Early Rehabilitation Protocols Eng_light

7/27/2019 Early Rehabilitation Protocols Eng_light

1/138

EARLY REHABILITATIONPROTOCOLS FOR VICTIMSOF NATURAL DISASTERTraining Capitalization Manual

Robert Fall (G2 Studio) for

Demey Didier - Nielsen Susanne - Weerts Eric

Handicap International

August 2010


2/138


3/138

Page - 3

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

EARLY REHABILITATION PROTOCOLS FORVICTIMS OF NATURAL DISASTER

Training Capitalization Manual

Rehabilitation The path towards autonomy

Publication co-funded by Handicap International and:

The content of this publication is the sole property ofHandicap International and can in no way be taken toreflect the views of the co-funders.

Please quote the source of the document in case of use.

Sanofi Aventis Ministry of Foreign Affairs ofLuxemburg

French Government Electricit de France Brussels Region

Municipality of Paris Chaine du Bonheur Rotary Club ofKowloon North

Rotary Club ofShanghai

Belgian Embassy inChina

Partnerships forCommunity

Development


4/138


5/138

Page - 5

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

A C K N O W L E D G M E N T

Handicap International would like to thank Mr Cai Sheng for the translation of the followingdocuments from English into Chinese. His dedication was greatly appreciated.

We also would like to thank the Hong Kong Rehabilitation Society and, especially Sheila

Purves (project director) and Mrs Phoebe (secretary), as well as Mr. Wang Yuling (DeputyDirector, Department of Rehabilitation Medicine of First Affiliated Hospital and Secretary,Department of Rehabilitation Therapy of Sun Yat-sen Medical College, Sun Yat-senUniversity) for their help in revising the accuracy of the content and translation of thisdocument.


6/138


7/138

Page - 7

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

P R E F A C E

Handicap International has been working in China for more than 12 years. Our objective isto improve the autonomy and social inclusion of persons with disabilities, especially in ruralareas, through pilot projects run in close cooperation with governmental partners, civilsociety and associations of people with disabilities. We intervene in both long termdevelopment and emergency contexts.

The provision of active and quality rehabilitation treatment following an injury, surgery orillness is essential to minimize the disabling effects and ensure the optimal recovery offunction. It is a key component of the comprehensive rehabilitation process promoted byHandicap International. This process includes early rehabilitation in hospital, follow-up athome and long term support for the social inclusion of people with disabilities.

Active rehabilitation techniques are however not yet promoted enough in China and there isa huge lack of professionals in this field. This training capitalization manual aims at providingrehabilitation therapists and other medical staffs in China with practical protocols and toolsthat they can follow to treat injured persons during their hospitalization. Although it wasdeveloped in the framework of a post earthquake intervention, it is not restricted toearthquake casualties, but is a transferable resource to other conditions commonly treatedin hospital. It is also hoped that it could serve in other contexts than China.

I would like to sincerely thank all the persons who contributed to this manual. Special thanksgo to Didier Demey, Susanne Nielsen and Eric Weerts whose professionalism andcommitment made our emergency interventions in Sichuan and Qinghai possible. They notonly provided direct care to the casualties but also had the intelligence to document theirwork and capitalize on it. Particular thanks as well to all our partners in Chengdu, Mian Zhuand Yushu. Last but not least, I would like to thank our donors without whom our activitieswould not be possible.

Jean Van Wetter

Country DirectorHandicap International China


8/138


9/138

Page - 9

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

I N T R O D U C T I O N

This training capitalization manual has been produced by Handicap Internationals expertsfollowing the earthquake and emergency intervention in Sichuan in May and June 2008. Ithas then been revised after the post-emergency intervention in Qinghai province (Yushuearthquake, April 2010).

The material was produced to train physiotherapists and other medical staff (surgeons,doctors, nursing staff) in Huaxi and Number 3 Hospitals in Chengdu. Information materialwas also produced for the victims of the earthquake and their families.

The early rehabilitation protocols presented in this document contain basic physiotherapyexercises and techniques that can be used in the early stage (during hospitalization) formost victims of earthquake. Those, in the majority of the cases, suffer from bone fracture,head injury, spinal cord injury, peripheral nerve injury, burns and/or amputation. Because ofthe prolonged hospitalization, victims from an earthquake may also suffer from commoncomplications due to confinement in bed (bedridden complications).

Some of the PT exercises and techniques that are described in the protocols can be used forpeople having different types of impairment or injury. In order to prevent from repeating indifferent protocols the same types of exercises, two main types of protocols were created:the protocols by injury and the protocols by technique.

The "protocols by injury" are specific to one injury (bone fracture, head injury, spinal cordinjury, amputation, bedridden patients, peripheral nerve injury and burns). They containgeneral information on that specific injury and a detailed protocol (assessment, exercisesand techniques to be used during hospitalization and long-term rehabilitation).

The "protocols by technique" contains detailed description of specific techniques (passivemobilization, active mobilization and strengthening, balance exercises, stretching, chesttherapy, positioning, transfer and mobility and teaching the patient/family).

The techniques described in the "protocols by technique" are not described in details in the"protocols by injury". When they are suitable, they are just named and referred in the"protocols by injury". Therefore, both types of protocols have to be used in parallel, as theycomplement each other.


10/138


11/138

Page - 11

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

C O N T E N T S

This manual is made of 4 different parts:

1. The first part of the manual presents preliminary notes regarding the provision ofearly rehabilitation services (importance and benefits of early rehabilitation forhospitalized patients, early rehabilitation pathway and patient management)

2. The second part contains the 7 early rehabilitation protocols by injury (bone fracture,head injury, spinal cord injury, amputation, bedridden/ICU patients, burn andperipheral nerve injury).

3. The third part contains the 8 early rehabilitation protocols by technique (passivemobilization, stretching, active mobilization and strengthening, chest therapy,positioning and changing of position, transfer and mobility and teaching thepatient/family).

4. The last part contains a list of annexes that are referred to in the other parts of thedocument. Soft copies of those annexes can be found on the capitalization DVD.

Table of content

ACKNOWLEDGMENT .................................................................................................................................5

PREFACE .................................................................................................................................................. 7

INTRODUCTION .......................................................................................................................................9

CONTENTS ............................................................................................................................................. 11

PART 1. PRELIMINARY NOTES REGARDING THE PROVISION OF EARLY REHABILITATION SERVICES... 13

Note I - Importance and Benefits of Early Rehabilitation for Hospitalized Patients...........................................13Note II - The Early Rehabilitation Pathway.................................................................................................18Note III Patient Management ................................................................................................................19

PART 2. THE EARLY REHABILITATION PROTOCOLS BY INJURY ............................................................. 20

Early Rehabilitation Protocol for Amputation ..............................................................................................211. General Information on Amputation...................................................................................................212. PT Protocol for Amputees .................................................................................................................27

Early Rehabilitation Protocol for Bone Fracture ...........................................................................................331. General Information on Bone Fracture ...............................................................................................332. PT Protocol for Patients with Bone Fracture.........................................................................................38

Early Rehabilitation Protocol for Spinal Cord Injury .....................................................................................471. General Information on Spinal Cord Injury (SCI).................................................................................472. Physiotherapy Protocol for Spinal Cord Injury ....................................................................................53

Early Rehabilitation Protocol for Head Injury ..............................................................................................571. General Information on Head Injury ..................................................................................................572. PT Protocol for Head Injury ..............................................................................................................61

Early Rehabilitation Protocol for Bedridden/ICU Patients ..............................................................................701. General Information on Bedridden and ICU Patients ............................................................................702. PT protocol for Bedridden/ICU Patients ..............................................................................................75

Early Rehabilitation Protocol for Peripheral Nerve Injury ..............................................................................781. General Information on Peripheral Nerve Injury (PNI)..........................................................................782. PT Protocol for Peripheral Nerve Injury ..............................................................................................83

Early Rehabilitation Protocol for Burn ........................................................................................................861. General Information on Burn ............................................................................................................862. PT Protocol for Burn Patients ............................................................................................................90

