PHYSIOTHERAPY FOLLOWING DISCHARGE Katie Wilson and Sally Reffold Physiotherapists

Aims Before discharge Physiotherapy after discharge Ongoing needs Maintaining functional skills e.g. transfers Joint care Respiratory Strengthening and fitness

Recommendations on discharge Goal planning meetings Discharge planning meeting Discharge report Carer training Family training Handover to out patient physiotherapist Handover to community physio if appropriate Discharge planning – for those who will need care Discharge report – will outline ongoing needs - planning for discharge will be discussed in GPM - your relative will have opportunity to direct care / exercises and will be discussed in great depth in physio sessions If specific ongoing issues the out patient physio will be contacted and often will then be able to attend a session prior to discharge Training proir to discharge if able if not able often community PTs get involved or out patient PT

Out patient physiotherapist Handover from in to out patient team Role is to provide - advice & education - assessments on ongoing and changing needs - Link between the community Referrals: patients can self refer, GP, carer, physio, OT e.t.c. Not routinely seen when the patient has a consultant appointment but can book a physiotherapy assessment to coincide if indicated. If you feel that your relative needs to be seen in spinal out patients then contact spinal out patients in advance to discuss. Diary can be often booked 1 month in advance!!

Community physiotherapy May be involved initially to help with transition but not long term Their role may include Teaching to carers or family members Progress goals not achieved during admission Review due to changing level of needs

Ongoing needs in community Will vary on level of lesion, completeness of injury, age, function e.t.c. but following principles apply Maximise function Minimise complications

Functional activities During admission practice skills Practice skills during therapy sessions, weekend leave and bungalow stay On discharge assist with functional activities to encourage independence if able During admission pts will practice many different skills and should be equiped to cope with different scenarios should they occur. Some of these skills will be needed infrequently we hope such as the scoop method!! Or transfers in to a bath (often people opt for wet room but only when they go away and then the disabled room that they have booked as only a bath) do they need to call upon these skills. Assist with skills – do not do if able as you may not always be around – motivate them Encourage them to maintain skills such as drivers side transfers and wheelchair in and out of the car – often wait for car on discharge and might not start work straight away but will need this skill

Range of movement Maintain range by:- Stretches Standing Positioning – 24 hour (bed, wheelchair, car e.t.c.) Splints / orthoses

Why? Hygiene Function Pain management Reduce effects of tone Prevent contractures

Stretches Frequency varies - normally 2-3 times a week Often can be incorporated in to daily routine Joint taken through full movement – but care needed not to overstretch Physio / OT will show you how to stretch

24 hour positioning Also used to stretch especially on front or side over a roll Seating discussed in next lecture but think also about 24 posture Aims to - maintain symmetrical postures - encourage stretching - reduce spasm - minimise adaptive shortening of the muscles - prevent complications, e.g. Contractures Prone lying is useful for stretch and pressure relief Seating will be discussed in next lecture

Why stand Benefits include - effective stretching - reduction in spasm/spasticity - maintenance of bone density - improved bladder and bowel function - psychological effects Stretching of ankles, knees, hip and trunk. Through weight bearing 12

Standing Assessed for appropriate frame prior to discharge Requisition made for funding from local Primary Care Trust Varying level of assistance required to use frame at home

Other options

Splints Are used to :- - maintain joint range - assist with functional movement e.g walking Upper Limb Splints Lower Limb Orthoses Corsets/Braces/Binders Variety of types May require assistance to use

Review and replacement If a problem with the splint let us know Contact the OT / PT in spinal out patients if any problems and no community input OT will be able to review upper limb splints Orthotics clinic - 01296 315880 /63 or alternatively spinal out patients. Runs every Thursday in the afternoon. Requires a GP referral

Respiratory management After spinal cord injury Loss of muscles Weakness of muscles Easily fatigued Reduced cough Lead to difficulty in clearing secretions Loss of accessory muscles. If diaphragm not working then on ventilator, some relatives may require ventilation overnight especially C3-4 or sleep apnea Weakness of muscles – those with SCI will find it easier to breath lying down as if abdominals not innervated then will pull diagram down and make it harder for it to work. Fatigue of muscles as doing work that they would only normally do occasionally e.g. when running when short of breath. Those high energy muscles are now needed for endurance work – need to be trained – we will discuss later

Manual assisted cough Coughing is needed to clear secretions – build up may lead to chest infection If difficult to cough will need assistance – some people can do this technique independently Demonstration audience participation in sitting - explanation on technique – discussing timing, deep breath

Cough assist machine Mechanical cough Pushes air in and then pull it out quickly to clear secretions – mimic a cough Via mouth or tracheostomy Trial as an in patient Funding sought through PCT if needed long term.

Chest infections Recognise the signs and symptoms - increasing breathlessness - increasing volumes of secretions - change in colour of secretions (green, yellow, blood-stained) - raised temperature - generally unwell - ?chest pain See GP (?and physiotherapist) for advice

Sports and fitness Inclusive fitness initiative Gym buddy scheme ‘Back up Trust’ – activity weeks Sports – teams and individual events Work and leisure pursuits linked to quality of life, psychological well being. Encourage participation in any hobby – no matter what it is

Exercise Encourage strengthening and exercise to improve CV fitness – as is a must for able bodied even more so for SCI population due to decreased metabolism

Computer consoles adaptations Other useful links Wii habilitation Remap Special effect

Summary Once discharged a patient needs to maintain the skills they have learned as an inpatient to prevent any complications This will enable them to maximise their quality of life As their relatives, you can help them to do this by assisting them in their maintenance exercises and daily régime

But remember! Help is at hand! engage in your relative’s therapy sessions to learn the skills required to help them once home, contact the Spinal Outpatient Service for further advice and support as needed 01296 315828 /9 alternatively, assistance from a community therapist can be arranged if appropriate support from a variety of sources exists for you as well as your relative