Rehabilitation for Specific Problems

Rehabilitation can be tailored for many specific problems. Examples are heart disorders, stroke, hip surgery, replacement of a knee, amputation of a leg, speech disorders, blindness, and hearing loss.

Heart Disorders

Rehabilitation for people with a heart disorder is called cardiac rehabilitation. It may help after a heart attack or heart surgery. It may also help when heart failure develops or worsens. The goals are to enable people to care for themselves—at the least, to do the basic activities of daily living—and to live as independently as possible.

Cardiac rehabilitation is started as soon as possible, usually while the person is still in the hospital. Before rehabilitation can begin, some people, such as those who have had a heart attack, must be stabilized. For example, they may need to be treated to stop sudden changes in blood pressure.

Typically, cardiac rehabilitation begins with a relatively undemanding activity, such as transferring to and sitting in a chair. All activities are supervised by a trained attendant. When these activities can be done comfortably, usually by the second or third day, the person tries somewhat more demanding activities, such as dressing, grooming, and walking short distances. More demanding activities are tried as the person progresses. Before a person is discharged from the hospital, doctors measure the person's heart and breathing rates while the person does certain activities. Then doctors and other members of the rehabilitation team can tell the person which activities are safe and which are not. The person is also given a detailed description of exercises to be done at home.

The number and intensity of activities are slowly increased. The goal is full resumption of normal activities after about 6 weeks. Most people benefit from a cardiac rehabilitation program. Typically, there are 3 sessions a week for about 8 to 12 weeks after discharge from the hospital.

Cardiac rehabilitation programs provide help handling the psychologic effects of having had a heart attack or heart surgery. People are also taught about changes in lifestyle that can help prevent or slow the progression of a heart disorder or reduce the risk of another heart attack. Examples are quitting smoking, losing weight, controlling blood pressure, reducing cholesterol levels (by changing the diet and taking drugs), and doing aerobic exercises at least 3 times a week.

These programs improve endurance (making physical activity less tiring), improve quality of life, and decrease the risk of dying after a heart attack or bypass surgery. The benefits of cardiac rehabilitation are at least as great for older people as for younger people.

Stroke

Rehabilitation can help people recover some or all of the abilities they have lost as a result of a stroke. However, the extent of recovery depends heavily on how well the damaged areas in the brain heal on their own. How much and how quickly the brain will heal cannot be predicted. How successful rehabilitation is depends partly on the person's general condition, including flexibility of joints, muscle strength, motivation, and the ability to understand and learn.

Rehabilitation is begun as soon as the person can tolerate being moved and exercising. Starting rehabilitation soon helps prevent problems, such as weakening of muscles, stiffening of joints, undernutrition, pneumonia, development of blood clots, pressure sores, and depression.

Rehabilitation usually begins with a therapist moving the person's affected limbs through their range of motion (as passive range-of-motion exercises). When able, the person is encouraged to help move (as active-assistive range-of-motion exercises) or to move the affected limbs alone (as active range-of-motion exercises). The unaffected limbs should also be exercised to prevent them from weakening. As soon as the person is able (often within 1 week), coordination exercises are started.

The person is expected to practice other activities, such as moving in bed, turning, changing position, and sitting up. When able, the person is taught to transfer from the bed to a chair or wheelchair safely and independently. Being able to get out of bed as soon as possible helps physically—in terms of exercising—and mentally—in terms of feeling independent and making progress in recovery.

Some of the problems caused by a stroke require specific therapies. Exercises to improve strength, balance, and coordination and gait training may be needed. People may need help learning how to compensate for problems with vision, hearing, speech, swallowing, or thinking (cognitive problems).

If one leg is greatly weakened, walking (gait) training focuses on teaching people to walk safely, not necessarily to walk as they did before. Such training can help prevent falls. A cane with four tips is useful because it provides more support than a cane with one tip. A leg or an ankle brace can enable people with one paralyzed leg or with tight, stiff (spastic) muscles to walk. If one arm is paralyzed, therapists teach people how to dress with one arm.

After a stroke, many people cannot do activities that require fine coordination. That is, they cannot move their hands precisely or coordinate the movement of their hands and eyes. Occupational therapy may help. People may learn new ways to do activities, such as fastening clothing, opening and closing containers, and getting objects that are too far to reach. Devices, such as Velcro closures for clothing and dinner plates with rims and rubber grips (to prevent slipping), may be recommended.

After a stroke, some people are partially or completely blind in one or both eyes. People who are blind in one eye are taught ways to avoid bumping into door frames or other obstacles. Turning the head toward the affected side can help. Specific therapies are used for people who are blind in both eyes.

Rehabilitation for cognitive problems is a very slow process. It requires a one-on-one approach. Also, it must be tailored to the person's situation. A stroke can cause different types of cognitive problems, depending on which area of the brain was damaged. Therapy includes specially designed exercises to retrain the brain and ways to compensate for problems.

Speech therapists can retrain people to use the muscles involved in speaking and breathing (which is necessary for speaking. If necessary, people are taught other ways to communicate effectively. Speech therapists also help people with swallowing problems learn to eat more safely.

