For many problems—for example, heart disorders, stroke, other brain injuries, spinal injuries, hip fractures, amputation, and loss of hearing, speech, or vision—specific rehabilitation programs are available. Rehabilitation is sometimes needed for other types of fractures (see see Rehabilitation and Prognosis).
Cardiac rehabilitation is useful for some people who have had a recent heart attack (see see Rehabilitation), sudden onset or worsening of heart failure, or heart surgery. The goal is to maintain or regain independence or, at the least, to do basic activities of daily living, within the constraints of abnormal heart function.
Remaining in bed for longer than 2 or 3 days can lead to weakening of muscles and the heart (deconditioning) and even depression. Therefore, cardiac rehabilitation is started as soon as possible after the person has been stabilized, if needed (as after a heart attack), and usually while the person is still in the hospital.
Rehabilitation programs typically begin with light activity, such as transferring to and sitting in a chair. When these activities can be done comfortably, usually by the second or third day, more moderate activities, such as dressing, grooming, and walking short distances, are begun. If fatigue or discomfort occurs as activity is increased (as when walking the length of the hall), the person is instructed to stop immediately and rest until symptoms disappear. A doctor then reassesses the person's readiness to continue rehabilitation.
After discharge, the amount and intensity of activity are slowly increased, and a full range of normal activities can be resumed after about 6 weeks. Most people benefit from an outpatient cardiac rehabilitation program, which is usually about 12 weeks long, because they receive instruction and are monitored. For example, they may receive help with handling the psychologic effects of having had a heart attack or heart surgery. People learn why changes in lifestyle are necessary and how to make them, so that risk factors are modified. Quitting smoking, losing weight, controlling blood pressure, reducing blood cholesterol levels through diet or drugs, and doing daily aerobic exercises all help prevent or slow the progression of coronary artery disease and reduce the risk of another heart attack. Similarly, modifying risk factors may help slow the progression of heart failure.
If a stroke or head injury damages but does not destroy brain tissue, the tissue can gradually recover its function. Recovery can take 6 months to several years, but rehabilitation can speed recovery and make it more complete. Brain tissue that is destroyed cannot recover its function, but other parts of the brain sometimes learn to take over some of the duties of the destroyed area. Rehabilitation can help this learning process. The amount and rate of recovery of function cannot be predicted with certainty. Thus, rehabilitation is begun as soon as people are medically stable. Early rehabilitation also helps prevent complications such as shortened muscles (contractures), weakened muscles, and depression.
A detailed evaluation of the person, including psychologic testing, helps the rehabilitation team identify the type and severity of damage. Members of the team then assess which lost functions may benefit from rehabilitation therapy and create a program focusing on the person's specific needs. The success of rehabilitation depends on the person's general condition, range of motion, muscle strength, bowel and bladder function, functional ability before the brain injury, social situation, learning ability, motivation, coping skills, and readiness to participate in a rehabilitation program.
If brain injury results in weakened or paralyzed limbs, therapists move the affected limbs or encourage the person to move them. Moving the affected limbs helps prevent or relieve contractures and maintain the joints' range of motion. Usually, the unaffected limbs should also be exercised regularly to maintain muscle tone and strength. The person is expected to practice other activities, such as moving in bed, turning, changing position, and sitting up. Being able to get out of bed and transfer to a chair or wheelchair safely and independently is important to a person's physical and mental health. Coordination exercises may also be needed. Sometimes therapists restrain the unaffected limb (called constraint-induced movement therapy). For example, people with a partially paralyzed arm may wear a mitt or sling on their unaffected arm as they repeatedly practice daily activities, such as eating, washing, grooming, writing, and opening doors. This strategy helps rewire the brain to use the weakened or paralyzed limb.
Some problems due to brain injury require specific therapies—for example, to help with walking (gait or ambulation training), to improve coordination and balance, to reduce spasticity (continuous contraction of muscles), or to compensate for vision or speech problems. For example, people who are having trouble walking may be taught how to prevent falls. Occupational therapy may improve coordination. Heat or cold therapy may temporarily decrease spasticity in muscles and allow muscles to be stretched. People with one-sided blindness may be taught how to avoid bumping into door frames or other obstacles—for example, by turning the head toward the affected side.
