Farid Blog: Rehabilitation: A concept with far-reaching significance and potential
Over the past 20 years, we have seen a welcome expansion of provider reimbursement for rehabilitation services. What used to be a nursing home option for patients who did not have the ability to care for themselves has evolved into a nursing home and rehabilitation center with updated capabilities for restoring function. In addition, there are acute rehabilitation centers embedded in acute care facilities for patients needing exercise and ambulation who have serious cardiovascular conditions.
In an effort to avoid the rapid de-conditioning that occurs in disabled middle-aged and elderly persons that occurs even in relatively short admissions, skilled nursing facilities are staffed with internal medicine and gerontology physicians and adult nurse practitioners who manage day-to-day care in assigned, in-house patient populations. These changes make it possible to keep the patients in an environment where the caretakers know the patients’ baselines and potential and avoid thrusting the patient into aggressive, medical/surgical situations of large community hospitals and medical centers.
Loss of mobility has its own potential for multiple losses of function and the circumscription of the individual’s world, which carries its own psychological and interpersonal aberrations. The largest muscles in the body are below the waist (ie, abdominal, gluteal, paraspinal, thigh, and calf). Rehab works to keep these muscles conditioned, which provides enormous circulatory and metabolic advantages. Individuals who are physically active usually have energy and alertness that go well beyond that of individuals who don’t. People who don’t have a daily fitness program age faster and are more prone to stress-related physical conditions and psychological/emotional overreactions to stress.
Diabetes mellitus rates soar among people (even teenagers and children) who are sedentary and can compound the circulatory and neurological effects of immobility with im-paired metabolism of insulin and carbohydrates that takes place in those large, below-the-waist muscles. When persons with diabetes are advised to stay off their feet (perhaps due to diabetic neuropathy and diabetic foot ulcers), these large muscle groups become increasingly flaccid, which increases insulin resistance, setting up a situation rife for the patient’s diabetes to become brittle and unstable. However, if the patient is encouraged to walk, even with a cane or walker, the ulceration may not heal and the occurrence of cellulitis in the wound and leg is increased, causing high blood sugar and HgA1c levels.
One way to handle this conundrum is to devise a way for the patient to safely ambulate. At our diabetic foot clinic, we had a talented pedorthist who was a wizard in the application of total contact casts (the plaster ones, not the prefabricated ones). The from-scratch plaster casts enabled him to adjust the positioning when applying the plaster; he would have the patient lie prone with his knee bent so the foot was uppermost and the soft calf tissues would drape down toward the knee during the application. When the cast was finished and the patient was standing, the soft tissues would move back into place, causing the cast to become snug in the area of the cast above the ankle. This is essential to distribute the patient’s weight from the foot to the calf area, reducing the pressure on the wound and preventing edema in the lower leg. We would then have the patient use a cane or walker to further reduce weight on the lower extremities and enable the patient to safely adjust to the weight of the cast and encourage the patient to walk as much as possible to keep the lower extremity muscles in good condition.
This is an excellent application of rehabilitation principles. This scenario enabled the patient, putting him back in control of his life. He no longer needed to worry about the ulcer and the ulcer healed quickly. When the ulcer was healed, the pedorthist would then cast the patient’s feet to produce the mold for the custom-manufactured diabetic shoes and the cushioned inserts. Once the patient was in the shoes, he had the ability to function, in many cases, better and stronger than before the ulceration ever occurred.
This is the rehabilitation way of thinking. Rehabilitation is a lifetime philosophy. Through my training, I learned, regardless of the patient’s injury or diagnosis, the nurse must do ongoing assessments of function and the possibilities for increasing and achieving the maximum efficiency and extent of physical function. This goal is also essential to drug, psychological, and emotional rehabilitation. With these goals in mind, nurses need collaborate with physical therapists, occupational therapists, and all other members of the therapeutic team.