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Patients suffering major trauma require an integrated  

interdisciplinary approach across the continuum of care from


early injury management to later community reintegration
and beyond to achieve the best outcome for quality of life
and independence. Rehabilitation commences on the first
day of injury and requires development of a good
understanding by all members of the treating team of the
person’s personality, lifestyle, interests and motivation, as
well as family situation and social support network.

Key points

• Rehabilitation commences on the first day of injury

Definitions

Rehabilitation is a process of restoration to achieve


maximum physical, social, psychological, vocational and
avocational functioning following injury or illness. As well as
primary restoration, rehabilitation also places a strong
emphasis on secondary prevention through identification of
the causative or risk factors and provision of education and
appropriate interventions to maintain future health and well-
being.
Rehabilitation after traumatic injury can be divided into four
overlapping phases.

i. Acute: Stabilization of injury with surgical and medical


management, early rehabilitative measures to prevent
secondary impairments and initial remobilization. (Acute
Hospital)

ii. Subacute: Comprehensive assessment and intensive


inpatient rehabilitation to enhance level of functional
independence and psychological adjustment, prescribe
appropriate prostheses, orthoses, aids and equipment and
assess necessary home modifications in anticipation of
discharge. (Rehabilitation Centre)

iii. Community: Resettlement into a safe independent living


environment with continuation of therapeutic input as an
outpatient to achieve patient’s optimum recovery and
potential. Also covers further education and retraining if
required, return to work and leisure pursuits. (Day Therapy /
Day Hospital / Outreach)

iv. Maintenance: Ongoing management of disability and


maintenance of support network. (Outpatient Clinics)

Developing a framework for rehabilitation requires an


understanding of some basic concepts (ICIDH-2 1997).
Impairment relates to the injury at the tissue level and the
body. In the case of a compound lower limb fracture a
possible impairment may be vascular insufficiency and
amputation of the limb. The resulting disability would cause a
limitation to activities at the level of the person. In this case
there would be a limitation to activities such as walking. This
limitation to activities would affect the person’s participation
in society. This would involve psychological aspects and
choices for work and leisure.

The team approach

The rehabilitation team must always recognize the


involvement of the patient and family as the key to
successful rehabilitation. Self implemented programs are
preferred as rehabilitation is an active rather than passive
process.

Consulting and participating members of the team include


the doctor, nurse, physiotherapist, occupational therapist,
social worker, speech pathologist, psychologist and
recreation therapist.

Key points

• The rehabilitation team must always recognize the


involvement of the patient and family as the key to
successful rehabilitation.

Rehabilitation planning

A problem list is prepared and goals set as part of a


rehabilitation plan.

The goals may be medical or therapy based and must be


negotiated with the patient to be achievable within a set time
frame. Regular case conferences and review of goals is
essential.

Rehabilitation plan checklist:

• Impairment/diagnosis

• Functional score (e.g., functional independence


measure or Barthel Index)

• Problem list

○ Medical/surgical

○ Physical and therapeutic

○ Functional

○ Psychosocial

○ Avocational

• Vocational

• Educational

• Rehabilitation goals

○ Problem oriented

○ Specific, achievable, time limited

○ Negotiated patient goals

• Review date

Components of rehabilitation

Measurement in rehabilitation

Functional

Rehabilitation and its progress can be monitored to assess


improvement and response to treatment. Although most
rehabilitation centres have developed local measures of
function, a number of activities of daily living (ADL) scales
have become internationally accepted.

These measures provide a useful checklist of basic functions


such as self-care, bladder control, bowel control, transfer,
locomotion, and assist the team in goal setting. They are
regularly reviewed at a case conference and provide a basis
for clinical decision making regarding treatment strategies
and care requirements. It is important to remember when
setting goals that performance may be influenced by
numerous factors other than impairment alone, including
adaptive equipment, suitable environment, social supports,
time and energy required, and safety.

A simple and reliable measure of activities of daily living is


the Barthel Index (Mahoney and Barthel 1965). Another more
sensitive ADL scale developed by the State University of
New York is the Functional Independence Measure (FIM)
(Keith et al. 1987). The FIM in addition records
communication as well as social cognition items. See
examples of data collection sheets (Tables 35.1 and 35.2).

Key points

• A number of activities of daily living (ADL) scales


have become internationally accepted (The Barthel
Index and the FIM).

Physical

Serial measures of muscle strength and recording on a


muscle chart will assist in monitoring the progress of
exercise programs. Grading of muscle strength from 0 to 5
has been widely accepted. Grading movement against slight,
moderate and strong resistance as 4, -4 and +4 is
sometimes a useful variation to the original scale (MRC
1976).

0 No contraction
1 Flicker or trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power
Measures of mobility such as the motor assessment score
add extra detail to the less sensitive FIM and Barthel index in
neurological disorders. Other tests of mobility may be very
simple such as a 6 metre (20 feet) walking speed or the
timed “up and go” (Posiadlo and Richardson 1991) test. In
this test the patient is observed as they rise from an armchair
and walk 3 metres, turn, walk back and sit down again.

Checking and recording the range of motion (ROM) at hip for


patients in bed requires flexing of the contralateral hip and
straightening the lumbar spine (Thomas test). Assessment of
ROM at the knee and ankle should also be routine for non-
ambulant patients.

Cognitive

Traumatic head injury is often associated with impaired


cognition. This can be initially assessed on admission by the
Glasgow Coma Scale (GCS) (Teasdale and Jennett 1974)
(Table 35.3). However, patients with a GCS score of 15/15
may still have significantly impaired cognition and be
suffering Post Traumatic Amnesia (PTA) (Table 35.4).
Monitoring the period of PTA in which the injured person has
no reliable short term memory and particularly recovery from
PTA is extremely valuable in the management of a head
injured patient. Once a patient is capable of remembering
from one day to the next, then they can actively participate in
a rehabilitation program. A scale which is easily applied is the
Westmead Post Traumatic Amnesia Scale (Shores et al.
1986) (Table 35.4).

Basic screening tests of cognitive function such as the Mini-


Mental State Examination (Folstein et al. 1975) (Table 35.5)
test orientation, short and long-term memory and language.
It is essential to establish rapport and leave the patient
relaxed and comfortable. The patient must have adequate
hearing and vision to respond to questions. This is only a
screening instrument for cognitive dysfunction. A low score of
<24 indicates a need for more detailed evaluation rather than
establishing a diagnosis of permanent cognitive impairment.

More detailed neuropsychological assessment must be


performed by a neuropsychologist. A variety of scales and
batteries are available to examine a wide range of cognitive
abilities, including concentration, attention, planning, problem
solving, judgement and other executive functions. Tests of
learning use diagrams such as the Rey-Ostereith Complex
Figure, card sorting, mazes and trail making tests. Standard
texts contain more detailed explanations (Deutsch 1995).
Results from such tests prove most helpful when determining
issues such as a patient’s competency to handle financial
affairs, ability to safely drive a motor vehicle or return to work
and may assist choices for employment.

