Recreational Therapy: An Introduction Chapter 11: Physical Medicine and Rehabilitation Practice PowerPoint Slides

Physical medicine and rehabilitation (PM&R)  PM&R is a setting in which RTs treat individuals who are recovering from physical injuries, both traumatic (e.g., from an accident) and nontraumatic (e.g., from a surgery).  In PM&R settings, RTs work with individuals who have damage to nerves, muscles, bones, and the brain.  The focus in PM&R settings is restoring function and helping patients return to being fully involved in their lives.

Focus of PM&R chapter:  Cerebrovascular disease (stroke)  Traumatic brain injury  Spinal cord injury  Neuromuscular disorders  Joint replacements

Cerebrovascular disease  Cerebrovascular accident (CVA), or stroke, is a blockage or rupture of the blood vessels that supply blood to the brain, most often caused by a blood clot.  A CVA causes damage to the brain and is considered a nontraumatic brain injury.

Traumatic brain injury  A traumatic brain injury (TBI) is caused by an external force to the brain.  A penetrating TBI is caused by something that is able to penetrate the brain, such as shrapnel from a missile, and an injury that does not penetrate the brain is called a closed head injury.

Spinal cord injury A spinal cord injury (SCI) may be classified as incomplete or complete. An incomplete SCI results when the injury to the spinal cord does not result in its complete severing and some motor or sensory function remains below the level of the injury. A SCI is considered complete when the spinal cord is completely severed and no function or sensation remains below the level of injury.

Spinal cord injury An additional classification in SCI has to do with the level at which the injury occurred. These classifications are tetraplegia (injury at the cervical spine, C1, to thoracic spine, T1), paraplegia (thoracic spine, T2, to sacrum, S5) and spinal fracture (injury to bone around spinal cord but not to the spinal cord.

Neuromuscular disorders  Neuromuscular disorders cause changes to voluntary muscles by impacting the nerves that control them. When these nerve cells are impacted and become unhealthy or die, changes or wasting in the muscles and nervous system result.  Many health conditions fall into this category, including amyotrophic lateral sclerosis (ALS), Parkinson’s disease (PD), and multiple sclerosis (MS).

Amyotrophic lateral sclerosis (ALS):  Commonly know as Lou Gehrig’s disease, named for New York Yankee great, Lou Gehrig, who first brought light to this condition.  ALS is a progressive degenerative disease that impacts the brain and spinal cord nerve cells. As the motor neurons die, the brain is no longer able to initiate or control the movements of muscles. Persons with ALS have progressive difficulties with walking, writing, speaking, and eventually breathing.  ALS has no cure at this time, although one FDA-approved drug (riluzole) has been shown to slow the progression of ALS.

Parkinson’s disease (PD):  Parkinson’s disease typically impacts people over the age of 50, although younger persons may get it as well.  Symptoms most associated with PD are tremor or trembling of the upper extremities, legs, jaw, or face; stiffness or rigid movements in the limbs or trunk, slow movements; and problems with balance and coordination. Individuals with PD often experience tremors, shuffling gait, and balance instability.  PD currently has no cure, but medications are available to reduce symptoms.

Multiple sclerosis (MS):  MS is a progressive disease caused when the covering of the spinal cord and brain are damaged. When the covering is damaged, lesions are formed that cause the individual limitations in functioning.  Persons with MS may vary in the amount of limitations they experience; their lesions may be numerous and in areas of the brain or spinal cord that greatly limit function, or they may have few lesions and remain ambulatory most of their lives.  MS has no cure but medications are available to reduce the likelihood of a new attack.

Joint replacement  In joint replacement, a damaged joint is replaced with an artificial joint that is implanted in the body.  Often following a joint replacement, individuals experience limitation in range of motion (ROM) and pain.  The goal of joint replacement often is for patients to fully function without using an assistive device, although this process is sometimes prolonged. Persons may have lifetime limitations on the amount of weight that should be lifted, and high-impact activities such as running and jogging often are prohibited.

Purpose of RT in PM&R The purpose of recreational therapy in PM&R settings is to improve functioning skills so the patient is able to return home and function as independently as possible.

Role of RTs in PM&R Settings  In PM&R settings, RTs must address client functional and psychological outcomes. This is because changes in physical functioning may wreak havoc with how individuals feel about themselves, which in turn, may make physical functioning or healing worse or better.  RTs work on functional outcomes and psychosocial well-being simultaneously by engaging patients in enjoyable activities that increase functional skills.  RTs also work on community reintegration and help patients and their families become aware of recreational resources in the community.

Assessment in PM&R  Assessment involves determining the patient’s needs, strengths, and preferences to determine interventions to meet the patient’s needs, as well as to establish baseline data to which the RT may refer when determining the client’s progress following the intervention.  The Rehabilitation Measures Database provides the RT with access to assessment and outcome measures of physical health conditions.

Planning in PM&R  Planning in PM&R closely resembles planning in other settings in that plans must be based on comprehensive assessment.  It will be important that the RT select the proper challenge and skill level required of the patient to reach rehabilitation objectives.  Collaboration with patients is important throughout the planning phase to actively involve them in the process so having the opportunity to provide input they will be apt to be more willing to actively work toward sought outcomes.

Implementation A principle to keep in mind during the implementation phase is that the RT is facilitating the patient’s reintegration into his or her everyday environment. Working through the transition to the community promotes the patient’s independent functioning and allows the person to problem solve or adapt to situations.

Evaluation  Progress may be measured by comparing the patient’s original assessment data to their current status.  The discharge summary should include the areas of client functioning that have been successfully addressed, as well as those that still need improvement.  A transition plan should be tailored specifically for the individual patient and the RT should create it with the client’s reintegration into his or her community in mind. Prior to discharge, the RT should discuss the transition plan with the patient.