D. Heterotopic ossification (HO) is a pathologic process during which new bone
IV. THE SCOPE OF REHABILITATION FOLLOWING TRAUMA
A. Rehabilitation of patients after trauma occurs in several stages, each with a corre- sponding venue.
1.Subacute rehabilitation facilities—a phenomenon greatly created with the Medi- care policy revisions of 2009 and 2010 and in the implementation of the prospec- tive payment system for inpatient rehabilitation facilities (IRFs). This is a setting for rehabilitative efforts that will provide for a lower overall intensity of thera- peutic services over a longer period of time. The capacity of the facility to deal with ongoing medical concerns is variable. If the patient does not meet the cri- terion for acute inpatient rehabilitative services at an IRF, but cannot care for themselves in the community and would benefit from some degree of therapy to
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Chapter 20 rRehabilitation 211 continue to recover from their injuries, then subacute rehabilitation services are appropriate.
2.Acute inpatient rehabilitation is required when patients are unable to manage their own basic self-care or mobility needs because of physical or cognitive limitations.
The goal of inpatient rehabilitation is to reestablish capability for basic routines of daily living so the patient can function safely in the community with a minimal amount of physical assistance or supervision. Ideally, patients are restored to the point where they are both physically and cognitively independent, although this is not always possible. Rehabilitation interventions are directed toward minimiz- ing the amount of physical or cognitive assistance that a patient will require on return to the community. Most facilities follow the Medicare guidelines for admis- sion to the IRF as outlined below.
a.The patient must require the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech–
language pathology, or prosthetics/orthotics therapy), one of which must be physical or occupational therapy.
b.The patient must require an intensive rehabilitation therapy program; generally consists of at least 3 hours of therapy per day at least 5 days per week.
c.The patient must reasonably be expected to actively participate in and benefit from the intensive rehabilitation therapy program. The patient is expected to make measurable improvement (that will be of practical value to improve the patient’s functional capacity or adaptation to impairments) as a result of the rehabilitation treatment and such improvement is expected to be made within a prescribed period of time.
d.The patient must require physician supervision.
e.The patient must require an intensive and coordinated interdisciplinary approach to rehabilitation.
3.Initial phases of outpatient rehabilitation are directed toward enhancing the abil- ity of the patient to return to active participation in the community outside the home and improving the patient’s ability to manage more complex instrumental activities of daily living (e.g., cooking, laundry, managing finances, home main- tenance). These tasks involve more complex organizational and executive skills that are frequently affected in brain injury. Patients may require assistance with behavioral problems that affect their interpersonal relationships. Residual deficits that limit mobility in the community can also be addressed along with continu- ing cognitive limitations. This phase of rehabilitation is sometimes referred to as
“community reentry.”
4.The final phase of rehabilitation involves helping the affected individual (now often referred to as a “client” rather than a “patient”) return to some form of competitive employment. Referred to as “vocational rehabilitation,” this involves teaching training skills that enable an individual to return to the workplace. It can also involve providing some assistive services (e.g., job placement and job coaching) as well as trial placements in voluntary positions in the community.
AXIOMS
■The rehabilitation team must teach the patient the skills to return to independence.
■Secondary disability is the result of prolonged immobilization of the patient.
■Contractures and decubiti can and should be prevented.
■Complete bed rest result in loss of 10% to 15% of muscle strength per week. Maintaining strength through therapeutic exercise is essential.
Suggested Readings
Acute Management of Autonomic Dysreflexia: Individuals with Spinal Cord Injury Presenting to Health- Care Facilities. Consortium for Spinal Cord Medicine. July 2001.
Banovac K, Sherman AL, Estores IM, et al. Prevention and treatment of heterotopic ossification after spinal cord injury. J Spinal Cord Med 2004;27(4):376–382.
Bar-Shai M, Carmeli E, Coleman R, et al. Mechanisms in muscle atrophy in immobilization and aging.
Ann N Y Acad Sci 2004;1019:475–478.
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LWBK1111-20 LWW-Peitzman-educational August 6, 2012 13:2
212 The Trauma Manual: Trauma and Acute Care Surgery
Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Providers. Consortium for Spinal Cord Medicine. August 2006.
Bogner J. The Agitated Behavior Scale. The Center for Outcome Measurement in Brain Injury. 2000.
http://www.tbims.org/combi/abs (accessed January 25, 2012).
Kirschblum S, Campagnolo DI, Delisa JA, eds. Spinal Cord Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:261–274.
Lombard L, Zafonte R. Agitation after traumatic brain injury: Considerations and treatment options.
Am J Phys Med Rehabil 2005;84(10):797–812.
Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A (Rev.
119, 01-15-10) Section 110.2 - Inpatient Rehabilitation Facility Medical Necessity Criteria.
Neurogenic Bowel Management in Adults with Spinal Cord Injury. Consortium for Spinal Cord Medicine.
March 1998.
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Consortium for Spinal Cord Medicine. August 2000.
Silver J, Yudofsky S, Anderson K. Aggressive disorders. In: Silver JM, McAllister TW, Yudofsky SC, eds.
Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Press; 2005.
Wagner AK, Fabio T, Zafonte RD, et al. Physical medicine and rehabilitation consultation: Relationships with acute functional outcome, length of stay and discharge planning after traumatic brain injury.
Am J Phys Med Rehabil 2003;82(7):526–536.
Zafonte R, Lombard L, Elovic E. Antispasticity medications: Uses and limitations of enteral therapy. Am J Phys Med Rehabil 2004;83(10 suppl):S50–S58.
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21A Trauma in Children
Daniel J. Grabo, Thane A. Blinman, Michael L. Nance and C. William Schwab
I. INTRODUCTION
Nearly 8 million children under the age of 15 visit the emergency department yearly for injury in the United States. Advances in injury prevention and healthcare have led to a decrease in the number of deaths from unintentional injury in children from 1997 to 2007 by 30%. Unintentional injury remains the cause of more childhood (ages 1 to 14) deaths than all other childhood diseases combined and is responsible for nearly 30% of all years of potential life lost.
Most pediatric trauma care occurs outside the setting of a designated pediatric trauma center. It is imperative that any treating hospital, knowing the limitations of their institution, transfer severely injured children to a higher level of care when con- ditions exceed capabilities. Pre-existing transfer agreements between institutions facil- itate transfer and care.