Key points

• Traumatic head injury is often associated with


impaired cognition

Passive physical modalities

Heat, cold and electricity are adjuvants to active physical


therapy. There effects are only short term. A knowledge of
the risks and benefits may add substantially to the safe
design of a rehabilitation program.

Heat

Superficial heat can be applied by conduction such as a hot


pack, radiant heat or paraffin bath, or by convection as
occurs in hydrotherapy or moist air (sauna). Conversion of
non-thermal to thermal energy occurs in deep heat
modalities such as microwave and ultrasound.

Contraindications to the application of heat includes:

• Acute trauma, haemorrhage and oedema.

• Anaesethic areas where burns may occur.

• Vascular insufficiency particularly feet and hands.

• Bleeding disorders.

• Sepsis

• Unreliable or cognitively impaired patient.

• Pregnancy.

• In the region of the gonads.


• Altered thermoregulation (precaution depending on
modality).

Benefits to the application of heat include:

• Increase extensibility of collagen, aiding stretching


of ligaments and musculo-tendinous unit.

• Decrease in joint stiffness.

• Decrease pain.

• Decrease muscle spasm by an effect on the muscle


spindle.

• Increase of superficial blood flow through arteriolar


and capillary dilatation.

• Increase tissue metabolism.

• Consensual response in opposite limb or deeper


structures.

• Psychological benefits.

Recommended selective heating of skin and subcutaneous


tissues should be within the therapeutic range of 40-45
degrees C for no longer than 30 minutes. Prolonged heating
should be avoided as core temperature will eventually rise.

Applications of heat that are commonly used:

• Hot packs, hydrocollator and Kenny Packs. Usually


applied wrapped in towelling for ten minutes
repeated 2 - 3 times.

• Infra-red lamps provide superficial heating only and


carry the risk of superficial burns.

• Paraffin baths or wax baths consist of heated


melted mixtures of oil (usually one part mineral oil to
6 or 7 parts paraffin wax). It can be applied to the
skin despite the high temperature of 52 degrees C
because of the low specific heat. Application is by
dipping 3 to 4 times and wrapping in a towel, or by
brushing or immersion. Specific contraindications
are open wounds. It is specifically used for joint
stiffness and for mobilization after hand trauma.
• Contrast baths consist of alternate immersion in hot
(40-43 degrees C) and cold water (15-18 degrees
C) for 4 cycles of 4-min and 1-min durations
respectively, ending in hot water. This produces a
hyperaemia and maybe useful in regional pain
management.

• Ultrasound produces high frequency sound above


the audible range (0.8-1.0 MHz) causing heating at
the interface between tissues of differing density,
typically at fascial planes and bone. Ultrasound is
produced by a piezoelectric transducer in the
applicator or head of the machine. The intensity
may vary from 0.5-2 W/ cm2 area applied for 5-10
minutes duration. The head is applied to the skin
with a coupling medium of gel or water if the treated
part is submerged. This medium is necessary to
provide efficient energy transmission. Whilst non-
thermal effects may be beneficial in certain
situations those arising from gaseous cavitation,
caused by alternating compression and rarefaction
where gas bubbles form, may have a destructive
effect on tissues. To avoid overheating of tissues
and gaseous cavitation, ultrasound should never be
applied over large fluid filled areas such as the
eyeball, amniotic sack or larger effusions.
Ultrasound should also not be applied over nerve
roots following laminectomy, implants or devices,
and epiphysis in growing children. The transducer
head is continually moved with a stroking technique
by the operator to avoid local damage.

• Hydrotherapy in heated pools and spas allows a


patient to exercise in a non or partial weight bearing
environment. This is particularly useful in the
rehabilitation of lower limb fractures. Pool
temperatures vary from around 28 degrees C for
recreational activities to 31 degrees C for
therapeutic sessions of less than 30 minutes.

Cold therapy (cryotherapy)


Cold therapy is used for a variety of acute ligament and
muscle trauma and superficial burns and analgesia. The
benefits are:

• Reduction of swelling and bleeding by


vasoconstriction.

• Pain reduction by slowing nerve conduction in


peripheral nerve fibres.

• Muscle relaxation by reducing muscle spindle


activity.

Contraindications to the application of cold includes:

• Peripheral vascular disease, Raynauds


phenomenon/disease.

• Anaesethic areas where cold burns may occur.

• Severe cardiovascular disease (pressor response if


large area).

Application of ice for cooling deep tissues may be as:

• crushed ice in plastic bag

• ice with dry towel

• ice via wet towels

• immersion in iced water with or without movement

• gel pack

The cooling medium should be kept in close contact with the


treated area. It is best to bandage the bag of ice or gel pack
onto the limb. The period of application will depend on the
thickness of subcutaneous fat. Ice packs are usually applied
for 15 - 20 minutes 3 - 4 times daily for the first 48 - 72 hours
following injury. If acute trauma is being treated, cold is
usually combined with compressive bandaging and elevation
using RICE regime - Rest, Ice, Compression, Elevation
(Johannsen and Langberg 1997).

Key points
• It is best to bandage the bag of ice or gel pack onto
the limb.

Electrical therapy

Laser

Low intensity laser can non-destructively alter cellular


function without significant heating. It is used affects muscle
skelation and soft tissue conditioning (Basford 1993).

TENS

Direct application of electricity to the strain has been used to


relieve acute and chronic pain. Two or four electrodes are
applied in the pain related segment with a frequency of fren
75-100H3 for over 20 minutes. Narcotic analyses should be
ceased while therapy is trialled. Contraindictions include:

• Cardiac pacemaker

• Cardiac disease or arrythmias

• Pregnancy

• Larynx/Pharynx/eye

Active physical therapy

Following major injury or illness, in addition to the directly


related impairments to neurological, musculoskeletal and
cardiovascular systems, prolonged bed rest and immobility
leads to deconditioning with reduction in strength, endurance
and fitness. Physical therapy and exercise aims to increase
range of motion, muscle strength and endurance, improve
balance, motor control and coordination, teach important
functional skills and upgrade physical fitness to enhance
overall performance and independence.

Broadly, therapeutic exercise can be divided into the


following components:

• Strengthening and endurance

• Stretching
• Balancing, motor control and coordination

• Cardiovascular fitness

Strengthening and endurance

The principle generally used in strength training of “overload”


is not entirely applicable to major trauma without judicious
modification of program to avoid producing further injury or
delaying healing whilst promoting progressive physiological
and psychological adaptation.

Exercise prescription entails specification of the following:

• Type of exercise

• Intensity

• Number of repetitions and sets

• Recovery interval

Traditionally, different guidelines have been used for muscle


strengthening (high resistance, low repetitions) and training
endurance (low resistance, high repetitions), although there
are crossover effects. Exercises may be performed either
concentrically or eccentrically, with the former more usual
early after traumatic injury.