PART 3. THE PT PROTOCOLS BY TECHNIQUE.......................................................................................... 93

PT Protocol for Passive and Assisted Mobilizations ......................................................................................941. General Information on Passive and Passive Assisted Mobilizations........................................................942. Technique ......................................................................................................................................96

PT Protocol for Active Mobilization and Strengthening Exercises ...................................................................991. General Information on Active mobilization and Strengthening Exercises................................................992. Technique ....................................................................................................................................101

PT Protocol for Stretching Exercises ........................................................................................................1061. General Information on Stretching Exercises ....................................................................................1062. Technique ....................................................................................................................................107

PT Protocol for Balance Exercises ...........................................................................................................1091. General Information on Balance Exercises ........................................................................................1092. Technique ....................................................................................................................................110

PT Protocol for Chest Therapy ................................................................................................................113


12/138

Page - 12

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

1. General Information on Chest Therapy.............................................................................................1132. Technique ....................................................................................................................................116

PT Protocol for Transfer and Mobility.......................................................................................................1191. General Information on Transfer and Mobility ...................................................................................1192. Technique ....................................................................................................................................120

PT Protocol for Positioning and Changing Position .....................................................................................1311. General Information on Positioning and Changing Position..................................................................1312. Technique ....................................................................................................................................132

Teaching and Informing the Patient and His/Her Family Members...............................................................134

PART 4. ANNEXES ................................................................................................................................ 137


13/138

Page - 13

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

P A R T 1 . P R E L I M I N A R Y N O T E S R E G A R D I N G TH E P R O V I S I O N O F E A R L YR E H A B I L I T A T I O N S E R V I C E S

Note I - Importance and Benefits of Early Rehabilitation for Hospitalized Patients

This chapter will quantify why rehabilitation needs to be commenced as soon as possible. Ina situation after a natural disaster there are many other needs, which will need to beaddressed, but rehabilitation must be incorporated into any healthcare plan in order toensure optimal recovery.

Definition of early rehabilitation

Early rehabilitation means that a person is assessed immediately following the traumaticevent or illness which has brought them to hospital in order to prevent secondarycomplications and ensure optimal recovery.

The benefits of early rehabilitation?

Early rehabilitation will ensure that a person has a greater possibility of recovering to theirprevious level of function before their injury or illness.

If the injury or illness is severe, the earlier the rehabilitation is commenced, the more likelyis the possibility of the person to reach a more independent life on discharge from hospital.For specific benefits, please see below table.

The risks of no rehabilitation?

No rehabilitation can lead to short and long-term secondary complications. The table below

outlines the most common complications. These complications can lead to disability and inworst cases may cause premature mortality.

How soon can detrimental effects occur of having no rehabilitation?

This depends on the premorbid condition of the patient. General guidelines are set out inbelow table.

When to start rehabilitation?

Some people may not have sustained so severe injuries or illness and will not needrehabilitation, but simply an assessment and recommendations regarding how to preventsecondary complications, which otherwise could result in long-term problems.

Some people will have sustained more severe injuries or illness, that will require immediateassessment and start of rehabilitation, following the rehabilitation guidelines (see annexes)and risk assessment (see annexes).

ICU to treat or not? ICU

All evidence emphasizes the need for early rehabilitation. This means that rehabilitation willstart when the respiratory system and haemodynamics have stabilized, normally within 24-48 hours.

Some patients may be too sick or too sedated to be able to start rehabilitation, but daily

monitoring of changes and the window of opportunity of when to start rehabilitation isimportant. One of the main complaints following critical illness is ICU-acquiredneuromuscular weakness. There is now a growing body of evidence, which shows thereduced ICU-related neuromuscular weakness, if rehabilitation is started early.


14/138

Page - 14

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

The earlier the intervention, the less secondary complications.

The table below and video clips on the capitalisation DVD underline this need.

Who can provide early rehabilitation?

If there is a rehabilitation department, the patient should be referred to the rehabilitation

staff for assessment and treatment.

If there is no rehabilitation staff, then rehabilitation can be provided by staff, who have beentrained in providing basic rehabilitation, for example nursing or medical staff.The staff who complete early rehabilitation will need to know how to assess that the patientis ready for rehabilitation (assessing risks and safety), be able to identify the main problemsand possible complications with no rehabilitation and make a basic rehabilitation plan.During rehabilitation, they will need to continue to review the risks and safety issues(monitoring of vital signs, contra-indications and precautions during rehabilitation (refer tothe risk assessment form in annex), to ensure the rehabilitation is not detrimental to thepatient.

When the patient is medically stable, the staff can educate family and relatives on how tosafely complete the basic positioning, exercises and mobility. This way the patient will get24/7 care in a rehab-orientated way! and not only rehabilitation during the treatmentsessions.

How long should an early rehab treatment session be?

This really depends on the condition of the patient. Sessions as short as 10-15 minutes maybe required increasing to 30-45 minutes of gentle exercise and positioning. Treatment doestake longer because it has to be completed with caution and more assistance is required.

The most important issue is to carefully review the contra-indications and precautions for

early rehabilitation, before the treatment and to monitor the patients vital signs (heart rate,respiratory rate, blood pressure, temperature, saturation of oxygen in the blood (Sp02)),before, during and after treatment.

Can early rehabilitation be harmful?

No, by assessing the patient properly, using the rehabilitation risk assessment form andmonitoring the vital signs (heart rate, respiratory rate, blood pressure, temperature,saturation of oxygen in the blood (Sp02)), then all research has shown the benefits of earlyrehabilitation.

However, there are risks and therefore rehabilitation in the early stage needs to becompleted with caution. The problems that may occur are:

Dislodgement of medical equipment (lines, tubes, ventilation) Worsening gas exchange and haemodynamics Inadequate patient comfort, pain control

References on safety:Kathy Stiller et al. 2007,Schweickert WD, Pohlman MC, Pohlman AS, et al. Lancet. 2009;373:1874-1882.Berney and Denehy (2003) Australian Journal of Physiotherapy 49: 99-105.

What equipment is needed to provide early rehabilitation?

For early rehabilitation assessment, a copy of the available checklist guidelines, assessmentform, risk assessment form provided here (soft version on the capitalisation DVD), are thebasic documentation materials needed.


15/138

Page - 15

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

For the early rehabilitation treatment, the Early Rehabilitation Equipment Catalogueprovides specific details of the early equipment required for rehabilitation (view especiallyfirst part of the catalogue). However, most often the initial treatment will consist ofpositioning, sitting up in bed, joint range of motion exercise (passive, active-assisted andactive), sitting over the edge of bed, standing and transfers into chair. For these initialtreatments, it is mainly human resources that are needed; 1-2 people, sometimes 3 peoplein severe conditions, such as hemiplegia, SCI or with people with a low conscious-level.

Some basic equipment that will be needed are pillows and rolled up towels for positioning,walking aids for standing and transfers. Depending on the condition a wheelchair may beneeded to be able to sit out of bed and a toilet chair for toileting.

How can rehabilitation be of benefit for the hospital?

All evidence shows that early rehabilitation reduces the long-term impact of the injury orillness and that the actual costs for the hospital itself are not more (Morris et al. Critical CareMedicine (2008) Vol. 36, no. 8).

The main benefits are as follows:

Early rehabilitation will ensure a faster recovery from injury and illness and reducethe risk of secondary complications (see below table for detailed information). Lesssecondary complications, means less time spent with the patient, in order to treat thecomplications, that often take much longer to treat, than initial rehabilitation.

A higher turn-over of patients. By providing early rehabilitation, this increases the comprehensiveness of the service

provided by the hospital. Overall this means an improved quality healthcare service provision, which in turn

will increase the hospital reputation.

Body /System

Risks with norehab

How soon candetrimental

effects occur?

What can be

done?