A stroke or another brain injury, especially concussion (see see Concussion), can impair the ability to think (cognition). People may have problems with orientation, attention and concentration, perception, comprehension, learning, organization of thought, problem solving, memory, and speech (see see Speech Disorders). Which problems people have depends on the injury. Cognitive rehabilitation is a very slow process, has to be tailored to each person's situation, and requires one-on-one treatment. The goals are to retrain the brain and to teach ways to compensate for problems. For example, tasks, such as tying a shoe, are broken down into simple parts and practiced. Verbal, visual, and tactile (touch) cues, such as verbal hints, gestures, and color-coding items, also help people learn and remember how to do the task.
Recovery from spinal cord injury depends on the location (level) and degree of damage (see see Overview of Spinal Cord Disorders). The higher the level of injury, the greater the physical impairment. Injury at the level of the chest or below usually causes weakness or paralysis of the legs (paraplegia). Injury at the level of the neck usually causes weakness or paralysis of all four limbs (quadriplegia). If the level of injury is very high in the neck, the muscles that control breathing may be paralyzed, and a ventilator may be needed to assist breathing. Sensation also is impaired below the level of injury, and bladder and bowel control is usually lost.
The two most important aspects of caring for people with quadriplegia or paraplegia are the following:
People with paraplegia can live independently. Range-of-motion and strengthening exercises of the arms and hands enable them to use a wheelchair and to transfer from bed to a wheelchair and from a wheelchair to a toilet or a car seat. They can do many activities of daily living on their own, and many return to work. Some paraplegics can drive a car with the help of assistive devices.
People with quadriplegia can use a motorized wheelchair to move independently, but they must be lifted into the wheelchair manually or mechanically. Some quadriplegics can move their hands or fingers slightly and thus can operate the motorized wheelchair with a hand switch. If the hands and arms are completely paralyzed, quadriplegics can use a special device that enables them to control the motorized wheelchair with chin movements or even their breath. However, this method requires very intensive training. Most quadriplegics need support 24 hours a day.
Rehabilitation is begun as soon as possible after hip fracture surgery, often within a day. The initial goals are to help people retain the level of strength they had before the fracture (by keeping them mobile and by preventing loss of muscle tone) and to prevent problems that result from bed rest. The ultimate goal is to restore their ability to walk as well as they were able to before the fracture.
As soon as possible, sometimes within hours of surgery, people are encouraged to sit in a chair. Sitting reduces the risk of pressure sores and blood clots and eases the transition to standing. They are taught to do daily exercises to strengthen the trunk and arm muscles and are sometimes taught exercises to strengthen the large muscles of both legs. Usually within the first day after surgery, they are encouraged to stand on the uninjured leg, often with the assistance of another person or while holding onto a chair or a bed rail. While doing these exercises, people are directed to touch only the tips of the toes of the injured leg to the floor. Putting their full weight on the injured leg is often encouraged on the second day after surgery but depends on the kind of fracture and repair.
Ambulation (walking) exercises are started after 4 to 8 days as long as people can bear full weight on the injured leg without discomfort and can balance well enough. Stair-climbing exercises are started soon after walking is resumed. In addition, people may be taught how to use a cane or another assistive device and how to reduce the risk of falls.
Before surgery, a surgeon, prosthetist, and physical therapist discuss plans and goals with the person who requires amputation. A prosthetist is an expert who fits, builds, and adjusts artificial limbs (prostheses) and provides advice about how to use them. The exercises used in rehabilitation may be started before the amputation.
A prosthesis for a limb (arm or leg) consists of a socket in a rigid frame (interface), components, and a cover. The interface enables the prosthesis to be attached to the body. Components include terminal devices (such as artificial hands, feet, fingers, or toes) and artificial joints (see see Limb Prosthetics).
Arm (upper-limb) amputation:
Most arm amputations result from occupational injuries. Rarely, all or part of an arm is removed surgically to treat a disorder (such as cancer). The arm can be amputated below the elbow, above the elbow, or at the shoulder. Or a hand or one or more figures can be amputated.
