referring physician and rehabilitation team determine which activities are achievable and which are essential for the patient's independence. Once ADL function is maximized, goals that can help improve quality of life are added.
Patients improve at different rates.
Rehabilitation isconsidered for patients who have good potential for recovery and can participate in and tolerate aggressive therapy (generally, ³ 3 h/day). Many nursing homes have less intensive programs (generally, 1 to 3 h/day, up to 5 days/wk) and thus are better suited to patients less able to tolerate therapy (eg, frail or elderly patients). Less varied and less frequent rehabilitation programs may be offered in outpatient settings or at home and are appropriate for many patients. However, outpatient rehabilitation can be relatively intensive (several hours/day up to 5 days/wk).

An interdisciplinary approach is best because disability can lead to various problems (eg, depression, lack of motivation to regain lost function, financial problems). Thus, patients may require psychologic intervention and help from social workers or mental health practitioners. Also, family members may need help learning how to adjust to the patient's disability and how to help the patient.


A physician writes a referral/prescription to a physiatrist, therapist, or rehabilitation center.

The referral/prescription should state the diagnosis and goal of therapy. The diagnosis may be specific (eg, after left-sided stroke, residual right-sided deficits in upper and lower extremities) or functional (eg, generalized weakness due to bed rest). Goals should be as specific as possible (eg, training to use a prosthetic limb, maximizing general muscle strength and overall endurance). Although vague instructions (eg, physical therapy to evaluate and treat) are sometimes accepted, they are not in the patients' best interests and may be rejected with a request for more specific instructions. Physicians unfamiliar with writing referrals for rehabilitation can consult a physiatrist.

A team approach to chronic conditions is emphasized to coordinate care by building on and strengthening the resources of the person and family, providing for a facilitating environment, and developing performance goals in that environment.

Patient and Family Education

Patient and family education is an important part of the rehabilitation process, particularly when the patient is discharged into the community. Often, the nurse is the team member primarily responsible for this education. Patients are taught how to maintain newly regained functions and how to reduce the risk of accidents (eg, falls, cuts, burns) and secondary disabilities. Family members are taught how to help the patient be as independent as possible, so that they do not overprotect the patient (leading to decreased functional status and increased dependence) or neglect the patient's primary needs (leading to feelings of rejection, which may cause depression or interfere with physical functioning).

Emotional support from family members and friends is essential. It may take many forms. Spiritual support and counseling by peers or by religious advisors can be indispensable for some patients.


Geriatric Rehabilitation

Disorders requiring rehabilitation (eg, stroke, MI, hip fracture, limb amputation) are common among the elderly. The elderly are also more likely to have become deconditioned before the acute problem that necessitates rehabilitation.

The elderly, even if cognitively impaired, can benefit from rehabilitation. Age alone is not a reason to postpone or deny rehabilitation. However, the elderly may recover slowly because of a reduced ability to adapt to a changing environment, including

· Physical inactivity

· Lack of endurance

· Depression or dementia

· Decreased muscle strength, joint mobility, coordination, or agility

· Impaired balance

Programs designed specifically for the elderly are preferable because the elderly often have different goals, require less intensive rehabilitation, and need different types of care than do younger patients. In age-segregated programs, elderly patients are less likely to compare their progress with that of younger patients and to become discouraged, and the social work aspects of postdischarge care can be more readily integrated. Some programs are designed for specific clinical situations (eg, recovery from hip fracture surgery); patients with similar conditions can work together toward common goals by encouraging each other and reinforcing the rehabilitation training.

Physical Therapy

Physical therapy aims to improve joint and muscle function (eg, range of motion, strength) and thus improve the patient's ability to stand, balance, walk, and climb stairs. For example, physical therapy is usually used to train lower-extremity amputees. On the other hand, occupational therapy focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities.

Range of motion: Limited range of motion impairs function and tends to cause pain and to predispose patients to pressure ulcers. Range of motion should be evaluated with a goniometer before therapy and regularly thereafter (for normal values, see
Table 350-1).

Range-of-motion exercises stretch stiff joints. Stretching is usually most effective and least painful when tissue temperature is raised to about 43° C (see p. 3459). There are several types:

· Active: This type is used when patients can exercise without assistance; patients must move their limbs themselves.

· Active assistive: This type is used when muscles are weak or when joint movement causes discomfort; patients must move their limbs, but a therapist helps them do so.

· Passive: This type is used when patients cannot actively participate in exercise; no effort is required from them.

Strength and conditioning: Many exercises aim to improve muscle strength (for grading muscle strength, see
Table 350-2). Muscle strength may be increased with progressive resistive exercise. When a muscle is very weak, gravity alone is sufficient resistance. When muscle strength becomes fair, additional manual or mechanical resistance (eg, weights, spring tension) is added.

General conditioning exercises combine various exercises to treat the effects of debilitation, prolonged bed rest, or immobilization. The goals are to reestablish hemodynamic balance, increase cardiorespiratory capacity and endurance, and maintain range of motion and muscle strength.

For the elderly, the purpose of these exercises is both to strengthen muscles enough to function normally and possibly to regain normal strength for age.

