Neurorehab Plan of Care after Trauma: Conceptual Framework
Traumatic events in life, such as neural trauma, are sometimes a part of life. They happen, and often require timely medical attention. As we noted in the section in Module 1 on the field of clinical rehabilitation, the three largest inpatient populations at the typical comprehensive rehabilitation hospital for adults all involve addressing the consequences of neural trauma: stroke, traumatic brain injury (TBI) and spinal cord injury (SCI, here's another good info page for SCI).
In this section we will overview the plan of care from an engineering systems perspective. Significant trauma, whether neural or other forms (e.g., musculoskeletal, cardiopulmonary), normally initiates two types of dynamic processes:
- a sequence of processes internal to the body that relate to minimizing the damage and then helping promote healing and "spontaneous" recovery; and
- a sequence of processes within the healthcare system that also relate to helping understand and minimize the damage and then working with internal healing processes to maximize the degree of recovery and independence of the person, through a plan of care that includes strategic interventions.
Both of these are areas of considerable scientific inquiry. Clearly there is still much to be learned about dynamic healing bioprocesses, as we discussed in the section in Module 1 on rehabilitation science (this is also a key focus in our BIEN 267 course on rehabilitative science). There is also much to be learned about how to best use limited resources to provide effective care, as we conceptualized in the section in Module 1 on optimizing clinical rehabilitative care. In this section, the clinical rehabilitative service delivery process was broke down into a collection of stages: diagnosis, prognosis, intervention, assessment, outcomes. These stages, classically covered in allied health practice guidelines and textbooks as key components of a plan of care (or "clinical algorithm"), were mapped via our "systems" perspective to an optimization problem (from Module 1). From this perspective (see diagram below), the plan of care and its implementation is a function of the prognosis, with the prognosis being a function of diagnostic information, desired outcomes and available resources.
Conventional assessment data that is gathered throughout the process of diagnosis, prognosis, intervention and outcomes assessment include patient records (paper, electronic) and scales (also called "instruments" or "forms" or "measures"). Typically these data come from trained practitioners, self-report, various biochemical tests, and imaging technologies. Objective (sensor-based) measures are not as common, but there are examples from areas such as performance on physical therapy equipment, speech performance, and gait analysis. The next section, on neuro-assessment, will develop this further.
- The Unitherapy project, presented to the class by Xin "Tyre" Feng, is an example of a novel tool in this area, and it and other new approaches at assessment are discussed in the Neuro-Innovation section.
Prognosis prediction, a critical part of developing a plan of care, involves use of an interesting synthesis of evidence-based prediction, expert training and experience, and common sense. It is most commonly the job of the physiatrist (or rehab doctor), working with other clinicians, the patient and family. While it is challenging, it is based on clinical training and hopefully a pillar in knowledge of the relevant scientific literature.
- A doctoral student has created a modeling environment that was initially designed to try to extract expert knowledge of clinicians so as to try to predict prognosis as a function of interventions (input events) to the system. This model, developed by Wang and Winters, originally called Intelligent Telerehab Assistant-Prediction mode (ITA-Predict) with a Med-Predict module, is now called SoftBioME, and is used in the BIEN 269 (Modeling Rehabilitative Biosystems) course. This model uses fuzzy logic to develop differential equations of rehabilitative bioprocesses and practitioner experience. Inputs to the model include facts from a patient record, therapeutic sessions, medications, and context data. States typically represent degrees of impairment or physiologic variables. Outputs typically relate to predicted performance metrics, and outcomes are predictions of general measures to be maximized or minimized, such as independence.
Typically available resources are tied to a certain stage within the plan of care, with different resources available for inpatient services, outpatient services, homecare, etc. One of the reasons that neurotrauma dominates inpatient care is that it is widely recognized that the classic outpatient/homecare reimbursement model of roughly 3 interventions per week, often sufficient for musculoskeletal soft tissue and cardiopulmonary healing, is typically not enough for neurorehabilitation. More frequent interventions are needed. A conceptual example is displayed below that shows how interventions can affect outcomes, and how a "chronic" steady-state doesn't necessarily mean an optimal state.
Figure: Conceptual example of the scientific challenges associated with optimizing the rehabilitative plan for therapeutic interventions so as to maximize outcomes, using as an example a typical scenario representative of the neurorehabilitative process related to stroke. Therapeutic interventions (represented as vertical lines in top trace) occur every weekday for about a 3-week inpatient time, during which the degree of recovery (thick line) is presumed better than spontaneous recovery (fine line). This period is followed by roughly twice per week interventions during several months of outpatient/home therapy, in which the person is also encouraged to follow a home exercise program on his/her own. In this case, a gradual decrease in compliance is commonplace, and some of the recovery is lost, though the sustainable level is still above spontaneous. Evidence suggests that 2-3 sessions per week is ineffective for neurorehabilitative recovery. There is, however, considerable evidence that intensive therapy sessions of several weeks duration can be very beneficial for certain cases (represented by dashed lines). The scientific issue relates to optimizing the timing, intensity, and duration of interventions.
Background: Standard Intervention Tools
- Structure and General Forms of Interventions
- Applied Therapy
- Administered by (or directly supervised by) specially trained clinician
- Technology-assisted (e.g., exercise machines, bio-stim, speech software)
- Self-initiated, with health management support (e.g., nurse)
- Self-initiated (e.g., training as inpatient or outpatient, then implemented at home)
- Medication/injection therapy
- Administered by clinician (e.g., injection)
- Self-administered (perhaps with reminders, often implementing prescription by physician)
- Health management (both preventative and therapeutic)
- Access to clinician support and expertise
- Access to caregiver
- Self (e.g., diet, etc.)