Benefits of

rehab

Reference

Muscles

MuscleshorteningMuscleweakness andatrophyDecreasedmotor unitactivityNecrosis ofmuscle

In a healthypopulation areduction of 1-1.5% of musclemass occurs perday of bed rest

Active and active-assisted exercisesStrengtheningexercisesPositioning tomaintain musclelengthMuscle stretching

Maintain musclelength, musclestrength andoverall musclephysiologyMaintainfunctional abilities

Van Peppen et al. 2004

http://www.hopkinsmedicine.org/Press_releases/2010/04_09_10.htmlNeedham et al., Volume91, Issue 4, Pages 536-542 (April 2010)P. Bailey et al. Crit CareMedicine, 2007 Vol. 35,

Paddon-Jones D et al.(2004) J Clin EndocrinolMetab 89:43514358Honkonen SE et al.(1997) InternationalOrthopaedics, 21:323-

326

Joints

Joint stiffnessand contracturePain as a resultof joint stiffness/ contracture

At least withintwo weeks of bedrest

Joint range ofmotion exercisesPositioningUse of assistivedevices tomaintain jointrange

Reduce risk ofjoint contracturesMaintainfunctional abilities

Brower, Critical CareMedicine 2009,37(Suppl 1) S422.

Heidi Clavet et al. CMAJ2008 178 (6)

Bone Health

Reduced bonemineral density,which could leadto onset ofosteoporosis

and increasedfracture riskPoor bonehealingfollowingfracture

Bonedemineralisationoccurs at a rate of6mg per daycalcium. This

equals to approx.2% bone massper month, whichcan take up to 2years to recover

Following fracture:Muscle strengtheningexercises to increase thetensile strength of the bonesEarly weight-bearing (as

soon as fracture stabilisedand weight-bearing safe)The bedridden patient:Early muscle strengtheningexercises and weight-bearing to maintain bone

Prevention of bonedemineralisationIncrease bone healing withearly weight-bearing (thiswill increase the local blood

supply)Early rehab (exercises andweight-bearing) followingfracture will ensure fasterrecovery through increasedloading of bone, which will


16/138

Page - 16

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

mineral density stimulate local blood supplyand bone healing/growthand long-term tensilestrength of bone

NervousSystem

Critical illness polyneuropathy(CIP) = Acute primary axonalsensorimotor degenerationReduced muscle and jointproprioception. This meansthe sense of movement andposition of a particular bodypart through the proprioceptivenerve endings in the musclesand joints. These are reduceddue to immobility

2-5 days afteronset ofcritical illness

Ensure

exercise assoon aspossible

Reduce risk ofmuscle

atrophyMaintainfunctionalabilities

Pandit and AgrawalClin Neuro

Neurosurg2006;108:621-7.Hermans et al.(2008. Critical care12 (6)

Skin Pressure sore

Skin break-downcan happen within2 hours or evenquicker,depending on theperson (age,nutritional health,age, incontinenceetc.)

Position change atleast every 2hours (dependingon skin condition)Pressure relievingcushion/mattress

Reduce risk ofpressure sore

http://www.nice.org.uk/nicemedia/pdf/clinicalguidelinepressuresoreguidancercn.pdf (2001)

RespiratorySystem

DecreasedoxygensaturationReduced VO2Max. - Thismeans themaximumoxygen uptakeper minute)PneumoniaReduced chestcompliance

VO2 Max maydecrease up to0.9% per dayThe respiratorysystem deficitswill also dependon the pre-morbidcondition (forexample age, pastmedical history ofrespiratoryproblems)

PositioningEarly sit up in bedand exerciseStanding andmobilising as soonas possibly andfrequentlyDeep breathingexercise

Improve lungfunction byoptimizingVentilation/Perfusion,lung volumes andairway clearanceReduce durationof mechanicalventilation

Schweickert WD,Pohlman MC, PohlmanAS, et alLancet. 2009;373:1874-1882. Epub 2009 May14Trauma: Critical CareBy William C. Wilson etal. (2007)

Cardio-vascularSystem

Increased heart rate(needed to maintain theresting V02 max.)Reduced stroke volume(SV). This means theamount of blood, which ispumped out of the leftventricle in one heart beatDecreased aerobic capacity(exercise tolerance)Orthostatic hypotensionThrombo-embolic disease:deep vein thrombosis,pulmonary embolism

Reducedstroke volume(SV) ofapprox. 28%after 10 daysbed restDepending onpre-morbidcondition (forexample age,past medicalhistory ofcardiovascularproblems)

PositioningRegularmoving in bed,sitting andstandingEarly exerciseCompressiondevices

ImprovecardiovascularfitnessReduce risk ofcardiovascularcomplications

Trauma: CriticalCare By William C.Wilson et al. (2007)

Cognition

DecreasedcognitivefunctionConfusion andhallucinations(from bed restand medication)Reducedinteraction andcommunication

Depending oncondition, pastmedical history,medication

Early stimulationEarlyidentification ofcommunicationabilityExercise and dailyactivityDaytimeorientation

Improve level ofconsciousnessReduced deliriumwith earlymobilisation

Schweickert WD,Pohlman MC, PohlmanAS, et alLancet. 2009;373:1874-1882. Epub 2009 May14Trauma: Critical CareBy William C. Wilson etal. (2007)

PsychologicalHealth

DepressionAnxietyApathy

Decreasedpain ToleranceSocialwithdrawal

Depending on

premorbidcondition, medicaland social factors

Exercise and daily

activitySocial interaction

Improve

psychological wellbeing

Trauma: Critical Care

By William C. Wilson etal. (2007)


17/138

Page - 17

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Other factors

Patient andrelativeeducation

Complicationsas a result ofineffective 24/7care because oflack ofknowledge ofhow to care forpatient

Education aboutexercise,positioning, howto regain functionthroughparticipation inactivities of dailyliving

ImprovepsychologicalhealthOptimise recoveryof functionthroughappropriate carefrom relatives

Rehabilitation aftercritical illness, NICEClinical Guidelines 2009,UK

Hospitallength ofstay

Increasedhospital lengthof stay

Earlyrehabilitation

Reduced ICUlength of stay

Needham et al., Volume91, Issue 4, Pages 536-542 (April 2010)Morris et al. CriticalCare Medicine (2008)Vol. 36, no. 8

Dailyfunction

Loss of thisability or poorregain offunction due tolong duration ofbed rest andlearned non-useReducedbalance andmobilityReducedphysicalcapacity

Depends on pre-morbid condition,severity of injuryor illness

FunctionalexercisesParticipation inactivities of dailyliving as soon aspossible

More likely toreturn toindependentfunction at timeof discharge fromhospitalIncreased level ofmobility

Van Peppen et al. 2004.Schweickert WD,Pohlman MC, PohlmanAS, et alLancet. 2009;373:1874-1882. Epub 2009 May14P. Bailey et al. Crit CareMedicine, 2007 Vol. 35,No.1.Perme andChandrashekar (2009)American Journal ofCritical CareNeedham et al., Volume91, Issue 4, Pages 536-542 (April 2010)


18/138

Page - 18

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Note II - The Early Rehabilitation Pathway

The below graph presents the different steps through which patients receiving earlyrehabilitation in a hospital go through.

Admission in the hospitalWhen arriving at the hospital, the patient will first go through admission and registration procedures

Emergency care

Depending on the patients situation, it might be needed to first provide him with urgent medical care in orderto stabilize his condition

Early rehabilitation needs assessment

Within the first days of hospitalization (even if the patient situation is not totally stabilized), it is importantthat a doctor or a nurse does an assessment of the patients needs in terms of early rehabilitation.

To do so, the person in charge should use the Early Rehabilitation Needs Assessment Form (see below).

If the result of the early rehabilitation needs assessment shows that the patient is in need of early

rehabilitation, he/she should be referred to the rehabilitation department (or medical staff that receivedtraining on early rehabilitation)

Risk assessment and rehabilitation assessment

After the patient has been referred to the rehabilitation department, a deeper assessment has to be done toidentify the exact needs of the patients in terms of early rehabilitation and set up the exercise/treatment

plan. To do so, the person in charge should use the Assessment Form (see below).

