After the onset of a traumatic injury, the first course of treatment will be at the hospital. Imaging studies will examine the brain to look for trauma or dysfunction. A C.T. (computerized tomography) scan examines the brain structures. This imaging study will reveal an area of injury or dysfunction due to stroke or other brain injury. Other imaging studies that are typically performed include MRI (magnetic resonance imaging) and sometimes X-rays (radiographs) if there is suspicion of any fracture. The individual will receive care from nursing staff and physicians to ensure vital signs are stable and there is no risk of further injury or damage.
The main physician that will oversee the plan of care is the neurologist. Neurologists are physicians that specialize in the systems of the brain and nervous system. The neurologist will examine the function of the nervous system, identifying the area of damage to the brain and classifying extent of physical ramifications. Other physicians may be brought into the plan of care such as a cardiologist to oversee the monitoring of heart function, as well as a trauma doctor in case of brain injury occurrence. A physiatrist is a physician that specializes in rehabilitation. A physiatrist will oversee the care and progression during rehabilitation.
While in the hospital and at extended care, the patient will be cared for by nurses, nurse assistants, respiratory therapists, phlebotomists, nutritionists, case workers, psychologists, and (of course) physical, occupational and speech therapists. The three types of rehabilitation therapists have some overlapping roles, but three distinct specialties. The physical therapist specializes in functional movement training. The occupational therapist specializes in self-care training. The speech therapist specializes in speech and swallowing. Working with all three specialties is essential for rehabilitation progression.
During the recovery process, individuals are typically seen in a hospital setting, rehabilitation setting, home health setting and eventually outpatient clinic settings. The patient and family meet with a large number of healthcare providers for a comprehensive rehabilitation journey. Functional independence and safety are the main factors in determining where a patient will be placed after hospitalization.
Rehabilitation
During the hospital stay, the individual will begin his rehabilitation process. The licensed therapist will perform an initial evaluation to determine current functional limitations and impairments. The physical and occupational therapists will examine strength, sensory response, coordination, walking, and ability to move in and out of bed and chairs, as well as the ability to dress and handle personal care tasks.
The first task that the skilled therapist will teach and assist with is the ability to get up from lying down in bed. If the individual needs assistance, the therapist will provide that assistance and note how much assistance is needed. Then, the therapist will assess and instruct in moving from sitting to standing and getting up to sit in a chair. These tasks are called transfers. Standing balance and stability is assessed to determine level of independence and risk for falling. If there is a need for use of an assistive device for mobility, the therapist will instruct the individual in use of a walker, cane or wheelchair. The main goal of the rehabilitation in the hospital setting is to determine current level of dependence, teach basic skills for mobility (getting in and out of bed, walking), and set up the appropriate treatment course upon discharge from the hospital.
After the acute care stay at the hospital, which typically lasts less than one week, most individuals move to an inpatient rehabilitation setting or a skilled nursing facility. These facilities serve to provide care for the individual’s basic needs, such as getting in and out of bed, showering, dressing, nursing care and meals. In addition, the rehabilitation team will continue the care for teaching functional mobility training, as well as working to improve and restore balance and muscle strength. In the inpatient setting, the therapists help to order any necessary adaptive equipment, such as long handled reachers or ankle foot orthoses (AFOs). The stay in an inpatient setting can be anywhere from one week to several months. These facilities have nursing care, rehab care and visiting doctor oversight. The clients are provided with rooms (some private, some shared rooms) for sleeping and basic necessities. This setting serves as a transition point for individuals that need further care before return home. In addition, for individuals that are not able to return home, skilled nursing facilities offer long term care. In long term care, the individual is cared for by the skilled nursing team. This situation is for people that are dependent for basic needs, unable to care for themselves, and without others to care for them.
Outpatient physical therapy clinics are intended to continue rehabilitation after an individual has completed their initial rehabilitation stay after an injury or stroke. Typically, individuals attend outpatient therapy sessions 2or 3 days per week and complete their own exercises on non-therapy days. Outpatient therapy treatment cases are designed to further improve specific components of functional loss, and further improve safety with balance and mobility. Occupational therapy can be done in an outpatient setting, focusing on improving the use of the hand and upper extremity. In addition, outpatient occupational therapy works to improve self-care strategies. Speech therapy is often utilized in an outpatient setting to improve speech, articulation and swallowing.