Proprioceptive neuromuscular facilitation: This technique helps promote neuromuscular activity in patients who have upper motor neuron damage with spasticity; it enables them to feel muscle contraction and helps maintain the affected joint's range of motion. For example, applying strong resistance to the left elbow flexor (biceps) of patients with right hemiplegia causes the hemiplegic biceps to contract, flexing the right elbow.

[Table 350-1. Normal Values for Range of Motion of Joints*]

[Table 350-2. Grades of Muscle Strength]

Coordination exercises: These task-oriented exercises improve motor skills by repeating a movement that works more than one joint and muscle simultaneously (eg, picking up an object, touching a body part).

Ambulation exercises: Before proceeding to ambulation exercises, patients must be able to balance in a standing position. Balancing exercise is usually done using parallel bars with a therapist standing in front of or directly behind a patient. While holding the bars, patients shift weight from side to side and from forward to backward. Once patients can balance safely, they can proceed to ambulation exercises.

Ambulation is often a major goal of rehabilitation. If individual muscles are weak or spastic, an orthosis (eg, a brace) may be used (see p.
3457). Ambulation exercises are commonly started using parallel bars; as patients progress, they use a walker, crutches, or cane and then walk without devices. Some patients wear an assistive belt used by the therapist to help prevent falls. Anyone assisting patients with ambulation should know how to correctly support them (see
Fig. 350-1).

As soon as patients can walk safely on level surfaces, they can start training to climb stairs or to step over curbs if either skill is needed. Patients who use walkers must learn special techniques for climbing stairs and stepping over curbs. When climbing stairs, ascent starts with the better leg, and descent starts with the affected leg (ie, good leads up; bad leads down). Before patients are discharged, the social worker or physical therapist should arrange to have secure handrails installed along all stairs in the patients' home.

Transfer training: Patients who cannot transfer independently from bed to chair, chair to commode, or chair to a standing position usually require attendants 24 h/day. Adjusting the heights of commodes and chairs may help. Sometimes assistive devices are useful; eg, people who have difficulty standing from a seated position may benefit from a chair with a raised seat or a self-lifting chair.

[Fig. 350-1. Supporting a patient during ambulation.]

Figure Thumbnail
Fig. 350-1. Supporting a patient during ambulation.

Aides should place one arm under that of the patient, gently grasp the patient's forearm, and lock their arm firmly under the patient's axilla. Thus, if the patient starts to fall, aides can provide support at the patient's shoulder. If a patient is wearing a waist belt, aides use their free hand to grasp the belt.0

Occupational Therapy

Occupational therapy (OT) focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities. Unlike physical therapy, which focuses on muscle strength and joint range of motion, OT focuses on activities of daily living (ADLs) because they are the cornerstone of independent living. Basic ADLs (BADLs) include eating, dressing, bathing, grooming, toileting, and transferring (ie, moving between surfaces such as the bed, chair, and bathtub or shower). Instrumental ADLs (IADLs) require more complex cognitive functioning than BADLs. IADLs include preparing meals; communicating by telephone, writing, or computer; managing finances and daily drug regimens; cleaning; doing laundry, food shopping, and other errands; managing finances; traveling as a pedestrian or by public transportation; and driving. Driving is particularly complex, requiring integration of visual, physical, and cognitive tasks.

Evaluation: OT can be initiated when a physician writes a referral for rehabilitation, which is similar to writing a prescription. The referral should be detailed, including a brief history of the problem (eg, type and duration of the disorder or injury) and establishing the goals of therapy (eg, training in IADLs). Lists of occupational therapists may be obtained from a patient's insurance carrier, a local hospital, the telephone book, state occupational training organizations, or the web site of the American Occupational Therapy Association.

Patients are evaluated for limitations that require intervention and for strengths that can be used to compensate for weaknesses. Limitations may involve motor function, sensation, cognition, or psychosocial function. Examiners determine which activities (eg, work, leisure, social, learning) patients want or need help with. Patients may need help with a general type of activity (eg, social) or a specific activity (eg, attending church), or they may need to be motivated to do an activity. Therapists may use an assessment instrument to help in the evaluation. One of the many functional assessment instruments is described in Table 350-3. Patients are asked about their social and family roles, habits, and social support systems. The availability of resources (eg, community programs and services, private attendants) should be determined.

Occupational therapists may also assess the home for hazards and make recommendations to ensure home safety (eg, removing throw rugs, increasing hallway and kitchen lighting, moving a night table within reach of the bed, placing a family picture on a door to help patients recognize their room).

Determining when driving is a risk and whether driver retraining is indicated is best done by occupational therapists with specialized training. Information that can help elderly drivers and their caregivers in coping with changing driving abilities is available from the American Occupational Therapy Association and the American Association for Retired Persons.

Interventions: OT may consist of one consultation or frequent sessions of varying intensity. Sessions may occur in various settings:

· Acute care, rehabilitation, outpatient, adult day care, skilled nursing, or long-term care facilities

· The home (as part of home health care)

· Senior housing developments

· Life-care or assisted-living communities

Occupational therapists develop an individualized program to enhance patients' motor, cognitive, communication, and interaction capabilities. The goal is not only to help patients do ADLs but also to do appropriate preferred leisure activities and to foster and maintain social integration and participation.