The first step of the assessment should consist in doing a risk assessment. The purpose of the riskassessment is to identify situations in which early rehabilitation is contra-indicated or in which specialattention should be paid when providing early rehabilitation services (relative contra-indications and

precautions). To do so, the person in charge should use the Rehabilitation Risk Assessment Form (seebelow).

Exercise plan

The next step is to set up an exercise plan. This step consists in deciding which exercises need to be donewith the patient, using the result and the information gathered during the rehabilitation assessment. To

record the exercises that need to be done, the person in charge should use the Exercise Plan (see below).

Provision of early rehabilitation and treatment follow-up

The exercises that were set up can now be provided to the patient on a regular basis (at least once/day).While providing early rehabilitation services, the person in charge should regularly (once/week) check the

patients improvement in order to adapt the treatment plan. This is called treatment follow-up. If thetreatment plan needs to be updated, such updates should be recorded in the exercise plan.

While providing early rehabilitation services, it is important not to forget about teaching and information tothe patient and/or his/her family. The patient should learn exercises he/she can do on his/her own; he/sheshould also be provided with recommendations and informed on his/her situation. To do so, the person in

charge should use the information brochures and the exercise cards (see part 4 of the manual)

Discharge and referral to community-based/institution-based rehabilitation services

When the patients situation has improved enough, he/she will be discharged from the hospital. If he/she stillneeds longer-term rehabilitation services and those services are available at community level (community-

based rehabilitation services or institution-based rehabilitation services), the patient should be referred to oneof those services.


19/138

Page - 19

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Note III Patient Management

1. The Blank Forms

- The Early Rehabilitation Needs Assessment Form should be used to assess thepatients needs in terms of early rehabilitation services. The form aims to help medical staff

who lack information on early rehabilitation, identify patients in need of such services. Theform is made up of a series of questions and if the answer to one of those questions is yes,it means that the patient is in need of early rehabilitation services and should, therefore, bereferred to the rehabilitation department (or a staff that was trained on early rehabilitation).

- The Rehabilitation Risk Assessment is a form that should be used to identify contra-indications, relative contra-indications and precautions regarding the provision of earlyrehabilitation services. The form should be filled in before doing the rehabilitationassessment and the result of the risk assessment should be recorded on the rehabilitationassessment form.

- The Rehabilitation Checklist Guidelines are guidelines (checklist format) that can be

use by medical or rehab staff to identify the needs for early rehabilitation, according to thepatients injury (there is one guideline per main injury). The form can also be used tomonitor the provision of early rehab services. It is, somehow, a very simplified andsummurized version of the PT protocols and, therefore, they should be used in parallel withthis manual.

- The Assessment Form should be used before starting to provide early rehabilitationservices. The purpose of the assessment is to gather information on the patients situationand needs. The result of the assessment will then be used to set up the treatment/exerciseplan.

- The Exercise Plan is used to record the exercises that were prescribed at the end of the

assessment. This form can also be used to record updates and changes made in the initialexercise plan during the treatment follow-up.

2. The Patient File

The patient file is used to gather all the forms used for the patient. The file ensures that allthe forms and the information they contain will remain available in one place.

3. The Patient Database

The patient database is used to record the most important information regarding the patientsuch as his/her age, sex, address, injury, phone number, registration number, rehabilitationneeds Such database has a two-fold purpose: first, it allows tracking the patients (whenneeded) and, second it allows getting a general picture of the services provided andoutcome of services through statistics.


20/138

Page - 20

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

P A R T 2 . T H E E A R L Y R E H A B I L I T A T I O N P R O T O C O L S B Y I N J U R Y

Early Rehabilitation Protocol for Amputation Early Rehabilitation Protocol for Bone Fracture Early Rehabilitation Protocol for Spinal Cord Injury Early Rehabilitation Protocol for Head Injury Early Rehabilitation Protocol for Bedridden Patients Early Rehabilitation Protocol for Peripheral Nerve Injury Early Rehabilitation Protocol for Burn


21/138

Page - 21

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

TRAINING OF REHABILITATION STAFF, NURSES AND DOCTORS IN HOSPITALS

Early Rehabilitation Protocol for Amputation

1. General Information on Amputation

1.1. Definition

An amputation is the loss of a part of the body.

1.2. Causes

The causes of an amputation can be various. The amputation can be caused by atraumatism (for instance: traffic accident, job accident, a fall), by an illness (cancer,leprosies, diabetes, gangrene caused by frostbite), or by a congenital deformity (a partof the body was missing when the baby was born).

1.3. Types

Any part of the body can be amputated. The name given to the amputation depends on thepart of the body that is missing.

The main types of amputation are:

The shoulder disarticulation (1) The arm amputation (2) The elbow disarticulation (3) The forearm amputation (4) The partial amputations of the hand (5) The hip disarticulation (6) The trans-femoral amputation (AK) (7) The knee disarticulation (8) The trans-tibial amputation (BK) (9) The ankle disarticulation (10) The partial amputations of the foot (11)


22/138

Page - 22

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

1.4. Stump surgery

The stump is the part of the amputated limb that remains (for example, in case of BKamputation, the stump is the part of the leg between the amputation and the knee).

The quality of the stump depends on the quality of the surgery (the quality of the surgerydoes not depend only on the surgeon's skill but also on surgery conditions, on the conditionof the stump before surgery, and on the general condition of the patient). A good stump

condition is important to facilitate the patient's prosthesis fitting.

There are rules for this surgery, and we present here 3 of the most important:

Stump length (a) Bone covering (b) Special rules for the BK (below knee) amputation (c)

(a) Stump length

The length of the stump is very important when fitting a patient with a prosthesis: a too

short stump will give the patient difficulties in controlling his prosthesis well, and it will bemore difficult for the technician to fit (if he has to adapt the prosthesis with, for example, athigh belt above the knee). A too long stump will also give the technician problems(difficulties making the prosthesis alignment).

For these reasons, the ideal length for a stump is when theamputation is made at the level of the medium third of thelimb (this means: at least 10 cm below the proximal joint or 8cm above the distal joint).

Between these 2 points (10 cm below the superior joint and 8cm above the inferior joint), alllevels of amputation are possible and considered as ideal. The longest stump (between thosetwo points) will help the patient to control his prosthesis (higher force).

(b) Bone covering

After the surgeon cuts the bone and before hecloses the stump, the surgeon must cover thebones extremity with smooth tissue (muscleand skin) in order to protect the stump. For

that, in general, the anterior muscles of thestump are stitched up with the posteriormuscles.

More or less 2 centimeters of smooth tissue isnecessary to cover the extremity of the bonewell. If there is less than 2 cm, the extremityof the bone will be prominent below the skinand could create pain or a wound. If there istoo much smooth tissue (more than 2 cm), the

extremity of the stump will be too floppy andwill complicate the patient's prosthesis fitting.


23/138

Page - 23

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

(c) Special rules for BK amputation

For Below Knee amputations, there are 2 rules that must befollowed during surgery:

The anterior part of the extremity of the tibia should becut obliquely so it wont hurt and the bone wont grow.

The fibula should be cut 2 cm shorter than the tibia.

1.5. Complications

Possible amputation complications are varied:

Infection (a) Exostosis (b) Neuroma (c) Phantom pain (d)

Muscle shortness (e) Muscle weakness (f) Stump oedema (g)

(a) Infection

Like any kind of wound, the scar after an amputation is an open door to bacteria or a virus.An infection could appear easily at the scar. This infection can also go up to the bone andcause a major infection (osteomyelitis). In that case, the patient will need new surgery;otherwise the infection can become general and even kill the patient).

(b) Exostosis

Exostosis is an abnormal bone growth. Afteramputation, sometimes the extremity of the cut bonecan grow. This bone growth appears below the skinand can cause pain or a wound. The only possibletreatment for exostoses is surgery. It often happenswhen the tibia was not cut well, obliquely, as explainedpreviously.