The different types of exercise used for muscle strengthening


and training endurance are:

• Isometric

• Isotonic

• Isokinetic

Isometric exercises contracting muscles without joint


movement can be used when joint motion is painful or
contraindicated, but are of limited value due to angle
specificity. A maximal contraction is held for 5-secs with 5-10
repetitions. Care must be taken with individuals with a high
resting blood pressure or underlying cardiovascular disease
due to pressor response.

Isotonic exercises are the most commonly used during


rehabilitation after serious injury. As already mentioned, the
exercise program should be customized to the clinical
situation, carefully monitored and progressively upgraded as
possible. An arbitrary starting intensity must be chosen, for
example 3 sets of 10-15 repetitions at 40-65% of 1 repetition
maximum (RM). This endurance type of program
(low/medium resistance, low/medium repetitions) allows
patient to become familiar with exercises and provides a
stimulus to improve motor unit recruitment. The range
provided allows some flexibility and ability to progressively
upgrade program. When muscle strength in particular is a
limiting factor (e.g.. to lift body weight against gravity to
transfer independently) a predominant strength program, for
example 1 set of 6-8 reps at 85-100% of 1 RM, may be used.
Care must be taken when prescribing exercises not to
generate excessive torsional forces around injured joints and
bones.

Isokinetic exercise using a dynamometer such as Orthoton,


Cybex or Kincom allows maximum tension to be safely
exerted throughout complete range of movement, but is
generally only used for rehabilitation after traumatic injury to
larger joints, e.g. knee.

As strength and endurance improve in individual muscle


groups, the exercise program will progressively incorporate
more functional activities involving combined patterns of
movement.

Flexibility

Extended periods of bed rest and non weight bearing will


result in muscle shortening and contracture. This is most
common at the hip, knee and ankle. Maintenance stretching
regimes range from 30 to 60 seconds, 3 repetitions twice
daily. Self implemented slow stretch and techniques
progressing to the level of discomfort can be demonstrated
to the patient (Fig 35.1) (Sherry and Wilson 1998). Ballistic
(bouncing) exercises should be avoided due to the risk of
muscle tears.

In established contractures longer and more frequent


stretching is required to restore muscle length. These
passive techniques should be administered by a
physiotherapist. Passive stretching may be combined with
the use of mechanical devices and serial splinting.

Proprioception

Ligaments, tendons and joints are involved in determining


position sense of limbs. Rehabilitation for damage to these
structures should include retraining for balance and co-
ordination. Supervised balance exercises on one or two legs
involve distractions of visual cues, e.g. blindfolding bouncing
or throwing balls. The patient progresses form static to
dynamic exercises to mobility on flat and rough or undulating
surfaces or a moving surface (wobble board). Proprioception
may be temporarily enhanced by use of taping around joints
due to increased sensory input.

Cardiovascular fitness

Exercise prescription for cardiovascular conditioning entails


specification of the following:

• Type of exercise

• Frequency

• Intensity

• Duration

• Program length

• Interval/rest interval (if continuous exercise not


possible)

The type of exercise prescribed (e.g.. cycling, arm


ergometry) will depend to some extent on clinical situation. A
frequency of 3-4 times/week is usually recommended.
Intensity must be adjusted to 40-70% of heart rate reserve
(HRR). HRR is calculated by subtracting resting heart rate
(HR) from age predicted or observed peak HR. Standard
formulas to determine maximum HR (e.g.. 220-age) are not
reliable when significantly impaired and deconditioned after
injury. Under these circumstances, peak HR is best
determined using a progressive stress test (e.g.. cycling, arm
ergometry). Exercise duration should be a minimum of 20
minutes lasting up to 40 minutes. A program should run for a
minimum of 8 weeks to receive a benefit. If someone is
unable to perform continuous exercise for at least 20
minutes, then interval training can be used instead. Exercise
for a period of 5-7 minutes is undertaken followed by a rest
interval of half the exercise time or when HRR drops below
40%. Like other therapies, an individually tailored program
can be provided by consultation with an exercise specialist.

Key points

• The principle generally used in strength training of


“overload” is not entirely applicable to major trauma

• The type of exercise prescribed (e.g.. cycling, arm


ergometry) will depend to some extent on clinical
situation

Checklist for major injury

Reflex sympathetic dystrophy (also known as complex


regional pain syndrome, type 1)

This is covered in Chapter 13(page 00)

Rehabilitation after amputation

Overview

Amputations due to trauma have been reported as


accounting for over 20% of all amputations (Goldberg 1985).
This percentage is dropping in developed countries due to
better road safety, industrial standards and advances in
replantation surgery (Ebskov 1992).

The causes for traumatic amputation in developing countries


are quite different. In India train accidents are a frequent
cause with war and unexploded landmines contributing to the
problem in Africa and South East Asia. Estimations for
traumatic amputation are as high as 1 amputee per 256
people in Cambodia and 1 per 470 in Angola. These show a
marked contrast to 1 per 22,000 people in the USA (Staats
1992).

Lower limb trauma is a far more frequent cause for


amputation than upper limb with a ratio of approximately 11
to 1. Overall figures (from all causes) for amputation levels
reflect the trend to preservation of the knee for
proprioception input and length for biomechanical efficiency.
Published figures show: Above knee 38%, below knee 54%,
through knee/Gritti-Stokes 6%, Symes (through ankle) 1%,
forefoot 1% (Lisfranc, Pirigoff, Chopart) (Fyfe 1990).

Key points

• Amputations due to trauma have been reported as


accounting for over 20% of all amputations

Key issues in the rehabilitation of the lower limb amputee

• Surgery

Preservation of limb length has implications for prosthetic


fitting and the eventual energy cost of ambulation. Increased
energy costs of ambulation are reflected in the comfortable
walking speed (CWS) of amputees compared to normal. A
study of traumatic amputees demonstrated a velocity of 87%
of normal at the below knee level and 63% at the above knee
level when using a prosthesis. There is an even greater effort
required when using crutches (Waters et al. 1976).

Balance and stability of joints of the required residual limb


will result in better prosthetic outcome and activity for the
amputee in above knee transfemoral amputees. This is
achieved by myodesis of the adductor magnus to the
remaining femur. In transtibial amputation the musculo-
tendinous portion of the gastrocnemius is tethered to the
anterior distal tibia as a posterior flap. It is desirable to
achieve skin closure without tension (Bowker and Michael
1992).

Key points

• Preservation of limb length has implications for


prosthetic fitting
• Stump Care

Early amputation stump management is essential as a


means of hastening prosthetic rehabilitation. A variety of
methods are used post-operatively with the same intention.