Before developing a program, a therapist observes patients doing each activity of the daily routine to learn what is needed to ensure safe, successful completion of the activities. Therapists can then recommend ways to eliminate or reduce maladaptive patterns and to establish routines that promote function and health. Specific performance-oriented exercises are also recommended. Therapists emphasize that exercises must be practiced and motivate patients to do so by focusing on exercise as a means of becoming more active at home and in the community.

Patients are taught creative ways to facilitate social activities (eg, how to get to museums or church without driving, how to use hearing aids or other assistive communication devices in different settings, how to travel safely with or without a cane or walker). Therapists may suggest new activities (eg, volunteering in foster grandparent programs, schools, or hospitals).

Patients are taught strategies to compensate for their limitations (eg, to sit when gardening). The therapist may identify various assistive devices that can help patients do many activities of daily living (see
Table 350-4). Most occupational therapists can select wheelchairs appropriate for patients' needs and provide training for upper-extremity amputees.

[Table 350-3. Katz Activities of Daily Living Scale]

Occupational therapists may construct and fit devices to prevent contractures and treat other functional disorders.

Speech Therapy

Speech therapists can identify the most effective methods of communication for patients who have aphasia, dysarthria, or verbal apraxia or who have had a laryngectomy:

· Expressive aphasia: A letter or picture board

· Mild to moderate dysarthria or apraxia: Breathing and muscle control plus repetition exercises

· Severe dysarthria or apraxia: An electronic device with a keyboard and message display (print or screen)

· Postlaryngectomy: A new way to produce a voice (eg, by an electrolarynx¾see p. 490)

Therapeutic and Assistive Devices

Orthoses provide support for damaged joints, ligaments, tendons, muscles, and bones. Most are customized to a patient's needs and anatomy. Orthoses designed to fit into shoes may shift the patient's weight to different parts of the foot to compensate for lost function, prevent deformity or injury, help bear weight, or relieve pain, as well as provide support. Orthoses are often very expensive and not covered by insurance.

Walking aids include walkers, crutches, and canes (see
Fig. 350-2). They help with weight

[Table 350-4. Assistive Devices]

bearing, balance, or both. Each device has advantages and disadvantages, and each is available in many models. After evaluation, a therapist should choose the one that provides the best combination of stability and freedom for the patient (see
Table 350-5). Physicians should know how to fit crutches (see
Fig. 350-3). Prescriptions for assistive devices should be as specific as possible.

Wheelchairs provide mobility to patients who cannot walk. Some models are designed to be self-propelled and to provide stability for traveling over uneven ground and up and down curbs. Other models are designed to be pushed by an assistant; they provide less stability and speed. Wheelchairs are available with various features. For athletic patients with impaired lower extremities but good upper body strength, racing wheelchairs are available. A one-arm-drive or hemi-height wheelchair may be suitable for hemiplegic patients with good coordination. If patients have little or no arm function, a motorized wheelchair is prescribed. Wheelchairs for quadriplegics may have chin or mouth (sip and puff) controls and built-in ventilators.

Prostheses are artificial body parts, most commonly limbs designed to replace lower or upper extremities after amputation (see p. 3465). Technical innovations have greatly improved the comfort and functionality of prostheses. Many prostheses can be cosmetically altered to appear natural. A prosthetist should be involved early to help patients understand the many options in prosthetic design, which should meet the patients' needs and safety requirements. Many patients can expect to regain considerable function. Physical therapy

[Table 350-5. Ambulation Aids]

should be started even before the prosthesis is fitted; therapy should continue until patients can function with the new limb. Some patients seem unable to tolerate a prosthesis or complete the physical rehabilitation required to successfully use it.

Figure Thumbnail
Fig. 350-2. Correct cane height.

The patient's elbow should be bent at slightly < 45° when maximum force is applied.0
Figure Thumbnail
Fig. 350-3. Fitting crutches.

Patients should wear the type of shoes usually worn, stand erect, and look straight ahead with the shoulders relaxed. For a correct fit, the end of each crutch should be placed about 5 cm from the side of the shoe and about 15 cm in front of the toe, and the top of the crutch should be about 2 to 3 finger widths (about 5 cm) below the axilla. The hand grip should be adjusted so that the elbow bends 20 to 30°.0

Treatment of Pain and Inflammation

(See also Ch. 171)

Treatment of pain and inflammation aims to facilitate movement and improve coordination of muscles and joints. Nondrug treatments include therapeutic exercise, heat, cold, electrical stimulation, cervical traction, massage, and acupuncture. These treatments are used for many disorders of muscles, tendons, and ligaments (see
Table 350-6). Prescribers should include the following:

· Diagnosis

· Type of treatment (eg, ultrasound, hot pack)

· Location of application (eg, right shoulder, low back)

· Frequency (eg, once/day, every other day)

· Duration (eg, 10 days, 1 wk)

Heat: Heat provides temporary relief in subacute and chronic traumatic and inflammatory disorders (eg, sprains, strains, fibrositis, tenosynovitis, muscle spasm, myositis, back pain, whiplash injuries, various forms of arthritis, arthralgia, neuralgia). Heat increases blood flow and the extensibility of connective tissue; heat also decreases joint stiffness, pain, and muscle spasm and helps relieve inflammation, edema, and exudates. Heat application may be superficial (infrared heat, hot packs, paraffin bath, hydrotherapy) or deep (ultrasound). Intensity and duration of the physiologic effects depend mainly on tissue temperature, rate of temperature elevation, and area treated.