(c) Neuroma

Neuroma is an abnormal growth of a nerve that was cut during amputation.The nerve grows in a ball. If the skin is closed over it (it lies just belowthe skin), that zone can be very painful (kind of electric shock when wetouch it). In this case also, the only solution is surgery.


24/138

Page - 24

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

(d) Phantom pain

Phantom pain is an abnormal sensation around the amputated limb. Thepatient has the impression, for example, that the foot which was amputated isstill painful (the patient feels pain in the foot that does not exist anymore).The real cause of this pain is unknown. Some theories say that the part of thebrain that was responsible for the sensation of the amputated limb starts towork abnormally, which lead to perception that the body part still exists. Other

theories say that the sensory nerve that was cut will still send messages to thebrain. Since the messages that were carried by that nerve were coming beforethe amputation from the amputated limb, the brain interprets them as stillcoming from the same place (the amputated part of the limb).

Those pains are not dangerous but they can be very boring because they can be presentfor a long time after amputation. Nevertheless, most patients say that the pain decreasesafter a while, even without treatment.

(e) Muscle shortness

After the surgery and before receiving prostheses, the patient wont use his amputated limbmuch. In that case; some muscles might become shorter very quickly. This mainly happenswith the hip flexors, the hip abductors and the knee flexors (for lower limb amputation) andwith the shoulder adductors and elbow flexors (for upper limb amputation).

Muscle shortness might be a problem for the use of prostheses (if the knee or hip flexors aretoo short, the ranges of motion in the hip or the knee will be decreased which will makewalking difficult)

(f) Muscle weakness

For the same reason as for the muscle shortness (non-use of the amputated limb), themuscles around the limb might quickly become weaker.

Weak muscles will make the use of the prostheses quite difficult as using prosthesesrequires stronger muscles than usual. This is particularly true with the lower limbamputation; walking with prostheses requires strong hip extensors, hip abductors and (if theamputation is below the knee) knee extensors.

(g) Stump oedema

Stump oedema very often occurs right after the surgery and is a normal reaction. But if itpersists and is not addresses properly, the oedema will make the fitting of prosthesesharder. When starting to use the prostheses, the stump will, at first, quickly become thinner(the oedema will decrease). If the stump becomes much thinner (which will happen if thereis still swelling in the stump when the prostheses is produced), a new prostheses will beneeded after only a few days.

1.6. Notions about the prosthesis

Prostheses are fake limbs that are made to replace the missing part of the amputatedlimb. There are two main kinds of prostheses:

The lower limb prostheses (a) The upper limb prostheses (b)


25/138

Page - 25

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

(a) The lower limb prostheses

The BK (Below Knee) prosthesis

The BK prosthesis corresponds to an amputation at the level of the leg (thetibia -below the knee joint and above the foot). It is composed of 3 mainparts:

The socket (1)

The pipe (ppp or metal) (2)

The foot (3)

The AK (Above Knee) prosthesis

The AK prosthesis corresponds to an amputation at thigh level (the femur -below the hip joint and above the knee joint). It is composed of 4 main parts:

The socket (1)

The knee (2) The pipe (metal) (3)

The foot (4)

Note: There are also other types of prostheses for the lower limb amputation, such as thehip disarticulation prosthesis (that includes a hip joint), the knee disarticulation prosthesis(which look like the AK prosthesis but have some particularities with the socket) or thepartial foot amputation.

In a general way (which is not always true) we can say that the lower the amputation is, theeasier it will be for the patient to walk properly with the prostheses. This means that apatient with a foot amputation should be able to walk better than a patient with BKamputation or a patient with knee disarticulation or with AK amputation. This can beexplained by the fact that the less joints there are in the prostheses, the easier it gets tocontrol it (controlling the prosthetic knee can be a bit difficult). Also, the weight-bearing site(the place where the patient takes support to bear his body weight on the prostheses)change from one prostheses to another and the weight-bearing site in a BK is better adaptedthan the weight-bearing site on an AK which makes it easier to walk.

(b) The upper limb prostheses

The forearm prosthesis

Such prosthesis is composed of a socket and a prosthetic hand.


26/138

Page - 26

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

The arm prosthesis

Such prosthesis is composed of a socket, a prosthetic elbowand a prosthetic hand.

Note: Nowadays, new technologies allow developing myo-electric upper limb prostheses.Those allow controlling the hand (and the elbow) using the muscles of the shoulder.Electrodes are placed on some muscles of the shoulder and by contracting them, the personcan control the movements of the prosthetic hand and elbow. This makes those prosthesesmore useful because it is possible to control finer movements with mechanic prosthesis, thepatient can just open and close the hand, which is not always very functional.


27/138

Page - 27

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

2. PT Protocol for Amputees

After the patient has been hospitalized and, when needed, emergency medical care has beenprovided in order to stabilize the patient, it is necessary to make an assessment of his/herneeds in terms of early rehabilitation. To do so, doctors or nurses in charge of the patientshould use the Early Rehabilitation Needs Assessment Form (see annex). This form aims tohelp medical staffs that lack knowledge on early rehabilitation to identify the patients in

needs of such services. Depending on the result of this simple assessment, the patient wouldor would not be referred to the rehabilitation department (or staff trained on earlyrehabilitation). Usually, all amputees should be referred for early rehabilitation.

2.1. Assessment

Before setting up a treatment plan for an amputated patient, it is important to collect someinformation on the patient, on his/her history and on the amputation. Such informationshould be recorder in the assessment form (see annex).

Beside the general information on the patient (name, age, sex), here is a non-exhaustivelist of the main pieces of information that need to be collected:

(a) History of the amputation

What is the cause of the amputation? Was it an accident? What kind? Was it an illness?Which one? Is the amputation congenital (present from birth)?

When was the patient amputated (date of amputation)?

Which part of the body is amputated? The lower limb? Which part of the limb? The upperlimb? Which part of the limb?

Since the amputation, did the patient receive medical care (beside the normal scar care)?

How was the healing of the scar? No infection? No complications?

Since the amputation, did the patient receive rehabilitation care? What kind? For how long?What did it consist in?

(b) Assessment of the stump

How is the scar? Is it healed? Is it infected?

Are there other wounds on the stump?

How is the shape of the stump? Is it conic? Is it square? Is there oedema (compare the

perimeter of the stump with the perimeter of the sound limb to confirm swelling)?

How long is the stump? Too long? Too short? Is it the right length to produce a prosthesis?

Are there complications such as exostoses?

Does the patient feel pain in the stump? What kind of pain? When?

(c) Assessment of the muscle strength

Are the main muscles strong or is there weakness? Which muscles are weak?

(d) Assessment of range of motion

Is there any decrease of ROM? What causes that decrease of ROM? Muscle shortness or jointdeformity? Which ROM is limited?


28/138

Page - 28

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

(e) Assessment of the balance (if lower limb amputation)

How is the patients balance? Can he maintain standing position? Can he jump? Can pick upsomething from the ground?

(f) Assessment of function

Does the patient face difficulties with daily life activities (moving around, feeding, dressing,

using toilets)? What kind of difficulties?

Gathering those pieces of information is important in order to be able to set up a treatmentplan (what exercises to do) and to have a record of the patients situation before starting thetreatment (such record will allow the PT evaluating the efficiency of the exercises later on -during the treatment - by comparing the present situation and the initial situation suchcomparison allows to see if the patients abilities and condition are improving).

2.2. Treatment in the hospital (early rehabilitation)

Early rehabilitation will take place in the hospital, starting as soon as possible after the

amputation. The main purpose of the treatment will be to prevent complications fromappearing and to prepare the patient and the stump for receiving a device.

In order to do so, and according to the information collected during the assessment, thefollowing exercises should be done with the patient:

(a) Starting right after the surgery (day 1)

Passive mobilization: Passive mobilization aims to prevent muscle retraction anddecrease of ROM as well as other complications such as bedsores and blood circulationproblems. All limbs should be mobilized, included (and especially) the amputated limb. Fordetails, refer to the passive mobilization protocol.