After arm amputation, most people are fitted for an artificial arm (an upper-limb prosthesis). Components may include fingers, a hook or hand, a wrist unit, and, for an above-the-elbow amputation, an elbow unit. Movement of the hook or hand is controlled by movement of the shoulder muscles. A hook may be more functional, but most people prefer the way a hand looks. Control of an above-the-elbow prosthesis is more complicated than that of a below-the-elbow prosthesis. Newer prostheses that are controlled by microprocessors and powered myoelectrically (using energy produced by the person's muscles) have been developed, enabling the person to control movements with more precision. Bionic components, which are just now becoming available, may enable people to function even better. Rehabilitation includes general conditioning exercises and exercises to stretch the shoulder and elbow and to strengthen arm muscles. Endurance exercises may also be necessary. The specific exercise program prescribed depends on whether one or both arms were amputated and how much of the arm was amputated. People learn how to do activities of daily living using the prosthesis, adaptive devices, or other parts of the body (such as the mouth and feet).
Leg (lower-limb) amputation:
These amputations result almost equally from an injury (as in a motor vehicle crash or during combat) or from a surgical procedure to treat a complication of a disorder (such as decreased circulation due to atherosclerosis or diabetes). The leg can be amputated below the knee, above the knee, or at the hip. Or a foot or one or more toes may be amputated.
After leg amputation, most people are fitted for an artificial leg (a lower-limb prosthesis). Components may include toes, a foot, and, for an above-the-knee amputation, a knee unit. Newer prostheses that are controlled by microprocessors and powered myoelectrically or prostheses with bionic components enable people to control movements with more precision.
Rehabilitation includes exercises for general conditioning and exercises to stretch the hip and knee and to strengthen all arm and leg muscles. The person is encouraged to begin standing and balancing exercises with parallel bars as soon as possible. Endurance exercises may be needed. The specific program prescribed depends on whether one or both legs were amputated and how much of the leg was amputated.
The muscles near the amputated limb or at the hip or knee joint tend to shorten. This shortening (called contractures) usually results from sitting in a chair or wheelchair for a long time or from lying in bed with the body out of alignment. Contractures limit the range of motion. If a contracture is severe, a prosthesis may not fit correctly, or the person may become unable to use the prosthesis. Therapists or nurses teach the person ways to prevent contractures.
Therapists help people learn how to condition the stump, which promotes the natural process of stump shrinking. The stump must shrink before a prosthesis is fitted. An elastic stump shrinker or bandages worn 24 hours a day can help shape the stump and prevent fluid buildup in tissues. Soon after the amputation, people may be given a temporary prosthesis so that they may begin walking sooner and thus help the stump shrink. With a temporary prosthesis, people can start ambulation exercises on parallel bars and progress to walking with crutches or a cane until a permanent prosthesis is made. Sometimes people use a prosthesis with permanent components but with a temporary socket and frame. Because some parts remain the same, people may adjust to the new parts more quickly.
If a permanent prosthesis is made before the stump stops shrinking, adjustments may be needed to make it comfortable and to enable people to walk well. A permanent prosthesis is usually made several weeks after amputation to give the stump time to shrink completely.
When people receive the prosthesis, they are taught the basics of using it:
Training is usually continued, preferably by a team of specialists. A physical therapist develops a program of exercises to improve strength, balance, flexibility, and cardiovascular fitness. The therapist teaches people more about how to walk with a prosthesis. Walking begins with direct assistance and progresses to walking with a walker, then with a cane. Within a few weeks, many people walk without a cane. The therapist teaches them to use stairs, walk up and down hills, and cross other uneven surfaces. Younger people may be taught to run and participate in athletic activities. Progress is slower and more limited for people who have above-the-knee amputation, for older people, and for people who are weak or poorly motivated.
The prosthesis needed for an above-the-knee amputation weighs much more than that for a below-the-knee amputation, and controlling a prosthetic knee joint requires skill. Walking requires 10 to 40% more energy after a below-the-knee amputation and 60 to 100% more energy after an above-the-knee amputation.
After an arm or a leg amputation, people may feel pain that seems to be in amputated limb (phantom pain). The pain is real, but the location is wrong. Phantom pain is more likely if pain before amputation was severe or lasted a long time. Phantom pain is often more severe soon after the amputation, then decreases over time. For many people, phantom pain is more common when the prosthesis is not being worn (for example, during the night). If a spinal anesthetic and a general anesthetic are used during surgery, the risk of having this pain is reduced.