Infrared heat is applied with a heat lamp, usually for 20 min/day. Contraindications include any advanced heart disorder, peripheral vascular disease, impaired skin sensation (particularly to temperature and pain), and significant hepatic or renal insufficiency. Precautions must be taken to avoid burns.

Hot packs are cotton cloth containers filled with silicate gel; they are boiled in water or

[Fig. 350-2. Correct cane height.]

warmed in a microwave oven, then applied to the skin. The packs must not be too hot. Wrapping the packs in several layers of towels helps protect the skin from burns. Contraindications are the same as those for infrared heat.

For a paraffin bath, the affected area is dipped in, immersed in, or painted with melted wax that has been heated to 49° C. The heat can be retained by wrapping the affected area with towels for 20 min. Paraffin is usually applied to small joints¾typically, by dipping or immersion for a hand and by painting for a knee or an elbow. Paraffin should not be applied to open wounds or used on patients allergic to it. A paraffin bath is particularly useful for finger arthritis.

Hydrotherapy may be used to enhance wound healing. Agitated warm water stimulates blood flow and debrides burns and wounds. This treatment is often given in a Hubbard tank (a large industrial whirlpool) with water heated to 35.5 to 37.7° C. Total immersion in water heated to 37.7 to 40° C may also help relax muscles and relieve pain. Hydrotherapy is particularly useful with range-of-motion exercises.

[Fig. 350-3. Fitting crutches.]

Diathermy is therapeutic heating of tissues using oscillating high-frequency electromagnetic fields, either short-wave or microwave. These modalities do not seem superior to simpler forms of heating and are now seldom used.

Ultrasound uses high-frequency sound waves to penetrate deep (4 to 10 cm) into the tissue; its effects are thermal, mechanical, chemical, and biologic. It is indicated for tendinitis, bursitis, contractures, osteoarthritis, bone injuries, and complex regional pain syndrome. Ultrasound should not be applied to ischemic tissue, anesthetized areas, or areas of acute infection nor be used to treat hemorrhagic diathesis or cancer. Also, it should not be applied over the eyes, brain, spinal cord, ears, heart, reproductive organs, brachial plexus, or bones that are healing.

Cold: The choice between heat and cold therapies is often empiric. When heat does not work, cold is applied. However, for acute injury or pain, cold seems to be better than heat. Cold may help relieve muscle spasm, myofascial or traumatic pain, acute low back pain, and acute inflammation; cold may also help induce some local anesthesia. Cold is usually used during the first few hours or the day after an injury; consequently, it is seldom used in physical therapy.

Cold may be applied locally using an ice bag, a cold pack, or volatile fluids (eg, ethyl chloride, vapocoolant spray), which cool by evaporation. Spread of cold on the skin depends on the thickness of the epidermis, underlying fat and muscle, water content of the tissue, and rate of blood flow. Care must be taken to avoid tissue damage and hypothermia. Cold should not be applied over poorly perfused areas.

Electrical stimulation: Transcutaneous electrical nerve stimulation (TENS) uses low current at low-frequency oscillation to relieve pain. Patients feel a gentle tingling sensation without increased muscle tension. Depending on the severity of pain, 20 min to a few hours of stimulation may be applied several times daily. Often, patients are taught to use the TENS device and decide when to apply treatment. Because TENS may cause arrhythmia, it is contraindicated in patients with any advanced heart disorder or a pacemaker. It should not be applied over the eyes.

[Table 350-6. Indications for Nondrug Pain Treatments]

Cervical traction: Cervical traction is often indicated for chronic neck pain due to cervical spondylosis, disk prolapse, whiplash injuries, or torticollis. Vertical traction (with patients in a sitting position) is more effective than horizontal traction (with patients lying in bed). Motorized intermittent rhythmic traction with 7.5 to 10 kg is most effective. For best results, traction should be applied with the patient's neck flexed 15 to 20°. Generally, hyperextension of the neck should be avoided because it may increase nerve root compression in the intervertebral foramina. Traction is usually combined with other physical therapy, including exercises and manual stretching.

Massage: Massage may mobilize contracted tissues, relieve pain, and reduce swelling and induration associated with trauma (eg, fracture, joint injury, sprain, strain, bruise, peripheral nerve injury). Massage should be considered for low back pain, arthritis, periarthritis, bursitis, neuritis, fibromyalgia, fibrositis, hemiplegia, paraplegia, quadriplegia, multiple sclerosis, cerebral palsy, and certain types of cancer. Massage should not be used to treat infections or thrombophlebitis. It is not advised for patients with severe allergies because it causes histamine to be released throughout the body. Only a licensed or certified massage therapist should use massage for treatment of an injury because of variability in therapists' training and skills.