• Rapid resolution of stumpoedena

• Prevention of stump fibrosis

• Promotion of would healing

• Wound protection

• Desensitisation and pain management

• Reduction of infection

• Early mobilization and weight bearing

• Muscle strengthening and stability

• Anti-contracture treatment

Key points

• Early amputation stump management is essential

The following techniques are currently in use:

1. The non removable rigid dressing is applied in the


operating theatre and maintained until removal of
sutures at about 2 weeks post-operative (Jones and
Burniston 1970). The advantages are early (7-14
days) weight bearing through the plaster of Paris
dressing and early mobilization with a temporary
prosthesis applied at the end of week two to three
post-operative when the dressing is removed. The
reason that this technique is used in only 8% of
centres in the USA is due to the need to access for
inspection of the surgical incision.

2. The removable rigid dressing can be applied post-


operatively and used continuously until a temporary
or definitive prosthesis is fitted (Yeongehi and Krick
1987). The advantages are that the wound may be
inspected as required and stump socks may be
applied as the stump shrinks. The additional use of
a supporting strap allows patients to perform
quadriceps exercise, anti-contracture and
antioedema movement while sitting in a wheelchair
(Hughes et al. 1998).

3. Elastic bandaging stockingette and support


stockings (shrinkers) are the most commonly used
techniques. Stump compression may commence
within 1 to 3 days post-operatively depending on
wound condition and pain tolerance. Bandaging
techniques should provide more distal than proximal
compression. Correct bandaging and avoidance of
a tourniquet effect is essential. Stump compression
with bandaging or stocking usually continues for 12
to 18 months post-operatively at times when the
prosthesis is not in use.

• Contractures

Contractures at the hip and knee form quickly with the loss of
the limb as a lever. An anticontracture program should start
within the first post-operative week. This program involves
lying prone for 30 minutes twice daily to encourage extension
at the hip. Knee exercises involve 10 second isometric
quadriceps exercises 10 repetitions every hour. An extension
stump board should be attached to the wheelchair for below
knee amputees.

• Mobilization

Mobilization should occur as soon as tolerated. Partial weight


transference through a rigid dressing should be attempted
after the first post-operative week with full weight bearing as
tolerated after sutures are removed. After the third week an
interim prosthesis should be considered to commence gait
training. The choices are either a polypropylene patellor
tendon bearing socket for the below knee amputee or a
quadrelateral ischial weight bearing socket for the above
knee amputee. Modular aluminium tubing shanks or pylons
with solid ankle cushion healed (SACH) feet are commonly
used and in the above knee amputee a single axis semi
locking safety knee may be fitted. Due to the need for socket
changes over the first weeks to months some centres use
other alternatives until fitting of the definitive prosthesis.
Sockets for interim prostheses may be fabricated in Plaster
of Paris, or a variety of resin wraps. Pneumatic weight
bearing temporary prostheses utilize an air splint inflated
around the stump and enclosed in a metal frame (Little
1971). They have been used from day 6 post-operatively and
as with other interim methods aid in reduction of oedema,
maturation and shaping of the above or below knee stump
(Redhead 1978).

• Pain management

Pain management should occur post-operatively to reduce


the incidence of Phantom pain post-operatively. Post-
operative pain relief may be achieved by narcotic analgesics,
spinal anaesthesia or local anaesthetic infusions into
sensory nerves. Narcotic analgesics and other methods
usually cease by day 5 to 7 when simple analgesia i.e.
paracetamol is adequate for treating stump and wound pain.
Phantom sensation occurs in nearly all patients. Phantom
pain often commences as stump pain subsides in the second
or third post-operative week. The pain may be episodic and
stabbing or of a constant and burning nature. Adequate
stump compression bandaging, massage, physical and
diversional therapy may be useful in the daytime. Often the
pain is worse at night with the patient finding difficulty
sleeping. Simple analgesics with an adjuvant medication
may assist sleeping and reduce phantom pain. Medications
often used are tricyclic antidepressants such as Amytriptylin
and Doxepin. Sometimes an anti-epileptic medication is
added or used as an alternative e.g.. Carbamazepine
Transcutaneous electrical nerve simulation (TENS) has been
reported to reduce pain when applied to the amputation
stump or on the contralateral limb (Carabelli 1985).

• Psychological adaptation

Psychological adaptation to the loss of a limb is associated


with grief and mourning (Elberlik 1980, Furst and Humphrey
1983). The phases of denial, anger, depression and
acceptance may continue over months or years following
amputation. There is a functional impairment which can be
compensated for by fitting of a prosthesis. This is not always
accompanied by an adjustment of body image. Counselling
with patients and family adjustment to disability, body image
and roles in the family and society is integral to the
rehabilitation process. Relaxation and pain coping
techniques are useful skills.

Rehabilitation of traumatic spinal cord injury

Overview

Traumatic spinal cord injury (SCI) has an incidence of


approximately 15-30 per million population. Young males
between 16-30 years of age are at greatest risk, with motor
vehicle-related injury the most common cause, followed by
falls, sporting/recreational accidents, and violence in some
countries (Go et al. 1995). Improved survival following injury
has resulted from better roadside resuscitation, rapid
retrieval to specialized trauma centres and intensive medical
care. Likewise, advances in rehabilitation and management
of complications following SCI, as well as long-term medical
follow up by dedicated spinal cord injury specialists have
lead to improved life expectancy and quality of life for
individuals with SCI.

Key rehabilitation issues

Successful rehabilitation following severe SCI involves not


only developing as much functional independence as
possible through physical training, adaptive techniques and
specialized aids (Fig 35.1), but also adjusting to disability
and ultimately reestablishing a fulfilling lifestyle in the
community with satisfying roles and interests. Intensive,
interdisciplinary rehabilitation as an inpatient provides the
initial stepping stones for reintegration into the community,
but in many ways rehabilitation only really begins once the
person has returned home.

The purpose of this section is not to provide a


comprehensive coverage of all aspects of rehabilitation after
SCI, but rather to highlight some key issues and the
importance of early rehabilitation to prevent complications
and achieve the best functional outcome.

• Skin

After SCI patients are at great risk of developing skin


complications due to factors such as immobility, loss of
protective sensation, weight loss and altered tissue viability.
The injured patient should be transferred off the spinal board
immediately on arrival in hospital and skin over entire body
including the back must be inspected for evidence of injury or
pressure as soon as possible (Mawson et al. 1988).
Nutritional status must be closely monitored with the aid of a
dietitian and enteral or parenteral nutrition considered early
to avoid later complications of altered body composition such
as decubitus ulceration secondary to poor coverage of bony
points.

Patients should be managed on an appropriate mattress,


such as a convoluted foam mattress initially and later a ripple
mattress, and must be turned or lifted and repositioned every
2 hours by a team of four trained staff with the skin checked.
Sheep skins may also prove helpful. Particular attention must
be given to areas at greater risk overlying any bony
prominence, such as the sacrum and heels when lying
supine or greater trochanter, medial aspect of knee and
lateral malleolus if on side.