Some people experience phantom limb sensation, which is not painful but feels as if the amputated limb is still there. When people with an amputated leg have this sensation, they may stand up (and thus fall back down). This experience usually occurs at night when people wake to use the bathroom. Phantom limb sensation is more common than phantom pain.
The stump itself may be painful. Massaging the stump sometimes helps relieve this pain. The pain may be due to infection or wearing away of the skin (skin breakdown). In such cases, people may need to see a doctor.
Aphasia is partial or complete loss of the ability to express or understand spoken or written words. It often results from a stroke or another brain injury that affects the language center in the brain (see Fig. 1: When Specific Areas of the Brain Are Damaged).
The goal of rehabilitation is to establish the most effective means of communication. For people with mild impairment, a speech therapist uses an approach that emphasizes ideas and thoughts rather than words. Pointing to an object or picture, gesturing, nodding, and relying on facial expressions are often sufficient for basic communication. For people with more severe impairment, a stimulation approach (frequently repeating words to the person) and a programmed stimulation approach (speaking words and presenting objects that can be touched and seen) help people regain some ability to use language. People with aphasia may use a letter or picture board to communicate.
Caregivers of a person with aphasia need to be very patient and to understand the person's frustration. Caregivers must also realize that the person is not mentally impaired and should not be spoken to in baby language, which is insulting. Instead, caregivers should speak normally and, if necessary, use gestures or point to objects.
People cannot articulate words normally because part of the nervous system that controls muscles used in speech is damaged.
Rehabilitation goals depend on the cause of the dysarthria. If the cause is a stroke, a head injury, or brain surgery, the goal is to restore and preserve speech. If dysarthria is mild, repetition of words or sentences may enable people to relearn to use facial muscles and the tongue for correct pronunciation. If dysarthria is severe, people may be taught to use a letter or picture board or electronic communication device.
If dysarthria is caused by a progressive disorder of the nervous system, such as amyotrophic lateral sclerosis (Lou Gehrig's disease) or multiple sclerosis, the goal of therapy is to maintain speech function for as long as possible. People are taught exercises that increase control of the mouth, tongue, and lips and to speak more slowly and use shorter phrases. Poor control of breathing muscles may force people to take a breath in the middle of a sentence. Planning punctuation in a sentence can help. Doing breathing exercises can also help, sometimes by breathing through handheld assistive devices, which help dislodge mucus in the airways.
Verbal apraxia is the inability to produce the basic sound units of speech because of an abnormality in initiating, coordinating, or sequencing the muscle movements needed to talk. Verbal apraxia is often caused by brain injury, as results from a stroke or head injury. A therapist may have people practice making sound patterns over and over or teach them to use the natural melody and rhythm of common phrases. Every phrase has its own melody and rhythm depending on the mood of the speaker. For example, "Good morning! How are you?" has a particular melody and rhythm when the speaker is feeling cheerful than it does when the speaker is feeling unsociable. The therapist encourages people with verbal apraxia to exaggerate the natural melody and rhythm of phrases. As people progress, the exaggeration of melody and rhythm is gradually toned down.
Rehabilitation for people who are blind depends on whether blindness was present at birth (congenital) or at a very young age or whether it developed later in life. Children who are born blind or who become blind at a very young age usually receive special education about how to function without sight from the beginning. Thus, most of them become well adjusted. However, people who become blind later in life must learn new ways of dealing with daily living, such as how to feed themselves. Usually, people are taught the clock method. The dinner plate is pictured as a clock, and the meat is always placed at 8 o'clock, with the vegetable at 4 o'clock and the beverage at 1 o'clock.
Blind people also have to learn how to use a cane, and family members and other caregivers must learn how to walk with them. Family members are instructed not to change the location of furniture or other objects without telling the blind person. Learning how to use a seeing eye dog and Braille come much later. In the interim, audio books help the blind participate in reading.
Last full review/revision July 2007 by Masayoshi Itoh, MD, MPH; Mathew H. M. Lee, MD