Acupuncture: Thin needles are inserted through the skin at specific body sites, frequently far from the site of pain (see p. 3419). Acupuncture is sometimes used with other treatments to manage acute and chronic pain.

Cardiovascular Rehabilitation

Rehabilitation may benefit some patients who have coronary artery disease or heart failure or who have had a recent MI or coronary artery bypass surgery, particularly those who could do activities of daily living independently and walk before the event. Cardiac rehabilitation aims to help patients maintain or regain independence (see p. 2117).

Typically, rehabilitation begins with light activities and progresses on an individualized basis; ECG monitoring is often used. High-risk patients should exercise only in a well-equipped cardiovascular rehabilitation facility under the supervision of a trained attendant.

When patients are able, they are taken by wheelchair to a physical therapy gym in the hospital. Exercise may involve walking, a treadmill, or a stationary bicycle. When patients tolerate these exercises well, they progress to stair-climbing. If shortness of breath, light-headedness, or chest pain occurs during exercise, the exercise should be stopped immediately, and cardiac status should be reassessed. Before hospital discharge, patients are assessed so that an appropriate postdischarge rehabilitation program or exercise regimen can be recommended.

Physical activity is measured in metabolic equivalents (METs), which are multiples of the resting rate of O2 consumption; 1 MET (the resting rate) equals about 3.5 mL/kg/min of O2 (see
Tables 350-7). Normal working and living activities (excluding recreational activities) rarely exceed 6 METs. Light to moderate housework is about 2 to 4 METs; heavy housework or yard work is about 5 to 6 METs.

For hospitalized patients, physical activity should be controlled so that heart rate remains < 60% of maximum for that age (eg, about 160 beats/min for people aged 60); for patients recovering at home, heart rate should remain < 70% of maximum.

For patients who have had an uncomplicated MI, a 2-MET exercise test may be done to evaluate responses as soon as patients are stable. A 4- to 5-MET exercise test done before discharge helps guide physical activity at home. Patients who can tolerate a 5-MET exercise test for 6 min can safely do low-intensity activities (eg, light housework) after discharge if they rest sufficiently between each activity.

Unnecessary restriction of activity is detrimental to recovery. The physician and other members of the rehabilitation team should explain which activities can be done and which cannot and should provide psychologic support. When discharged, patients can be given a detailed home activity program. Most elderly patients can be encouraged to resume sexual activity, but they need to stop and rest if necessary to avoid overexertion. Young couples expend 5 to 6 METs during intercourse; whether elderly couples expend more or less is unknown.

Stroke Rehabilitation

Rehabilitation after stroke aims to preserve or improve range of motion, muscle strength, bowel and bladder function, and functional and cognitive abilities. Specific programs are based on the patient's social situation (eg, prospects of returning to home or work), ability

[Table 350-7. Endurance Exercises and Their Metabolic Requirement]

to participate in a rehabilitation program supervised by nurses and therapists, learning ability, motivation, and coping skills. A stroke that impairs comprehension often makes rehabilitation very difficult.

To prevent secondary disabilities (eg, contractures) and help prevent depression, rehabilitation should begin as soon as patients are medically stable. Preventive measures for pressure ulcers must be started even before patients are medically stable. Patients can safely begin sitting up once they are fully conscious and neurologic deficits are no longer progressing, usually £ 48 h after the stroke. Early in the rehabilitation period, when the affected extremities are flaccid, each joint is passively exercised through the normal range of motion (see Table 350-1) 3 to 4 times/day.

Regaining the ability to get out of bed and to transfer to a chair or wheelchair safely and independently is important for the patient's psychologic and physical well-being. Ambulation problems, spasticity, visual field defects (eg, hemianopia), incoordination, and aphasia require specific therapy.

Hemiplegia: For patients with hemiplegia, placing 1 or 2 pillows under the affected arm can prevent dislocation of the shoulder. If the arm is flaccid, a well-constructed sling can prevent the weight of the arm and hand from overstretching the deltoid muscle and subluxating the shoulder. A posterior foot splint applied with the ankle in a 90° position can prevent equinus deformity (talipes equinus) and footdrop.

Resistive exercise for hemiplegic extremities may increase spasticity and thus is controversial. However, reeducation and coordination exercises of the affected extremities are added as soon as tolerated, often within 1 wk. Active and active-assistive range-of-motion exercises are started shortly afterward to maintain range of motion. Active exercise of the unaffected extremities must be encouraged, as long as it does not cause fatigue. Various activities of daily living (eg, moving in bed, turning, changing position, sitting up) should be practiced. For hemiplegic patients, the most important muscle for ambulation is the unaffected quadriceps. If weak, this muscle must be strengthened to assist the hemiplegic side.

A gait abnormality in hemiplegic patients is caused by many factors (eg, muscle weakness, spasticity, distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls, which often result in a hip fracture; functional prognosis of hemiplegic patients with a hip fracture is very poor. Consequently, as long as hemiplegic patients can walk safely and comfortably, gait correction should not be tried.

Novel treatments for hemiplegia include the following:

· Constraint-induced movement therapy: The functional limb is restrained during waking hours, except during specific activities, and patients are forced to do tasks mainly with the affected extremity.