Essential to avoid pressure problems in the longer term


include the following:

• Appropriate prescription of equipment such as


mattress overlay, commode chair or toilet seat
cover and pressure relieving cushion for wheelchair
(such as air floatation, gel or cut-out foam design)

• Regular pressure relief when sitting by lifting,


leaning forward or to one side, or tilting motorised
wheelchair in space for 15-30 seconds 2-3
times/hour

• Self-inspection of skin (with assistance if necessary)


using a mirror to monitor for pressure marks twice
daily

Key points

• After SCI patients are at great risk of developing


skin complications

• Pain
Pain frequently accompanies SCI and can significantly
impact upon a person's functional ability, ability to return to
work, psychological well-being and quality of life. At present
there are no clear links between acute pain management
and longer term outcomes. However, there is some evidence
emerging from studies in other areas such as phantom limb
pain after amputation to suggest that early treatment may be
helpful for preventing later development of chronic pain. Pain
should therefore be vigorously treated during the acute
period. Patients are more likely to be actively involved in
rehabilitation when pain is adequately controlled.

The most important issue in the treatment of pain is to


correctly classify the type of pain, which most commonly is
either musculoskeletal or neuropathic (Siddall et al. 1997).
Classification is crucial in terms of determining the
appropriate treatment. As with other types of acute
musculoskeletal pain, opioids are effective. In contrast, the
management of neuropathic pain remains difficult. There are
currently no available treatments that consistently and
effectively alleviate this problem. However, there are a
number of treatments in current use (Siddall et al. 1998).

In the acute phase, local anaesthetics such as lignocaine


administered subcutaneously or intravenously may be useful
and if effective followed by mexiletine orally. Anecdotally,
ketamine infusion has also been described, although side-
effects may be limiting. With chronic pain, a tricyclic
antidepressant such as amitriptyline alone or in combination
with an anticonvulsant such as carbamazepine or sodium
valproate are commonly used. More recently, anecdotal
reports suggest the effectiveness of Gabapentin in treating
intractable neuropathic pain.

Other techniques which have proved helpful in some cases


include anaesthetic blockade at various levels, namely
sympathetic, epidural or spinal blockades, and intrathecal
administration of baclofen, clonidine and morphine via an
implanted pump.

Physical treatments including exercise and hydrotherapy


programmes, postural reeducation, wheelchair and seating
adjustments and possibly other physical modalities are often
helpful in managing pain resulting from a mechanical cause.
It should never be forgotten that pain is a complex
phenomenon and that emotional, behavioural and
environmental factors may contribute to the experience of
pain. Therefore, attention should always be paid to
psychological factors and the use of cognitive-behavioural
techniques and strategies such as relaxation and distraction.

Key points

• Correctly classify the type of pain

• Positioning and contracture prevention

Contractures may develop as the result of immobilization and


poor positioning, spasticity, or muscle imbalance around a
joint and interfere with later rehabilitation. During the acute
phase, it is important to ensure that all joints are correctly
positioned, rested in mid-position of function and regularly
moved passively through a full range of motion at least once
daily.

Problems due to shortening of shoulder capsule can be


prevented by daily positioning of shoulders in abduction and
external rotation, the crucifix position. Foot drop can be
prevented with a pillow or bolster at the foot of bed
maintaining ankle in neutral position.

In the individual with C5 or partial C6 tetraplegia without


antigravity strength wrist extension, splinting of fingers and
hand at rest with a long opponens wrist-hand orthosis is
used to maintain wrist in 15-30º extension, metacarpo-
phalangeal (MCP) joints in 60º and thumb in abduction.
Particular attention in the tetraplegic hand must be given to
prevention of clawing (intrinsic-minus hand posture) and
MCP joint, proximal interphalangeal joint (apart from
functional finger flexor tightness for tenodesis) and thumb
adduction contractures. Presence of such contractures can
ultimately limit effectiveness of tenodesis grasp (natural
finger flexion with wrist extension), use of a wrist-driven
flexor-hinge splint and potential for later tendon-transfer
surgery (Keith and Lacey 1991).

• Spasticity

Spasticity is a common problem in SCI patients with upper


motor neurone lesions after spinal shock and tends to
increase in severity during the first few months after injury.
Severe spasticity during the early phase after injury may
exacerbate pain, predispose to pressure sores and
contribute to development of contractures. Spasticity which is
evident early and very pronounced or not symmetrical may
indicate an incomplete lesion.

Treatment should usually be instituted if spasticity interferes


with functional independence, endangers safety when
transferring, causes pain or places skin at risk from shearing.
Management is normally approached using a hierarchical
model of care, beginning with the simplest and least invasive
measures and progressing to more invasive methods as
required (Merritt 1981).

When the degree of spasticity increases significantly without


obvious explanation, consideration must always be given to
looking for aggravating factors such as:

• urinary tract infection

• renal or bladder calculi

• constipation

• skin ulceration

• ingrown toe nails

• less commonly, intra-abdominal or pelvic problems.

Key points

• Spasticity is a common problem in SCI patients

Regular stretching is important to maintain muscle length,


particularly hip flexes and plantar flexes. Medications
commonly used include baclofen (10-25mg qid) and
diazepam (5-7.5mg tds or qid). Other medications used less
commonly include dantrolene sodium and clonidine. Motor
point injections with botulinum toxin, phenol or alcohol or
more definitive surgical approaches such as tendon
lengthening, tenotomy and/or neurectomy may be used for
localised spasticity, whilst intrathecal management (Penn et
al. 1989) with baclofen may be used for more difficult
generalised spasticity. Surgical techniques such as
rhizotomies, myelotomies and cordotomies are rarely if ever
indicated.

• The neurogenic bladder

Overdistension of the neurogenic bladder during the acute


period should be avoided until after the post-injury diuresis
has occurred by indwelling urethral catheter or percutaneous
suprapubic drainage (eg. "Cystocath") on continuous
drainage. Catheter clamping for 2 hours twice daily may help
to maintain bladder capacity and compliance. After this
period, regular intermittent catheterisation by an attendant
may be commenced with appropriate fluid restriction.

Choice of definitive bladder management will be influenced


by factors such as:

• type of bladder impairment

• functional ability (particularly mobility, sitting


balance and hand function)

• patient’s motivation and lifestyle

The types of bladder impairment occurring after SCI may be


classified as:

• suprasacral or reflex (upper motor neurone type)

• infrasacral or acontractile (lower motor neurone


type)

• mixed (conus lesions)

It is important to remember that different underlying


impairments may lead to similar outward appearance of
bladder dysfunction, eg. detrusor hyperreflexia, poor bladder
compliance or bladder neck insufficiency all cause storage
failure, while similarly detrusor-sphincter dyssynergia (DSD),
acontractile bladder or myogenic insufficiency from chronic
overdistension may cause voiding failure (Wein 1981).
Common clinical presentations of DSD include high residuals
and recurrent urinary tract infections, autonomic dysreflexia
on voiding, increased spasticity, posture related difficulty
voiding and upper tract deterioration. Urodynamic
assessment (cystometry/anal sphincter EMG or x-ray video-
cystography) is performed after passage of spinal shock to
help to classify bladder type (Watanabe et al. 1996).