Hip Surgery

Hip surgery may be done to repair or replace bones in the hip joint that are damaged by arthritis or broken. After surgery, rehabilitation is begun as soon as possible. Depending on the type of surgery, rehabilitation may begin on the same day as surgery. The initial goals of rehabilitation are to help the person become mobile and to prevent loss of muscle tone and other problems that result from bed rest, such as blood clots and pressure sores. The ultimate goal is to enable people to walk as well as they could before the problem occurred.

After surgery, hospital staff members encourage the person to resume activities as soon as possible. To a person who is tired and in pain after surgery, this prodding may seem bothersome, too demanding, or even cruel. However, resuming activities is necessary for a good recovery. The person is encouraged to sit in a chair as soon as possible, sometimes within hours of surgery. Sitting in a chair helps counter the effects of too much bed rest. Sitting also makes the transition to standing easier. The person is taught range-of-motion exercises and exercises to strengthen the trunk, leg, and arm muscles. These muscles may have to be used more because the lower body is injured. Exercises should be done daily.

Usually within a day of surgery, the person is encouraged to stand on the unaffected leg (the one not operated on) with the help of a chair, a bed rail, or another person. The surgeon and therapist decide when and how much weight can be put on the affected leg. Sometimes the affected leg can bear full weight on the second day after surgery.

Walking (gait) training is started as soon as the affected leg can safely bear some or all of the person's weight without discomfort and the person can balance well enough—often just a few days after surgery. Stair-climbing exercises are started soon afterward.

An assistive device, such as a walker or cane, is often needed. People learn how to sit, stand, and walk in ways that will not reinjure the hip. They learn how to prevent falls. Therapists teach them exercises to strengthen the hip and maintain its range of motion. Doing them regularly aids recovery.

Therapists may recommend special equipment for the bathroom, such as a raised toilet seat or a bathtub bench, to make using the bathroom easier and to protect the hip.

Replacement of a Knee

One or both knees may need to be replaced because of arthritis. Rehabilitation for people who have had a knee replaced is similar to that for people who have had hip surgery. That is, rehabilitation emphasizes range-of-motion and strengthening exercises and walking (gait) training. However, the specific exercises vary.

Amputation of a Leg

Older people who have diabetes or peripheral arterial disease (usually due to atherosclerosis) may have to have one or both legs surgically removed (amputated). A leg may be amputated below the knee, above the knee, or at the hip. Sometimes only a toe or part of the foot is amputated.

Rehabilitation after amputation is extensive. Doctors usually recommend an artificial leg (prosthesis). An artificial leg consists of a foot, knee unit (if the leg is amputated above the knee), and socket. (The socket enables the artificial leg to be attached.)

After surgery, the remaining part of the leg (stump) must heal before an artificial leg can be worn. The stump is also swollen. A permanent artificial leg cannot be fitted until the swelling goes down, but a temporary one can be used. Therapists teach the person or a family member how to apply an elastic sock (called a stump shrinker), which helps the stump shrink. Exercise, including walking with a temporary artificial leg as soon as possible, also helps the stump shrink. Taking care of the stump is important. It should be kept clean and dry. The skin of the stump should be checked daily for irritation, breaks, and redness. Any problems should be reported to a doctor.

After surgery, physical therapy is started as soon as the person is able. Therapy varies somewhat depending on whether one or both legs were amputated and whether the amputation was above or below the knee. Exercises to stretch the hip and knee are started as soon as possible. These exercises help prevent muscles from stiffening. Exercises to strengthen arm and leg muscles are also started. Endurance exercises may be needed. At first, exercises are done in bed, then in a chair. The person is encouraged to do standing and balancing exercises with parallel bars as soon as possible.

People who have decided to use an artificial leg are taught how to walk with the leg on. Walking begins with assistance from one or more therapists and progresses to walking between parallel bars to using a walker, then a cane. Therapists teach people to use stairs, walk up and down hills, and walk on other uneven surfaces.

After amputation of one leg below the knee, most older people who are fitted with an artificial leg can learn to walk without a cane. However, people who have had a leg amputated above the knee may not. Controlling an artificial leg with a knee joint requires more skill, strength, endurance, and energy than controlling one without a knee joint. Some artificial legs for amputations above the knee are controlled by a microcomputer, enabling a person to control movements more precisely. Walking with an artificial leg of either type is more tiring than walking with a natural leg.

Gaining weight should be avoided because added weight makes walking with an artificial leg more difficult and may affect the fit of the leg.

When both legs have been amputated—regardless of where—walking may be limited, and a wheelchair is sometimes needed.

The person's home usually needs some modification. For example, grab bars in the shower or a hoist over the tub may be needed. Sometimes a new living arrangement is needed. Driving is often possible, but a car may need to be modified.

Problems after amputation: Rehabilitation can help with problems that may occur. The most common problem is stump pain. Pain may be felt when the stump is touched or when the artificial leg is worn. The pain may have a visible source (such as a sore) or an internal source in the bone or nerves (such as an irregular projection of bone called a bone spur). Pain may also be caused by a poorly fitted artificial leg, swelling, or weight gain. When such problems occur, the therapist works closely with the prosthetist.