· Robotic therapy: Robotic devices are used to provide intensive repetition of the therapeutic movement, guide an affected extremity in executing the movement, provide feedback (eg, on a computer screen) for patients, and measure patient progress.

· Partial weight-supported ambulation: A device (eg, treadmill) that bears part of a patient's weight is used during ambulation. The amount of weight borne and speed of ambulation can be adjusted. This approach is often used with robotics, which allows patients to contribute to ambulation but provides force as needed for ambulation.

· Total body vibration: Patients stand on an exercise machine with a platform that vibrates by rapidly shifting weight from one foot to the other. The movement stimulates reflexive muscle contraction.

Ambulation problems: Before ambulation exercises can be started, patients must be able to stand. Patients first learn to stand from the sitting position. The height of the seat may need to be adjusted. Patients must stand with the hips and knees fully extended, leaning slightly forward and toward the unaffected side. Using the parallel bars is the safest way to practice standing.

The goal of ambulation exercises is to establish and maintain a safe gait, not to restore a normal gait. Most hemiplegic patients have a gait abnormality, which is caused by many factors (eg, muscle weakness, spasticity, distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls.

During ambulation exercises, patients place the feet > 15 cm (6 in) apart and grasp the parallel bars with the unaffected hand. Patients take a shorter step with the hemiplegic leg and a longer step with the unaffected leg. Patients who begin walking without the parallel bars may need physical assistance from and later close supervision by the therapist. Generally, patients use a cane or walker when first walking without the parallel bars. The diameter of the cane handle should be large enough to accommodate an arthritic hand.

For stair-climbing, ascent starts with the better leg, and descent with the affected leg (good leads up; bad leads down). If possible, patients ascend and descend with the railing on the unaffected side, so that they can grasp the railing. Looking up the staircase may cause vertigo and should be avoided. During descent, patients should use a cane. The cane should be moved to the lower step shortly before descending with the bad leg.

Patients must learn to prevent falls, which are the most common accident among stroke patients and which often result in hip fracture. Usually, patients explain the fall by saying that their knees gave way. For hemiplegic patients, who almost always fall on their hemiplegic side, leaning their affected side against a railing (when standing or climbing stairs) can help prevent falls. Doing strengthening exercises for weak muscles, particularly in the trunk and legs, can also help.

For patients with symptomatic orthostatic hypotension, treatment includes support stockings, drugs, and tilt table training. Because hemiplegic patients are prone to vertigo, they should change body position slowly and take a moment after standing to establish equilibrium before walking. Comfortable, supportive shoes with rubber soles and with heels £ 2 cm (3/4 in) should be worn.

Spasticity: In some stroke patients, spasticity develops. Spasticity may be painful and debilitating. Slightly spastic knee extensors can lock the knee during standing or cause hyperextension (genu recurvatum), which may require a knee brace with an extension stop. Resistance applied to spastic plantar flexors causes ankle clonus; a short leg brace without a spring mechanism minimizes this problem.

Flexor spasticity develops in most hemiplegic hands and wrists. Unless patients with flexor spasticity do range-of-motion exercises several times a day, flexion contracture may develop rapidly, resulting in pain and difficulty maintaining personal hygiene. Patients and family members are taught to do these exercises, which are strongly encouraged. A hand or wrist splint may also be useful, particularly at night. One that is easy to apply and clean is best.

Heat or cold therapy can temporarily decrease spasticity and allow the muscle to be stretched. Hemiplegic patients may be given benzodiazepines to minimize apprehension and anxiety, particularly during the initial stage of rehabilitation, but not to reduce spasticity. The effectiveness of long-term benzodiazepine therapy for reducing spasticity is questionable. Methocarbamol has limited value in relieving spasticity and causes sedation.

Hemianopia: Patients with hemianopia (defective vision or blindness in half the visual field of one or both eyes) should be made aware of it and taught to move their heads toward the hemiplegic side when scanning. Family members can help by placing important objects and by approaching the patient on the patient's unaffected side. Repositioning the bed so that patients can see a person entering the room through the doorway may be useful. While walking, patients with hemianopia tend to bump into the door frame or obstacles on the hemiplegic side; they may need special training to avoid this problem.

When reading, patients who have difficulty looking to the left may benefit from drawing a red line on the left side of the newspaper column. When they reach the end of a line of text, they scan to the left of the column until they see the red line, cueing them to begin reading the next line. Using a rule to keep focused on each line of text may also help.

Occupational therapy: After a stroke, fine coordination may be absent, causing patients to become frustrated. Occupational therapists may need to modify patients' activities and recommend assistive devices (see Table 350-4).

Occupational therapists should also evaluate the home for safety and determine the extent of social support. They can help obtain any necessary devices and equipment (eg, bathtub bench, grab bars by the bathtub or toilet). Occupational therapists can also recommend modifications that enable patients to do activities of daily living (ADLs) as safely and independently as possible¾for example, rearranging the furniture in living areas and removing clutter. Patients and caretakers are taught how to transfer between surfaces (eg, shower, toilet, bed, chair) and, if necessary, how to modify ways of doing ADLs. For example, patients may be taught to dress or shave using only one hand and to eliminate unnecessary motion while preparing food or shopping for groceries. Therapists may suggest using clothing and shoes with touch fasteners (eg, Velcro) or dinner plates with rims and rubber grips (to facilitate handling). Patients with impairments in cognition and perception are taught ways to compensate. For example, they can use drug organizers (eg, containers marked for each day of the week).