Goals for bladder management include:

• protecting upper urinary tracts from sustained high


pressure (<40cm H20)

• minimising post-void residual volumes (ideally


<50mls)

• preventing urinary tract infections

• ensuring social continence

In both male and female patients with paraplegia or males


with tetraplegia and sufficient hand function, clean
intermittent self-catheterisation (CISC) every 4-6 hours with
anticholinergic medication such as oxybutynin hydrochloride
(5mg tds) or propantheline bromide (15-30mg tds or qid) to
relax bladder is the preferred method.

In males with tetraplegia and insufficient hand to perform


CISC, drainage by reflex voiding with tapping, Valsalva or
Crede manoeuvre using an external collection device or
indwelling urethral or suprapubic catheter is possible. If
employing bladder training to achieve balanced reflex
voiding, use of short-term cholinergic medication such as
bethanecol (10-20mg tds) to enhance detrusor tone with an
alpha adrenergic blocker such as phenoxybenzamine (10mg
tds) to reduce internal sphincter spasm is frequently
required. In addition, a sphincterotomy or urethral wall stent
may also be required to help manage DSD. Urinary
antiseptic medications to lower pH of urine such as hippuric
acid and vitamin C or cranberry juice/tablets, which in
addition appears to inhibit bacterial adhesion, are often
prescribed particularly in patients using reflex emptying or
CISC. In female tetraplegic patients due to greater difficulty,
either suprapubic or indwelling urethral catheter is most
common.

Urinary tract calculi are a common complication that should


be suspected when difficulty clearing or recurrent urinary
tract infections with the same or different organisms,
particularly urea-splitting Proteus. These will require removal
by lithopaxy, lithotripsy or rarely open methods.

Regular follow-up by ultrasound examination or intravenous


pyelogram every 2 years unless indicated more frequently
because of previous abnormal study is recommended,
particularly in those patients using reflex voiding/expression
techniques to monitor for early signs of
hydroureter/hydronephrosis (Staskin 1991).

Key points

• Overdistension of the neurogenic bladder during the


acute period should be avoided

• The neurogenic bowel

Patients should be kept nil by mouth initially until bowel


sounds return. A nasogastric tube is required to decompress
the stomach and reduce abdominal distension until ileus
resolves to prevent vomiting and risk of aspiration as well as
respiratory compromise due to diaphragmatic splinting. H2
receptor antagonists should be used to combat low pH and
stress ulceration. Initially, the neurogenic bowel is emptied
with assistance by an attendant, usually daily. Later bowel
management (Banwell et al. 1993, Steins et al. 1997) will
involve:

• developing a regular bowel routine (daily or 2nd


daily)

• adequate fluid intake (approx. 2000mls/day)

• healthy eating habits with a well balanced diet high


in fibre, such as from whole grain breads, cereals,
fruits and vegetables

• stool bulking agents such as psyllium and softening


agents such as dioctyl sodium sulphosuccinate
(commonly used to increase water content and
volume of stool, soften and regulate stool
consistency, and promote intestinal evacuation)

• avoidance of irritant laxatives such as senna and


bisacodyl if possible (these may be used in the
short-term to help establish a satisfactory bowel
program, but are best avoided in the longer term
due to unpredictability of results, tolerance and
potential long-term side effects)

• bowel emptying timed 20-30 minutes after a meal


(to utilise gastrocolic reflex)

• rectal emptying achieved using an enema,


suppositories, digital stimulation and/or manual
evacuation; the latter being particularly helpful in
lower motor neurone type bowel dysfunction.

• Psychological issues

The reality of a sudden traumatic SCI with the inherent


disbelief, fear, sadness and uncertainty about the future
places enormous stress both on the injured individual and
family. In this setting, anxiety and depression are common
following SCI (Craig et al. 1994). Post-traumatic stress
disorder may also occur early after injury in which the injured
individual re-experiences the traumatic event with distressing
flashbacks or nightmares often associated with a variety of
physical symptoms and increased arousal (APA 1994).

Whilst in the past perhaps insufficient attention has been


paid to psycho-social assessment and adjustment following
injury, their importance to the overall success of rehabilitation
(Trieschmann 1988) and the value of specific interventions
such as cognitive-behavioural therapy are now well
recognized (Craig 1997). The very specialized area of
psycho-social rehabilitation following SCI requires intensive
and coordinated input from an experienced psychologist and
social worker.

Key points

• The reality of a sudden traumatic SCI with the


inherent disbelief, fear, sadness and uncertainty
about the future places enormous stress both on
the injured individual and family

• Fertility
Infertility is common in males following SCI due to
anejaculation and/or poor semen quality. Since the majority
of spinal injuries occur to young, single males this is an
important issue. Two methods of semen retrieval are
commonly used, namely vibroejaculation and
electroejaculation (Linsenmeyer 1993). Vibroejaculation is
the most frequently used method in patients with lesions
above T11 level. However, electroejaculation may be used in
acute phase for collection of semen, when vibroejaculation
will be unsuccessful in the presence of spinal shock (Mallidis
et al. 1994). When this technique is performed within 7-10
days after injury, semen quality is usually normal and can be
cryopreserved for future use. Problems with reduced sperm
quality later can be overcome using assisted reproductive
technologies, such as in vitro fertilisation (IVF) and
micromanipulation techniques (Linsenmeyer 1993).

Key points

• Infertility is common in males following SCI

• Autonomic dysreflexia (hyperreflexia)

This condition is peculiar to individuals with SCI above the


splanchnic outflow (lesion generally above the T6 level) and
is the result of dissociation from higher centres. A triggering
sensory stimulus initiates excessive reflex activity of the
sympathetic nervous system below the level of injury,
causing vasoconstriction and a rapid rise in blood pressure,
which is uncontrolled due to isolation from the normal
regulatory response of vasomotor centres in the brain.
Parasympathetic activity occurs when the rise in blood
pressure is sensed by baroreceptors in the aortic arch and
carotid bodies resulting in compensatory slowing of the heart
and dilatation of blood vessels above the level of injury. If not
recognized or treated promptly the blood pressure may rise
to dangerously high levels and precipitate intracranial
haemorrhage, seizures or a cardiac arrhythmia (Colachis
1992, Braddom and Rocco 1991).

