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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 restore psychologic security and help patients deal with and influence the attitudes of others. 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.
Speech
problems:
Speech therapists can identify the most effective methods of communication for patients who have aphasia, dysarthria, or verbal apraxia or who have undergone laryngectomy. Patients with expressive aphasia may use a letter or picture board. Breathing and muscle control plus repetition exercises may help patients with mild to moderate dysarthria or apraxia. Those with severe dysarthria or apraxia may use an electronic device with a keyboard and message display (print or screen). After laryngectomy, patients require a new way to produce a voice (eg, by an electrolarynx—see Tumors of the Head and Neck: Rehabilitation).
Cardiovascular
disorders:
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 perform activities of daily living independently and walk before the event. Cardiac rehabilitation aims to help patients maintain or regain independence (see Coronary Artery Disease: Rehabilitation and Postdischarge Treatment).
Typically, rehabilitation begins with light activities and progresses; ECG monitoring is often used. When patients are able, they are taken by wheelchair to a physical therapy gym. 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.
Stroke:
Rehabilitation 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 to participate in a rehabilitation program supervised by nurses and therapists, learning ability, motivation, and coping skills. As soon as patients are medically stable, rehabilitation should begin to prevent secondary disabilities (eg, contractures, pressure ulcers) and help prevent depression. Patients can safely begin sitting up once they are fully conscious and neurologic deficits are no longer progressing, usually ≤ 48 h after the stroke.
Resistive exercise for hemiplegic extremities may increase spasticity and thus is controversial. 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.
Leg
amputation:
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. As soon as patients are medically stable, rehabilitation should be started to help prevent secondary disabilities. 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. Exercise assists the natural process of shrinking that must occur before a prosthesis can be used. All stumps must be tapered, so an elastic stump shrinker or elastic bandages are applied and maintained on a 24-h basis. Physical therapists teach amputees how to care for the stump and how to recognize the earliest signs of skin breakdown.
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. Phantom limb pain is less common and can be severe and difficult to control. Some experts think it is more likely to occur if the patient 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.
The most common cause of stump pain is a poorly fitted prosthetic socket. Other common causes are neuroma and spur formation at the amputated end of the bone. 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. Spurs may be diagnosed by palpation and x-ray. The only effective treatment of a spur is surgical resection.
Head
injury:
The term head injury is often used interchangeably with traumatic brain injury (TBI—see 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 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.
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 Spinal Trauma; see Table 1: Spinal Trauma: Effects of Spinal Cord Injury by Location ). 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 Spinal Cord Disorders: Pathophysiology, Symptoms, and Signs) 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.
Minor injuries:
Rehabilitation may be needed after minor injuries (eg, sprains, isolated distal extremity fractures).
Last full review/revision November 2005
Content last modified November 2005
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