Leg Amputation Rehabilitation

Before amputation, the physician describes to the patient the extensive postsurgical rehabilitation program that is needed. Psychologic counseling may be indicated. The rehabilitation team and the patient decide whether a prosthesis or a wheelchair is needed.

Rehabilitation teaches ambulation skills; it includes exercises to improve general conditioning and balance, to stretch the hip and knee, to strengthen all extremities, and to help patients tolerate the prosthesis. Because ambulation requires a 10 to 40% increase in energy expenditure after below-the-knee amputation and a 60 to 100% increase after above-the-knee amputation, endurance exercises may be indicated. As soon as patients are medically stable, rehabilitation should be started to help prevent secondary disabilities. Elderly patients should begin standing and doing balancing exercises with parallel bars as soon as possible.

Flexion contracture of the hip or knee may develop rapidly, making fitting and using the prosthesis difficult; contractures can be prevented with extension braces made by occupational therapists.

Physical therapists teach patients how to care for the stump and how to recognize the earliest signs of skin breakdown.

Stump Conditioning and Prostheses

Stump conditioning promotes the natural process of stump shrinking that must occur before a prosthesis can be used. After only a few days of conditioning, the stump may have shrunk greatly. An elastic stump shrinker or elastic bandages worn 24 h/day can help taper the stump and prevent edema. The stump shrinker is easy to apply, but bandages may be preferred because they better control the amount and location of pressure. However, application of elastic bandages requires skill, and bandages must be reapplied whenever they become loose.

Early ambulation with a temporary prosthesis helps in the following ways:

· Enables the amputee to be active

· Accelerates stump shrinkage

· Prevents flexion contracture

· Reduces phantom limb pain

The socket of the pylon (the internal framework or skeleton of a prosthesis) is made of plaster of paris (calcium sulfate hemihydrate); it should fit the stump snugly. Various temporary prostheses with adjustable sockets are available. Patients with a temporary prosthesis can start ambulation exercises on the parallel bars and progress to walking with crutches or canes until a permanent prosthesis is made.

The permanent prosthesis should be lightweight and meet the needs and safety requirements of the patient. If the prosthesis is made before the stump stops shrinking, adjustments may be needed. Therefore, manufacture of a permanent prosthesis is generally delayed a few weeks to allow shrinkage of the stump. For most elderly patients with a below-the-knee amputation, a patellar tendon-bearing prosthesis with a solid-ankle, cushion-heel foot, and suprapatellar cuff suspension is best. Unless patients have special needs, a below-the-knee prosthesis with thigh corset and waist belt is not prescribed because it is heavy and bulky. For above-the-knee amputees, several knee-locking options are available according to the patient's skills and activity level.

Care of the stump and prosthesis: Patients must learn to care for their stump. Because a leg prosthesis is intended only for ambulation, patients should remove it before going to sleep. At bedtime, the stump should be inspected thoroughly (with a mirror if inspected by the patient), washed with mild soap and warm water, dried thoroughly, then dusted with talcum powder. Patients should treat the following possible problems:

· Dry skin: Lanolin or petrolatum may be applied to the stump.

· Excessive sweating: An unscented antiperspirant may be applied.

· Inflamed skin: The irritant must be removed immediately, and talcum powder or a lowpotency corticosteroid cream or ointment should be applied.

· Broken skin: The prosthesis should not be worn until the wound has healed.

The stump sock should be changed daily, and mild soap may be used to clean the inside of the socket. Standard prostheses are neither waterproof nor water-resistant. Therefore, if even part of the prosthesis becomes wet, it must be dried immediately and thoroughly; heat should not be applied. For patients who swim or prefer to shower with a prosthesis, a prosthesis that can tolerate immersion can be made.


Stump pain is the most common complaint. Common causes include

· A poorly fitted prosthetic socket: This cause is the most common.

· Neuroma: An amputation neuroma is usually palpable. Daily ultrasound treatment for 5 to 10 sessions may be most effective. Other treatments include injection of corticosteroids or analgesics into the neuroma or the surrounding area, cryotherapy, and continuous tight bandaging of the stump. Surgical resection often has disappointing results.

· Spur formation at the amputated end of the bone: Spurs may be diagnosed by palpation and x-ray. The only effective treatment is surgical resection.

Phantom limb sensation (a painless awareness of the amputated limb possibly accompanied by tingling) is experienced by some new amputees. This sensation may last several months or years but usually disappears without treatment. Frequently, patients sense only part of the missing limb, often the foot, which is the last phantom sensation to disappear. Phantom limb sensation is not harmful; however, patients, without thinking, commonly attempt to stand with both legs and fall, particularly when they wake at night to go to the bathroom.