Specific rehabilitation treatment approaches include:
- Constraint induced movement therapy: This form of therapy restricts the use of the unaffected limb, forcing the patient to use the weakened part of the body. The therapist applies a mitten or sling to the unaffected arm to prevent the patient from using it. This forces the patient to use the weaker arm to perform everyday tasks. This process helps to build muscle strength, and functional coordination. It has been shown to improve nerve function and elicit new neural pathways.
- Functional Electrical Stimulation: Electric stimulation of the musculature is performed in order to elicit muscle contraction and make them more stable. Electric stimulation is often done at the shoulder and at the lower leg in order to compensate for shoulder subluxation and foot drop respectively. In addition, electric stimulation can be utilized to elicit muscle contraction for any area of paresis. The goal is to build muscle strength through artificial stimulation, in hopes of regaining control and regaining strength.
- Motor imagery and mental practice: With the therapist, the patient imagines performing a simple task such as standing up or walking. The area of the brain that controls movement for that task is stimulated, yielding new neuronal pathways.
- Virtual reality: Computer generated games and virtual experiences are now being used to practice daily tasks or movements. This simulated environment allows the patient to experience normal movement virtually. This strategy is intended to build new neuronal connections that will carry over into real improvements.
- Partial body weight support treatment: For individuals with weakness impacting their lower legs and trunk strength, partial body weight supported training is an excellent way to improve quality and tolerance for standing and walking. The therapist utilizes a body weight support harness for the patient, gradually decreasing the amount of support and increasing the amount of weight bearing through the patient’s legs. This increases the physical demands of strength for the postural and leg muscles, as well as increases demands on balance. Partial body weight support can be combined with a treadmill to improve walking quality.
- Biofeedback: Biofeedback is a form of electrical therapy that is used to increase an individual’s awareness of muscle control and activation. The therapist places electrodes on the skin over the affected muscle. The electrodes sense the amount of muscle activation and this is displayed on a monitor. The therapist helps the patient to elicit and control muscle activation in hopes of regaining strength or regaining functional use of a muscle group.
- Positioning: Positioning is utilized throughout a patient’s care after a brain injury. Because of limited strength and use of limbs, positioning is essential for joint safety and to reduce likelihood of skin breakdown. Positioning reduces muscle spasm, stiffness and pain. In addition, positioning helps to reduce likelihood of contractures in joints as well as improve efficiency and quality of breathing. The therapist will educate the patient in proper positioning strategies.
- Passive range of motion: Passive range of motion is performed by a therapist on the affected limbs of the patient. After a brain injury, there is risk of developing stiff and rigid joints, which make any form of mobility very difficult. Passive range of motion helps to keep limbs limber and moving. It reduces pain and muscle spasm. Passive range of motion should be taught to caregivers in order to ensure carry over after completion of therapy.
- Strength training: The therapist will direct the patient through exercises to facilitate muscle contraction in the affected limbs. Depending on the strength presents, the patient may only be able to move a limb through partial range of motion, or move the limb fully against gravity and even with some resistance. The therapist will facilitate exercise to create strong muscle development and stimulate new motor control pathways.
- Neuromuscular re-education: This type of intervention focuses on retraining the control and response of the nervous and musculoskeletal system. Neuromuscular re-education focuses in improving balance, posture and coordination. This form of treatment allows for independent sitting posture, standing stability and the ability to reach for an object outside of the base of support. Of all the types of intervention, a significant amount is focused on neuromuscular re-education.
- Gait training: Gait refers to walking and ambulation. Depending on the extent of involvement in the legs, the individual will need to re-learn how to walk. The patient will utilize assistive devices, braces and external support. As strength and balance improve, many people are able to regain some functional walking.
- Wheelchair training: At some point after a stroke, most patients will utilize a wheelchair for at least a short duration. A wheelchair allows for safe mobility and significantly decreases fall risk. The wheelchair can be passively pushed by another person, but if wheelchair use is going to be long term, it is essential that the patient make an attempt to self-propel. There are many wheelchair styles, including motorized, tilt-in-space, and single arm drive chairs.
- Aquatic therapy: Aquatic therapy utilizes the properties of water to facilitate muscle strengthening, flexibility, balance and ease with walking. Buoyancy supports limb movement and water resistance builds strength.