- Ties Between Intervention and Assessment
- Close ties (e.g., assessments embedded into intervention) are idea
- Optimize recovery and outcomes by using feedback of assessments to refine interventions
Early Diagnosis and Management Process for Stroke
- Background: Basic Mechanisms of a Stroke
- Ischemic (~ 70%)
- Hemmoragic (~30%)
- Advantages of Rapid Response - Minimizing Damage
- Thrombolysis with tPA (tissue plasminogen activator), if within ~ 3 hours of acute ischemic stroke
- Use of a quick CT or (or perhaps MRI / MR angiography in future) to make sure its ischemic
- Aspirin within 48 hours (mild benefit, low risk and cost)
- Early Medical Management: Refining Initial Diagnostic Assessment
and Documentation
- Stroke etiology and areas of brain involved
- Identification
of symptoms and basic functioning
- Imaging tools such as CT, MRI, MR angiography, ultrasound (type, location(s))
- Functional Assessment: Types/severity of neurological deficits
- Arm and leg function
- Check for dysphasia (problem with swallowing)
- Types/severity of comorbid diseases
- Any complications and abnormal health patterns
- Monitor for changes in clinical status over time
- Estimate (e.g., through interviews) functional status prior
to stroke
- Medical Management for All Stages
- Basic information on rehab therapy from www.stroke.org
- Nutrition/hydration/sleep/rest
- Stabilize medical condition
- Take steps to prevent recurrent stroke
- Minimize risk factors (these include hypertension, smoking,
diabetes, high serum cholesterol, heavy alcohol consumption, overweight)
- Medications include oral anticoagulants, aspirin
- Possibly surgery (not common)
- Secondary complications include:
- Deep vein thrombosis (DVT)
- Dysphasia (problem with swallowing) and aspiration
- Skin breakdown
- Bladder/bowel function
- Prevention of urinary tract infections
- Seizures/falls Acute care
monitoring will include:
- Spasticity/contractures (and treatment options)
- Shoulder injury (positioning
- Screening and Planning for Rehab (typically 1-4 days after trauma)
- Alternative choices for therapy (if resources permit):
- Needs specific rehab services
- Needs comprehensive rehab
- Needs further recuperation before rehab decision
- Too incapacitated for rehab
- Assessment
tools
- Baseline, during, at discharge, perhaps at later outpatient/homecare stages
- Scales
- Neurological deficit (NIH Stroke Scale)
- ADL abilities: FIM, Barthel
- Motor function/skills (Fugl-Meyer,
MAS, AMPS, Jebson, ...)
- Mental status (many), depression (many)
- Balance (Berg), Mobility (Rivermead)
- Speech/language aphasia (many)
- Activity log (MAL for amount/quality of use)
- Quality of life/health status, satisfaction,
...
- Imaging (internal estimates of structure, function)
- Common Functional Impairments in Stroke (each case in unique)
- Over 75% are hemiplegic (i.e., affecting mostly one side of body)
- Neurological domains
- motor (face, arm, leg)
- sensory (loss of sensations, change in sensation (altered sensitivity, numbness/tingling), loss of perception
- vision (monocular visual loss, left-sided neglect, etc.)
- language (dysphasia - disturbances include comprehension, naming, repetition, fluency, reading, writing)
- Muscle weakness (force, power deficit)
- Sensory reflex deficit
- Spasticity/spasms
- Posture/movement asymmetry & balance/gait
- Poor gross/fine coordination
- Often stages (related to spontaneous recovery, neural plasticity):
- Flaccadic/weak then spastic/stiff
- Synergy patterns evolve
- Typically lower extremity recovers earlier and better than upper
- Whole Body/Legs
- Weakness and/or spasticity big issues
- Standing - asymmetric body weight support, posture
- Gait - slow & asymmetric
- Arm
- Shoulder dysfunction (e.g., subluxation)
- Reaching and arm positioning
- Tendency for flexor synergy (flexed elbow &wrist, thus hand in front of chest)
- Grasping/manipulation: Tendency for weak wrist/finger extensors
- Pragmatic
considerations
- Emotional status, motivation, communication level,
endurance, tolerance for rehab
- Social/environmental: presence of caregiver, living
situation, family, ...
- Resources and available rehab programs
- Inpatient
- comprehensive rehab hospital
- acute care hospital
- Nursing homes
- Outpatient rehab (typically several hours for
3-4 visits/week
- Home rehab (typically some therapy, nursing
visits
- Other
- Prognosis
- Based on evidence and expert experience
- Often stages for spontaneous healing
- May be several prognosis, e.g. with/without rehab (spontaneous recovery vs spontaneous plus active rehabilitative intervention)
- Goal-Setting and Plan for Intervention
- Most interventions are like "impulses" to the dynamic healing process
- Key forms of intervention
- Therapy (PT, OT, speech):
- Considerations: type, timing, intensity,
duration
- maximize "functional
outcomes"
- controversy: more focus on returning key ADL functions
for independent living, or on (longer-term) skill development?
- Medication (ranging from oral medications to Botox injections)
- Education and support for self-care
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