After amputation, many people have a feeling that the amputated leg is still there (called phantom limb sensation). Sometimes people feel a mild tingling where the leg was. The sensation is so real that they can sometimes describe the position of the foot. Sometimes, usually at night when waking up to use the bathroom, people try to stand up as if they had both legs, and they fall down. Phantom limb sensation may last several months or years but usually disappears without treatment. Frequently massaging the stump often helps.

Some people feel extreme pain in the amputated leg (called phantom limb pain). It may be more likely to occur when pain was present before amputation or was not controlled well during or after amputation. Exercising both legs and using an artificial leg help relieve the pain. Often, massaging the stump or using a vibrator or an ultrasound device also helps. Certain antidepressants (such as nortriptyline or desipramine) or anticonvulsants (such as gabapentin or carbamazepine) are sometimes helpful.

Many people feel loss and grief when they lose a body part. Getting support from family members and talking with a counselor may help with these feelings and with the lifestyle changes required after amputation.

Speech Disorders

Different types of speech therapy are used depending on the speech disorder.

Aphasia: Some people have difficulty using or understanding spoken or written language. Others completely lose the ability to do either. These people have aphasia. Aphasia often results from a stroke that damages the part of the brain that controls language.

The goal of therapy is to find the most effective way to communicate. For mild cases of aphasia, a speech therapist points to an object or picture, the person says what the object is, and the therapist nods to reinforce the person's efforts to communicate. For more severe cases, words are repeatedly spoken to the person. Also, objects are named and presented to the person. Being able to touch and see an object as well as to hear the name of an object can help the person relearn words.

Family members and caregivers of a person with aphasia need to be patient and appreciate the person's frustration. For example, they should not interrupt when the person is speaking slowly. They should encourage the person to speak (for example, by nodding). A person with aphasia may think normally. So using baby talk is inappropriate and can increase the person's frustration. Instead, family members and caregivers should speak in simple sentences and, if necessary, use gestures or point to objects. Asking questions that can be answered with "yes" or "no" can make communicating easier.

Dysarthria: Some people have difficulty physically forming words. They have dysarthria. People who have dysarthria produce sounds that approximate what they mean and that are in the correct order. Dysarthria is caused by damage to the nervous system (for example, by a stroke or by multiple sclerosis). The damage affects control of the muscles involved in speaking, including those of the lips, tongue, palate, and vocal cords and those used in breathing (which help with speaking).

Depending on the cause of dysarthria, the goal of therapy may be to restore and preserve speech or to maintain the ability to speak for as long as possible.

Speech therapists can retrain people to use the muscles involved in speaking and breathing. For mild cases of dysarthria, therapy may involve making different sounds or repeating sounds, words, or sentences. These exercises may help the person relearn how to use facial muscles and the tongue. The person may be taught to speak more slowly and to use shorter phrases. For severe cases, the person may need to communicate using a board with letters, words, or pictures (sometimes homemade) or a specially designed electronic communication device.

Verbal apraxia: Some people cannot initiate, coordinate, or sequence the muscle movements needed to talk. They have verbal apraxia. They randomly mispronounce words and seem to have forgotten how to make the sounds of language. Verbal apraxia is caused by damage to the nervous system (for example, by a stroke, a head injury, or brain surgery).

A speech therapist may ask the person to say sound patterns over and over again. Or a therapist may teach the person to use natural melodic patterns for common phrases. Usually, each phrase has a melody (the voice goes high and low in a pattern) and a rhythm. The speech therapist encourages the person to speak using an exaggerated melodic pattern and rhythm. As speech improves, the person can gradually speak with less exaggeration.

Blindness

For people whose vision is impaired or who become blind, rehabilitation includes learning new ways to do daily activities. For example, food is always arranged on the plate in the same places. Clothing, furniture, and other objects should be kept in the same place. People may learn how to use a cane to get from one place to another. A cane can also be used to check for objects in the way.

Sometimes people who are blind need guidance when walking. So family members and other caregivers are taught how to guide them. For example, caregivers are taught to have the blind person hold onto their arm and to lead the person, rather than hold onto the blind person's arm and try to push him one way or another.

Blind people may learn how to get around with a seeing eye dog and may learn Braille. Until they learn Braille, audio books can be used. Household items, such as stoves, microwaves, and cooking ingredients, can be labeled with tags written in Braille. Items specially designed for the blind, such as talking watches, may be useful.

Hearing Loss

Rehabilitation for people with hearing loss (partial or complete) includes learning to read lips and to use a hearing aid. People with hearing loss learn how to modulate their speaking volume because they tend to speak loudly. Audiologists can help people choose a hearing aid that suits their needs. They can recommend devices that are specially designed for the deaf, such as doorbells, telephones, and alarms that display a flashing light when they ring. Some people benefit from having a dog trained to respond to certain sounds and then alert them.