Common symptoms and signs are:

• Sudden Hypertension

(Remember BP for these individuals is usually around 90/60-


100/60 mmHg lying down and possibly lower whilst sitting,
therefore patients may become symptomatic with BP in the
normal range for population. If untreated this can rapidly rise
to dangerously high levels).

• Pounding headache

• Bradycardia

• Flushing / blotching of the skin

• Sweating above spinal injury level

• Goose bumps

• Chills without fever

• Nasal stuffiness

• Blurred vision (dilatation of pupils)

• Shortness of breath and associated anxiety

Common causes include:

• Bladder – distended or severely spastic bladder,


urinary tract infection, urological procedure or even
inserting a catheter.

• Bowel – distended rectum, enema irritation.

• Skin – pressure sores, burns, ingrown toenails, tight


clothing.

• Other – any irritating stimulus, including fracture,


renal stones, epididymo-orchitis, distended
stomach, labour, severe menstrual cramping.

It is vitally important to remember that autonomic dysreflexia


is a medical emergency requiring urgent treatment (detailed
in Fig. 35.2).

Key points

• Autonomic dysreflexia (hyperreflexia) is a medical


emergency

Rehabilitation after traumatic brain injury


Overview

Traumatic Brain Injury (TBI) affects predominantly males


under 40 years of age (Lyle et al. 1986, Jennett 1996). Long
term disability and handicap issues relate to cognitive and
behavioural impact on social role, with little correlation with
physical disability (Jennet et al. 1981, Oddy 1984, Oddy et
al. 1985, Tate et a. 1989) In particular, disrupted families and
social contacts and poor work return are prevalent. These
are significant issues even for people who have made a
good recovery and require long term strategies implemented
by a team working with the patient and their family.

Most recovery and most rapid changes in terms of Glasgow


Outcome Score (Table 35.6) occurs in the first 6 months
(Jennett et al. 1981, Multi-Society Task Force on PVS 1994).
Of those who have Good recovery or are Moderately
disabled at 12 months, almost 2/3rds are already at that level
at 3 months and 90% at 6 months.

However, recovery significant to the individual can be seen


over 3 to 4 years after accident, particularly in people with
more Severely disability (Powell 1984). This highlights the
requirement for adequate follow-up.

Key points

• Traumatic Brain Injury (TBI) affects predominantly


males under 40 years of age

• Pathology & outcomes

Poorer prognosis is associated with older age (Vollmer


1991); forces of injury; evidence of hypoxia or hypotension;
acute subdural haematoma; widespread contusions; Raised
intracranial pressure; low GCS in the first 24 hours (Rimel
1983, Jennett 1979) post resuscitation and longer duration of
Post-Traumatic Amnesia.

Diffuse axonal injury is usual and may have few changes on


acute CT scan. Low Glasgow Coma Score and duration of
Post-traumatic amnesia may be better indications. The
characteristic Frontal & Temporal distribution of contusions
(Courville 1997) are associated with planning, organising &
executive impairments, personality & behaviour control
changes, and memory impairments (Oddy et al. 1985).
These deficits have been associated with unemployment
levels (Brooks et al. 1987, Crepeau and Scherzer 1993).
Penetrating injury, haematomas and infarction superimpose
focal syndromes on the diffuse and polar injuries. Hypoxia,
subdural haematoma, vascular spasm with subarachnoid
haemorrhage, cerebral oedema & hydrocephalus may all
complicate the presentation. The multiple pathologies
overlap to cause individual clinical presentation and may
place significant caveats to functional prognostication for the
individual (Choi et al. 1988).

Mild Head injury (GCS 13-15 or PTA < 1 hour), 70 to 90% of


admitted TBI, can have an appreciable incidence of sequelae
including headaches, memory changes and unemployment
after several months (Rimel et al. 1981).

Key points

• Poorer prognosis is associated with older age

• Coma and poor responsiveness

• Plum and Posner characterised coma by (Plum and


Posner 1980):

• unarousable psychological unresponsiveness

• eyes closed

• no psychologically understandable response to


external stimulus or inner need

• producing neither ..understandable words nor


accurately localise noxious stimuli with discrete
defensive movements

This is a feature of acute injury and is self limiting, rarely


lasting longer than four weeks.

Duration of coma is associated with outcome, with only one


third or less of those in coma longer than 2 weeks or more
making a Good to Moderate recovery (on GOS), in
comparison with 80 to 90% of those with coma less than two
weeks (Lyle et al. 1986).

Pathophysiology: The content of conscious behaviour is a


reflection of arousal and cognitive behaviour. Arousal is a
product of the brain stem reticular system interaction with the
cerebral cortex. Loss of consciousness occurs with
dysfunction either of upper brainstem structures or diffusely
of the cortex. The upper brainstem and cortical connections
seem particularly liable to injury where the head is free to
move on the trunk (Gennarelli et al. 1982).

Coma should be distinguished from brainstem death,


persistent vegetative state, locked in syndrome and severe
disability with minimal responsiveness

• Management

Progress is monitored clinically, including the GCS, to identify


complications. Exacerbating factors are excluded,
particularly Hydrocephalus or Intracranial Space occupying
lesion; Electrolyte disorders; Sepsis; Drug toxicity; Seizures
(see acute Ch. 00). Medications are critically reviewed,
minimizing those associated with adverse central nervous
system affects or negative effects on recovery, particularly
sedatives, anticonvulsants, anticholinergic and sympatholytic
agents.

Nutrition: Energy requirements are usually underestimated


by calculation of the Harris-Benedict equation (Wilson and
Tyburski 1998), because of the significant catabolic state
associated with TBI. Management requires regular review of
nutrition parameters and adjustment of intake. Gastrostomy
feeding may not necessarily prevent aspiration, being
associated with an appreciable risk of reflux aspiration
(Finucane and Bynum 1996). Indication for gastrostomy
feeding include agitation and risk of inappropriate removal in
post-coma recovery.

Bowel care: Regular enema and aperient regimen with the


aim of establishing predictable evacuation, promoting good
nursing care, hygiene and skin care.

Bladder: Early removal of urinary catheter & management


with a collection device is preferable to minimize the risk of
infection and bladder dysfunction. Monitoring for urinary
retention is required initially.

Immobility: Skin management, management of hypertonia &


maintenance of joint range of movement require appropriate
bed, seating system, splinting materials, pharmacotherapy
and staff expertise. A programme of positioning, maintained
stretching, seating and splinting needs to be managed

Respiratory: Clinical monitoring, tracheostomy and airway


management require attention to chest physiotherapy,
posturing and oral care.

Family knowledge & education are addressed and as are


issues such as emotional support, income support and
access to community assistance.

After the period of coma (rarely more than 4 weeks after


onset), the person establishes a new state in recovery. The
key issues after emergence from coma are the need to
identify the degree of the person’s ability to interact with their
surroundings and the setting up of programs to promote their
participation and skills acquisition.