Active mobilization: Active mobilization aims to prevent muscle retraction and muscleweakness as well as other complications such as bedsores and blood circulation problems.All limbs should be mobilized, included (and especially) the amputated limb. For details,refer to the active mobilization and strengthening protocol.

Positioning: The patient should learn which position should be avoided in order toprevent muscle shortness. Some of those positions cannot be completely avoided (forexample, the sitting position is not a very good position for AK amputees, but we cannot askthe patient to avoid sitting for the whole day. In that, we should recommend him to avoidthat position as much as possible and recommend him other positions which are better

Position to prevent (for BK amputation)

Laying on the back with apillow under the knee

Sitting with the knee inflexion

Standing with the knee inflexion (taking support on

the crutch)


29/138

Page - 29

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Position to recommend (for BK amputation)

Laying on the back with theknee in complete extension

Sitting with the knee inextension (using support for

the stump)

Position to prevent (for AK amputation)

Laying on the back with a pillowunder the thigh

SittingStanding with the hip in

flexion (taking support onthe crutch)

Position to recommend (for AK amputation)

Laying on the belly with apillow under the thigh

Other: if the patient has to stay in bed (bedridden patient), other common complications(respiratory problems, bedsores, blood circulation problems) also have to be preventedusing specific methods. For details, refer to the bedridden patients protocol.

Patient information and training: Information on the patients situation, his/her needsand his/her future should be provided to the patient or to his/her family. Informationbrochures can be used to do that. Also, when possible, the patient or his/her family shouldbe taught how to do basic exercises by themselves. Material is also available to ease theteaching. For details, refer to the Teaching and informing the patient and his/her familymembers protocol.

(b) Starting on day 2-3

Muscle strengthening: all limbs should be strengthen, included the amputated limb.For lower limb amputation, special attention should be given in strengthening the musclesimportant for a good gait (the hip extensors, the hip abductors and the knee extensors) andthe upper limb (for walking with crutches). For classic muscle strengthening exercises, referto the active mobilization and strengthening protocol. With lower limb amputees, thefollowing three specific exercises can also be used:

Hip extensors (lift up thepelvis, count until 5, then

Hip abductors (lift up thepelvis, count until 5, then

Knee extensors (lift up thebuttocks, count until 5, then


30/138

Page - 30

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

rest. Repeat the movement20 times, 3 times/day)



(c) Starting on day 3-4

Standing up: The patient should get out of bed as soon as possible to prevent thecommon complications of bedridden patients. For details, refer to the transfer and mobility

protocol.

Balance in standing position: Some balance exercises can be done in standingposition. For details, refer to the balance exercises protocol.

Walking with crutches/walking frame: If the patient is amputated from one of thelower limbs, he should learn how to move around using crutches or a walking frame (if thebalance is not good enough to use crutches).For details, refer to the transfer and mobilityprotocol.

Using a wheelchair: If the patient has an amputation of both lower limbs, he shouldlearn how to move around using a wheelchair.For details, refer to the transfer and mobility

protocol.

(d) Starting after the stitches have been removed (if there is no open wound or signsof infection)

Stump bandage: the stump bandage aims to prevent or decrease the stump swellingand give a good shape to the stump.

Rules to respect for the stump bandage:

A bandage should be made in a figure of "8". We cannot do acircular bandage (this means that the bandage should always

go up or down and not go in circles around the stump).

The pressure made by the bandage should be more at the extremity of the stumpthan at its proximal part (so it won't prevent the blood from circulating normally).

The extremity of the stump should be completely covered by the bandage (the skincannot be visible).

There must not be folds in the bandage. The stump must not be painful. If it is, it means that the bandage is too tight. The PT should teach the patient how to do the bandage by himself, so he can put it

on alone. The bandage should be reapplied everyday, after treatment, until the day of the first

fitting (the day the patient receives his prosthesis).

Technique for AK stump bandageTechnique for BK stump

bandage

The bandage should be kept the whole day.


31/138

Page - 31

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Note: The same technique and rules can be used for upperlimb amputation too.

(e) Starting when the scar is healed

Scar massage: The purpose of scar massage is to maintain the scar flexible bypreventing it from getting attached to underneath tissues (like muscles or bones). This isimportant because an attached scar will make more difficult for wearing a prosthesis (thescar would be painful and wound can appear).

Rules to respect during a scar massage:

The patient should be installed in a comfortable position.

The PT cannot use talcum powder for this kind of massage (because of the talc, thefinger will slip and won't be able to "grab" the scar properly). Only fingers are used during scar massage (not the whole hand). The movements should always be made in the direction of the scar. The massage is not made directly on the scar but around it. The following techniques should be used:

Scar massage should be done for about 10 minutes, 2 times/day.

Note: If for some reason the patient has to stay in bed for a long time after the amputation,he/she might develop bedridden complications. Those complications have to be prevented oraddressed properly. To do so, PT exercises can be used. For details, refer to the PT protocolfor bedridden patients.

Note: If the patient complains from phantom pain, the following techniques can be used

(their efficiency cannot be guarantied):

Before using any kind of treatment, explain to the patient what is happening (thebrain misinterprets messages) and that the pain is not linked to any kind of mentalillness, its a very common problem that most of the time decreases and disappearsafter a while.

TENS, acupuncture, medications (pain-killers, antidepressant, muscle relaxant),massage, heat or cold, ultrasound are reported as being useful to decrease phantompain.

An innovative technique uses a mirror box in which the sound limb and the stump areplaced. The mirrors give the impression to the patient that the amputated limb is stillthere (the patient, thanks to the arrangement of the mirrors, sees two legs or twoarms in the box while there is actually only one). Then, the patient moves the soundlimb and he/she has the impression that the amputated limb is also moving. This canhelp to release phantom pain.


32/138

Page - 32

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

2.3. Treatment in the rehabilitation centre and in the community (long-termrehabilitation)

Long-term rehabilitation will take place in a rehabilitation centre (or in a rehabilitationdepartment in a hospital) and in the community.

Note: For details on long-term rehabilitation, institution-based rehabilitation and communitybased rehabilitation, refer to the information brochure (Information on rehabilitation).

(a) In a rehabilitation centre

The main purposes of the treatment in a rehabilitation centre will be to provide the patientwith a prosthesis and to teach him how to use it. In case of problems such as muscleshortness, muscle weakness, poor balance or stump problems, exercises will have to bedone to address those problems before producing the prosthesis.

Therefore, the treatment in the rehabilitation centre might be composed of the 3 followingsteps:

Pre-fitting treatment (muscle stretching, muscle strengthening, balance exercises,

stump bandage, scar massage, care of wounds). Production of the prosthesis Post-fitting treatment (exercises to teach the patient how to use the prostheses

properly).

Note: For details on exercises done in a rehabilitation centre, refer to the training document(PT management of patient suffering from lower limb amputation).

(b) In the community

Community-based Rehabilitation (CBR) program can be helpful for amputees in variousways:

Home visit to check up on the general patients physical situation Home visit to check up on the device (does it still fit? Is it broken?), and referral to

specialized structure (rehabilitation centre) if needed Guidance for home accessibility Guidance for access to school or vocational training centre or job Participation to self-help groups Awareness raising activities for the community members on disability-related issue

(disability, rehabilitation, disabled persons needs and abilities).


33/138

Page - 33

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

TRAINING OF REHABILITATION STAFF, NURSES AND DOCTORS IN HOSPITALS

Early Rehabilitation Protocol for Bone Fracture

1. General Information on Bone Fracture

1.1. Definition and causes

A bone fracture can be defined as a break in a bone (thebone is "broken").

Fractures generally happen because of a trauma (a hit onthe bone, a fall, a car accident), but it also can be the resultof a weakened bone (the bone may become weaker becauseof a disease, such osteoporosis or because of repetitivestress - during intensive sport activities, for example - suchas stress fracture).

