1. PHYSIOTHERAPY FOLLOWING DISCHARGE
Katie Wilson and Sally Reffold
Physiotherapists

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

3. 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

4. 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!!

5. 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

6. 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

7. 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

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

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

10. 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

11. 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

12. 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

13. 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

14. Other options

15. 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

16. 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 /63 or alternatively spinal out patients. Runs every Thursday in the afternoon. Requires a GP referral

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. Computer consoles adaptations
Other useful links
Wii habilitation
Remap
Special effect

24. 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

25. 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 /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