Phantom limb pain is less common and can be severe and difficult to control. Some experts think it is more likely to occur if patients had a painful condition before amputation or if pain was not adequately controlled intraoperatively and postoperatively. Various treatments, such as simultaneous exercise of amputated and contralateral limbs, massage of the stump, finger percussion of the stump, use of mechanical devices (eg, a vibrator), and ultrasound, are reportedly effective. Drugs (eg, gabapentin) may help.

Skin breakdown tends to occur because the prosthesis presses on and rubs the skin and because moisture collects between the stump and prosthetic socket. Skin breakdown may be the first indication that the prosthesis needs adjustment and needs to be managed immediately. The first sign of skin breakdown is redness; then cuts, blisters, and sores may develop, the prosthesis is often painful or impossible to wear for long periods of time, and infection can develop. Several measures can help prevent or delay skin breakdown:

· Having an interface that fits well

· Maintaining a stable body weight (even small changes in weight can affect fit)

· Eating a healthy diet and drinking lots of water (to control body weight and maintain healthy skin)

· For patients with diabetes, monitoring and controlling their blood sugar level (to help prevent vascular disease and thus maintain blood flow to the skin)

· For patients with a lower-limb prosthesis, maintaining body alignment (eg, wearing only shoes with a similar heel height)

However, even with a good fit, problems can occur. The stump changes in shape and size throughout a day, depending on activity level, diet, and the weather. Thus, there are times when the interface fits well and times when it fits less well. In response to such ongoing changes, people can help maintain a good fit by switching to a thicker or thinner liner or sock, by using a liner and a sock, or by adding or removing thin-ply socks. But even so, the stump's size may vary enough to cause skin breakdown. If there are signs of skin breakdown, patients should promptly see a health care practitioner and a prosthetist; when possible they should also avoid wearing the prosthesis until it can be adjusted.

Hip Surgery Rehabilitation

Rehabilitation is started as soon as possible after hip fracture surgery. The first goals may be to increase strength and to prevent atrophy on the unaffected side. Initially, only isometric exercise of the affected limb while it is fully extended is permitted. Placement of a pillow under the knee is contraindicated because it may lead to flexion contracture of the hip and knee.

Gradual mobilization of the affected limb usually results in full ambulation. Speed of rehabilitation depends partly on the type of surgery done. For example, after prosthetic hip replacement, rehabilitation usually progresses more rapidly, less rehabilitation is needed, and the functional outcome is better than after nail-and-plate or pin-and-plate fixation. Ideally, full weight bearing starts on the 2nd day after surgery. Ambulation exercises are started after 4 to 8 days (assuming that patients can bear their full weight and can balance), and stair-climbing exercises are started after about 11 days.

Patients are taught to do daily exercises to strengthen the trunk muscles and quadriceps of the affected leg. Prolonged lifting or pushing of heavy items, stooping, reaching, or jumping can be harmful. During ambulation, the amount of mechanical stress is about the same whether patients use 1 or 2 canes, but using 2 may interfere with certain activities of daily living (ADLs). Patients should not sit on a chair, particularly a low one, for a long period and should use the chair arm for support when standing up. While sitting, they should keep their legs uncrossed.

Occupational therapists teach patients how to modify ways of doing basic ADLs (BADLs) and instrumental ADLs (IADLs) safely after hip replacement, thus promoting healing and improving mobility. For example, patients may learn the following:

· To keep their hip correctly aligned

· To wash dishes and iron while sitting on a high stool

· To use a pillow to raise the seat of the car while transferring in and out

· To use long-handled devices (eg, reachers, shoe horns) to minimize bending over

This instruction may occur in the hospital, in longer-term rehabilitation settings, in the patient's home immediately after discharge, or in outpatient settings.

Rehabilitation for Other Disorders

Arthritis: 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)

· How to get in and out of the bathtub safely

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

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

· To 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.

Blindness: Patients are taught to rely more on the other senses, to develop specific skills, and to use devices for the blind (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 blind people 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 the 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 sighted person, a blind person can hold onto the bent elbow of the sighted person, rather than use an ambulation aid. The sighted person should not lead the blind person by the hand because some blind people perceive this action as dominant and controlling.

COPD: 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.

Head injury: The term head injury is often used interchangeably with traumatic brain injury (TBI¾see p. 3218). 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 (see also p. 3231). Such intervention includes prevention of secondary disabilities (eg, pressure ulcers, 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.

Spinal cord injury: Specific rehabilitation therapy varies depending on the patient's abnormalities, which depend on the level and extent (partial or complete) of the injury (see Ch. 325, particularly
Table 325-1 on p. 3228). Complete transsection causes flaccid paralysis; partial transsection causes spastic paralysis of muscles innervated by the affected segment. A patient's functional capacity depends on the level of injury (see p.
1805) and the development of complications (eg, joint contractures, pressure ulcers, pneumonia).

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.

Figure Thumbnail
Fig. 186-1. Spinal nerve.0


The 4th Year is the Clerkship Year. Learning is accomplished in the various Specialty Rotations. Diseases in patients encountered during these rotations can be studied by going to: Management of Diseases and Disorders of Organ Systems or doing a search:

USMLE Reviewer

(By Subscription)