1.2. Types of fracture

Here are some of the main kinds of fracture:

Comminutedfracture

A fracture ofmany relativelysmall

fragments

Openfracture

A fracturewhich breaksthe skin

Simplefracture

The bonebroke into twopieces; thetwo parts ofthe bone did

not move

Multiplefracture

More than onebone is brokenor the same

bone is brokenin different

places

Greenstickfracture

A fracture inwhich the bonebent but is not

completelybroken

Spiralfracture

A fracturewhich runsaround theaxis of the

bone

Displaced fracture: The bone is broken into two pieces and the two parts of the bone moved

Closed fracture: The bones which broke do not penetrate the skin


34/138

Page - 34

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

1.3. Diagnosis

In general, doing an X-ray is the best way to confirm a fracture. X-raysare a form of electromagnetic radiation (like light); they are of higherenergy, however, and can penetrate the body to form an image on film.Structures that are dense (such as bone) will appear white, air will beblack, and other structures will be shades of gray depending on density(the higher is the density, the whiter they appear).

The X-ray on the right shows a double fracture (multiple fracture) of thetibia and the fibula.

1.4. Complications

The complications of a bone fracture can appear directly or can appear during theconsolidation of the bone (the healing process).

Direct complications

The bones are the place of production of blood cells. Therefore, a fracture of a bonewill generally be accompanied by internal bleeding (hemorrhage).

If there is displacement of the fractured bone, thefractured extremity of the bone may damage internalorgans. This may happen, for example, with afracture of a rib that will pierce the lung(pneumothorax) or a fracture of the iliac bone thatwill pierce the bladder.

The fractured extremities of a broken bone may alsodamage blood vessels or nerves (peripheral nerveinjury). This may happen, for example, with afracture of the head of the fibula that will damagethe fibular nerve or with a fracture of the ulna thatdamages the ulnar nerve. If the patient presentswith peripheral nerve injury, refer to thecorresponding protocol for details on the exercisesthat can be done.

If the fracture is located onthe spine or the skull, it can

lead to spinal cord or braindamage and, therefore,paralysis.

Late complications

If the fracture was open, it can lead to infection (bone or othertissues)


35/138

Page - 35

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

A fracture can have problem to heal. This phenomenon is calledpseudarthrosis (the bone doesn't heal).

Compartment syndrome: compartments are groups ofmuscles in the limbs that are covered by a tough

membrane that cannot expend easily. Within thosecompartments, there are also nerves and blood vessels.Severe swelling on the fracture site will cause pressure onthe blood vessels because the membrane cannot expendmuch, which would decrease the blood supply to musclesand nerves. The decreased blood supply will lead to nervedamaged and muscle death. This most often happens withfracture of the legs bones (tibia and fibula).

Note: Patients with fractures that require staying in bed for a long time (complex fractures,tractions, fracture of the spine) may develop other types of complications that are linked tothe fact that they have to stay in bed. Those are called bedridden patient complications. Itis, for example: muscle weakness, muscle retraction, breathing problems, blood circulationproblems, digestive problems For details, see below.

Note: Plaster or other types of immobilization will generally lead to muscle problems aroundand close to the fractured bone. Those are: muscle weakness (the muscles dont work, sothey become weaker) and muscle shortness (the muscle stay for a long time in a shortposition and then become shorter).

Note: Victims of earthquake (or other natural disaster) that suffer from fracture might alsopresent with crush injury or soft tissues injuries. If the patient suffers from crush injury orsoft tissue injury, refer to the reference document on crush injury syndrome (available onthe capitalization DVD)

1.5. Medical treatment

To heal properly, a fractured bone should be realigned if displaced (the realignment of adisplaced fractured bone is called "reduction") and immobilized. There are different ways ofreducing and immobilizing a broken bone:

Methods of reduction

If there is no displacement, no reduction is needed. If there is a slight displacement, the reduction can be done without chirurgical

intervention (without operation). This can be done by doing traction on the bone(manual traction or using weights).

If the displacement is too important, surgery will be needed to reduce the fracture.In this case, the reduction is said "open reduction" (because the surgeon cuts theskin to reduce the fracture).

Traction Open reduction


36/138

Page - 36

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Methods of immobilization

The most common way of immobilizing a bone is using plaster or splint. If the fracture is open, external fixation might be recommended to prevent from

having plaster on the wound and risk infection. External fixation involves a surgery.External fixation is done with a device that supports the bone and holds it in thecorrect position while it is healing. An example of external fixation is shown on thedrawing below.

If the fracture is complex (comminuted, spiral, multiple), internal fixation might be the only way of stabilizing the bone. Internal fixation involves a surgery.

It is generally done by using metal rods, screws or plates that remain in place in thebone after the surgery. Examples of internal fixations are shown on the drawingsbelow.

Note: Unless the internal fixation causes problems, it is not necessary or desirable toremove it.

Plaster and splint External fixation Internal fixation

1.6. Healing process

Healing is the process of recovery of the integrity of an injured system, such as a fracturedbone.

The healing process of a fracture bone occurs in 4 different stages:

1. Right after the injury, the integrity of the brokenbone is provisionally restored by a blood clot (theblood clot takes the space left by the fracturebetween the bone fragments).

2. During the second stage, the blood clot will bereplaced by fibro-cartilaginous tissue. This fibro-cartilaginous tissue is called the callus. The callusis an irregular mass of tissue (it is bigger than thebroken part) and it is not yet strong bone tissue.Meanwhile, the dead bone tissue is removed.


37/138

Page - 37

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

3. The 3rd stage corresponds to the replacement ofthe fibro-cartilaginous callus by mature bonetissue. At that stage, the bone tissue is not yetlined up with the rest of the bone.

4. The last stage is the remoulding stage. Duringthat stage, the bone tissue is re-organized in theright direction (the bone is ordered into paralleland concentric layers that are aligned in precisely

the right way).

The X-rays here below show different stages of the healing process of a broken bone:

The fracture is wellvisible Here we can see the

callus in the middleof the femur

The callus disappeared and has been replaced bymature bone tissue. The new bone tissue has been

remoulded in order to give back the bone its originalshape. The new bone tissue is still visible (whiter).

In general, we consider that it takes 6 to 8 weeks for a bone to heal, but in some case alonger immobilization might be required (a vertebra needs 10 to 12 weeks to healcompletely).

Note: The time necessary for healing is influenced by various factors, such as:

The patients age (younger people heal faster than older people) The nutrition (varied food such as milk, rice, vegetables, meat) speed up the healing

process The type of immobilization (using internal or external fixation help healing faster

because they dont allow any movement in the bone while a plaster doesnt alwaysstabilize the bone very well)

The blood supply (more blood means better healing. Blood supply can be increasethrough exercises such as PT exercises)

The type of fracture (complex fractures such as comminuted or displaced or multiplefractures- take more time to heal then simple fractures)

The location of the fracture (some bones need more time to heal then others)

The table here below presents the average time needed for healing for the main bones ofthe body with a cast:

Bone fractured Time for healing Bone fractured Time for healing

Iliac bone 2 to 6 weeks Humerus 4 weeksFemur 12 weeks Ulna/radius 6 weeksPatella 6 weeks Wrist 3 to 8 weeksTibia/Fibular 6 to 8 weeks Vertebra 10 to 12 weeksAnkle 6 weeks

Note: The above table is just informative. As already explained, there are so many variables

that can influence the time needed for healing that it is always recommended to have thedoctors green light for starting exercises such as weight-bearing and mobilization.


38/138

Page - 38

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

2. PT Protocol for Patients with Bone Fracture

After the patient has been hospitalized and, when needed, emergency medical care has beenprovided in order to stabilize the patient, it is necessary to make an assessment of his/herneeds in terms of early rehabilitation. To do so, doctors or nurses in charge of the patientshould use the Early Rehabilitation Needs Assessment Form (see annex). This form aims tohelp medical staffs that lack knowledge on early rehabilitation to identify the patients in

needs of such services. Depending on the result of this simple assessment, the patient wouldor wouldnt be referred to rehabilitation department (or staff trained on early rehabilitation).Usually, all the patients with fracture should be referred for early rehabilitation.

2.1. Assessment

Before setting up a treatment plan for a patient with bone fracture, it is important to collectsome information on the patient, on his/her history and on the complications. Suchinformation should be recorded in the assessment form (see annex).