For people thought to be suffering from the vegetative state,


it is important to distinguish this from severe disability with
minimal responsiveness (Table 35.7). Misdiagnosis remains
a risk. Recent reviews of referrals to two specialty units,
showed 30 to 40% or more of people incorrectly diagnosed
as having persistent vegetative state. Visual impairment was
common.

• Post traumatic amnesia

Post Traumatic Amnesia (PTA) is a self limited confusional


syndrome characteristically following closed head injury in
which new memories are unable to be reliably established,
often associated with agitation. It is distinct from Retrograde
Amnesia in which memory is lost for events occurring prior to
the incident. Inasmuch as it is defined by being self-limiting, it
is can only be confirmed retrospectively.

The patient is inattentive and distractible, unable to orientate


to the environment or recent events. They are unable to
learn to compensate for other sensory, language or cognitive
deficits related to injury and unable to recall explanations for
injuries. Agitation, confabulation, disinhibition or
uncharacteristic behaviour may occur. Patient safety and
avoidance of elopement may be prominent management
problems, with lack of insight into safety or requirements for
injury healing.

Problems of retrospective assessment of PTA duration lead


to development of prospective measures such as the
Galveston Orientation and Amnesia Test (Levin et al. 1979),
Westmead PTA Scale (Shores et al. 1986) & the Oxford PTA
scale. The latter provide a hierarchy of orientation and recent
memory tasks.

Key points

• Post Traumatic Amnesia (PTA) is a self limited


confusional syndrome

Russell (Russell and Nathan 1946) related PTA to return to


full duty by military servicemen (Table 35.8)

Jennett and Teasdale (1981) noted the relationship between


PTA and outcome in terms of GOS for a group of patients
admitted with severe head injuries (GCS 8 or less), adding a
category extremely severe for PTA > 4 weeks duration (Table
35.9)

Management

Monitoring progress of PTA helps identify those in whom


exacerbating factors should be sought, and identifying when
resolution of PTA allows benefit from education and
strategies in rehabilitation.

Careful clinical survey is required to avoid additional


morbidity from mismanagement of associated injuries,
particularly when agitation is a prominent feature. Particular
attention is required to managing sources of pain and
impairments of vision & hearing, often needing serial
evaluation and observation over time

Other causes of delirium need excluding (Table 35.10)


Key elements in orientation in a suitable environment
include:

• <!--[if !supportLists]-->Limit
conflicting sensory stimulation and
noise

• <!--[if !supportLists]-->Provide clear


cues to time and place including
items of personal relevance, familiar
photographs and possessions

• <!--[if !supportLists]--><!--[endif]--
>Minimise changes of location

• <!--[if !supportLists]--><!--[endif]--
>Establish regular daily routine with
rest periods

• <!--[if !supportLists]-->Train family

  and staff to consistently deal with  


the person. Consistency in
communication may be enhanced
by use of a communication log book
& timetable

• <!--[if !supportLists]-->Limit visitor


numbers at any one time

• <!--[if !supportLists]--> <!--[endif]--


>Limit duration and scope of
activities within the patient’s
agitation and fatigue

• <!--[if !supportLists]-->Recognise
the patients inability to incorporate
strategies
Agitation is best managed without use of
restraints. Environment modification and
problem solving triggering factors are a
priority. Monitoring and control of the
environment requires appropriate ward
design with sensitivity to noise, patient
interactions and safety. Nursing on
mattresses on the floor or a modified, low
bed may be best for the markedly agitated
patient with impaired balance. Formal
behaviour control programs are not
indicated.

Where agitation is unable to be managed by


   
other means, physical restraint may be
required (Table 35.11).

Key points

• Agitation is best managed without


use of restraints

Communication and support of family and


staff requires regular review. Medication
management needs to observe the following
principles:

   
• <!--[if !supportLists]--> <!--[endif]--
>Withdraw any potentially
exacerbating medications

• <!--[if !supportLists]--> <!--[endif]--


>Trial adequate analgaesia

• <!--[if !supportLists]-->Medication in
management of extreme or
persistent agitation may be needed
to avoid unacceptable morbidity

• <!--[if !supportLists]--><!--[endif]--
>Document baseline target
behaviour, trial of medication with
titrated dosage, regular review of
effectiveness and trial of withdrawal

• <!--[if !supportLists]--><!--[endif]--
>Minimum dosage for shortest
period

• <!--[if !supportLists]-->Most
medications are associated with
negative effects on cognition and
perhaps recovery of function, with
the exception of adrenergic
agonists.

• <!--[if !supportLists]--><!--[endif]--
>Not clear that any particular
symptom complex may respond to
a particular therapy and
management is empirical

• <!--[if !supportLists]--> <!--[endif]--


>Paradoxical exacerbation as well
as withdrawal effects need to be
appreciated

  It seems likely that haloperidol, while used by


some as initial therapy, has no specific effect
on agitation or aggressive behaviour. Care in
use of neuroleptics is indicated by their effect
on memory and mobility, risk of
epileptogenesis and tardive symptoms in
management of a transient condition. Care of
withdrawal agitation is necessary, particularly
with less potent agents.

Sedation with benzodiazepines may be


helpful, particularly if sleep disturbance is an
associated feature, although this does not
establish a normal pattern. They may also be
useful where acute control is required.

Tricyclic and other antidepressants (including


doxepin), Beta-blocking agents (particularly
propranolol), anticonvulsants (valproate and
carbamazepine) may be effective.

Key points

• It seems likely that haloperidol,


while used by some as initial
therapy, has no specific effect on
agitation or aggressive behaviour

Rehabilitation after fracture

Heterotopic Ossification (HO)


Heterotopic Ossification (Table 35.12) is true
bone formation by intramembranous
ossification (Keenan and Haider 1996) at an
abnormal site, usually in soft tissues
surrounding joints. Neurogenic Heterotopic
Ossification is most associated with
traumatic brain or spinal cord injury & may be
distinguished (Garland 1988) from
"Traumatic" Heterotopic Ossification (without
neurological injury). Local trauma, surgical
intervention or decubitus ulceration increase
risk of HO in TBI. Spontaneous regression is
described (Hammond and Francisco 1996).

Incidence is increased in people with more


severe neurological injury, affecting the limbs
with hypertonia.

Spasticity and related disorders of tone &


posture
Primarily related to loss of descending
inhibition on polysynaptic reflex pathways.
Secondary viscoelastic changes in muscle
and joint contribute. Nociceptive and other
sensory stimulation modulates responses,
including complex postural reflexes.

Positive effects may include maintaining


muscle bulk over pressure prone areas
(especially buttocks); facilitating transfers;
allowing ambulation.

Negative effects may include: pain/spasm;


mobility/function; posture; hygiene; decubitus
ulceration

Management (Table 35.13) requires a focus


on the goals of the intervention. Combination
therapy is usually required.

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