Beside the general information on the patient (name, age, sex), here is a non-exhaustivelist of the main pieces of information that need to be collected:

(a) History of the fracture and the treatment

Which bone is broken? Where? What kind of fracture was it?

When and why the bone was fractured?

What kind of immobilization is used? Cast? External fixation? Internal fixation? What kind ofinternal fixation?

(b) Assessment of the complications

How are the ROM? Is there any decrease of range of motion? If yes, which movements havelimitations? How severe is the limitation?

How is the muscle strength? Is there any muscle weakness? Which muscles are weak? Howsevere are the weaknesses?

If the patient had surgery, how is the wound? Is there any sign of infection?

2.2. Treatment in the hospital (early rehabilitation)

Early rehabilitation will take place in the hospital, starting as soon as possible after the

patient has been hospitalized. The main purpose of the treatment will be to preventcomplications from appearing or to treat complications that are already present. Doingexercises also helps the fracture to heal faster as they increase blood circulation around thefracture.

In order to do so, and according to the information collected during the assessment, theexercises here below should be done with the patient. The exercises are presented by typeof fracture. When needed, refer to the protocols by techniques for futher details.

Note: The timeframe given hereafter are only informative and shouldnt be considered asuniversal reference. Indeed, there are many variables that will influence the healing process

and the possibility to start some exercises at the expected time. Before starting exercisessuch as weight-bearing, mobilization or strengthening, the doctors approval should besought. Nevertheless, the timeframe given hereafter provides the PTs with a clearer idea onwhen to seek for such approval.


39/138

Page - 39

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Note: In the treatment plans described here below, the obvious (such as active mobilizationand/or strengthening of sound limbs, prevention of other complications if the patient stays inbed, as well as stretching and/or strengthening of some muscles after immobilization andconsolidation) are not always described. The priority in those plans is given to the injuredparts of the limb during the time the patient will probably stay in the hospital. It is up to thetherapist to complete those plans with other exercises he/she would consider relevantaccording to the patients situation and needs.

(a) Shoulder fracture

Timeframe Exercise Description

Passive mobilization Elbow, forearm, wrist, fingers (and soundupper limbs and lower limbs, if needed).For details, refer to passive mobilizationprotocol.

Active mobilization Elbow, forearm, wrist, fingers and (andsound upper limbs and lower limbs, ifneeded). For details, refer to active

mobilization and strengthening protocol.Strengthening Forearm and hand muscles. For details,

refer to active mobilization andstrengthening protocol.

Day 1 week 3

Massage Neck, forearm and hand.From day oneon

Ice pack/ice cube Use cold (ice or pack) to decrease the painin the shoulder.

Pendular exercise andrelaxing exercise

See below

Passive mobilization Shoulder in all direction as tolerated (nostretching) (abduction, flexion, externalrotation +++)

Mobilization passive assisted Shoulder in all direction as tolerated andpossible (no stretching) (abduction,flexion, external rotation +++)

Day 2/3 week

3

Isometric contractions Deltoid, biceps, triceps

Form week oneHumerus head loweringexercises

Teach the patient how to actively lowerthe head of the humerus

Active mobilization Shoulder in all direction (no resistance)(abduction, flexion, external rotation+++)Week 3 week

6 Stretching Light stretching in all directions astolerated (abduction, flexion, externalrotation +++)

Strengthening Shoulder in all directions (abductors,flexors and external rotators +++)From week 6

on Stretching Shoulder in all directions (abduction,flexion, external rotation +++)

Here are examples of exercises that the patient can do by him/herself for the elbowfractures:

Pendual exercise Stand. Lean forwards. Let your arm hang down. Circleyour arm clockwise & anti- clockwise.Repeat 10x2 times.


40/138

Page - 40

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Relaxing exercise Stand or sit. Let your arm hand down (or the arm can be in

the arm sling). Circle you shoulder clockwise and anti-clockwise.Repeat 10 times.

Passivemobilization

Lying on your back. Support your operated armwith the other arm and lift it up overhead.Repeat 10 times.

Passivemobilization

Lying on your back. Grasp a stick in both your hands. Liftthe stick up and gently take overhead until you feel agentle stretch in your shoulder. Repeat 10 times.

Activemobilization

Standing in front of a wall. Put you hand on the wall andclimb up using your fingers. Try to reach as high aspossible.Repeat 10 times.

Stretchinginternalrotators

Lying or sitting. Put your hands behind your head, andgently stretch the elbows towards the floor/ backwardsto feel a gentle stretch on the front of your shoulders.Repeat 5 times.

Stretchinginternalrotators

Standing with your hand on the wall. Flex the elbow to 90degrees & hold the elbow close to your body. Gently turnyour body away until you feel a stretch at the front of theshoulder.Hold for 5 seconds.Repeat 10 times.

Stretching internalrotators

Lying on your back, keeping the elbow toyour side. Hold a stick in your hands. Movethe stick sideways, gently pushing thehand on your operated arm outwards.

Repeat 10 times.

Stretching flexors Standing with your arms behind your back andgrasp a stick between them. Gently lift the stick upaway from your body.Repeat 10 times.

Strengtheningextensors Standing with your back against a wall. Keep the armclose to your side, elbow bent. Push the elbow backinto the wall.Hold for 5 seconds. Repeat 10 times.Only use less than half your maximum effort.


41/138

Page - 41

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

Strengtheningabductors

Standing side on to the wall. Push arm into the wall.Do not allow the operated arm to move. Only use lessthan half your maximum effort.Hold for 5 seconds. Repeat 10 times.

Strengthening externalrotators

Standing, with elbow flexed to 90 degrees, andheld close to body, grasp the wrist of the affectedarm with the good hand. Attempt to move thehand of the affected arm outward resisting themotion with the good hand. Keep the affectedarm still. Only use less than half your maximumeffort.Hold for 5 seconds. Repeat 10 times.

(b) Humerus fracture


Active mobilization Finger and wrist (and sound upper limbsand lower limbs, if needed). For details,refer to active mobilization andstrengthening protocol.

Passive and passive assistedmobilization

If cast: Light passive mobilization ofshoulder joint (abduction and flexion, norotations).If internal fixators: Passive-assistedmobilization of shoulder joint (abductionand flexion, no rotations) with good

support (from the therapist) on thefracture.If possible: Passive mobilization elbow,wrist and fingers.For details, refer to passive mobilizationprotocol.

Strengthening Forearm and hand muscles. Isometriccontractions of deltoid. For details, referto active mobilization and strengtheningprotocol.

Day 1 week 6

(immobilizationperiod)

Massage Neck, forearm and hand.Passive mobilization All upper limb.

Active mobilization All upper limb.

From week 6(after

immobilization)

Strengthening Shoulder and elbow, against lightresistance and good support (from thetherapist) on the fracture. No resistanceapplied below the fracture forstrengthening exercises of the shoulder.Then increase slowly the resistance,depending on needs.


42/138

Page - 42

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

(c) Elbow fracture


Ice-pack / ice cube If possible, apply clod on the elbow todecrease pain.

Passive, passive assisted andactive mobilization

Shoulder, hand. If there no fracture of theepicondyles or the trochlea, the wrist can

also be mobilized.Massage Neck, forearm (not too close to the elbow)

and hand.

Day 1 day 10

(immobilizationperiod)

No elbow mobilization before 10 days even with internal

fixation!!!!

Mobilization passive assisted Elbow in flexion-extension and lightpronation-supination

From day 10 toweek 3

Active mobilization andstrengthening

All upper limb (except elbow and forearmand except wrist if fracture of epicondylesor trochlea).

Week 3 to week6

Active mobilization Elbow in flexion-extension (+++) andpronation-supination

Strengthening Elbow in flexion-extension (+++) andpronation-supintaion (start with lightresistance and increase progressively)

From week 6on

Stretching Stretching with participation of the patient(active mobilization plus stretching forceapplied by the therapist) in flexion (+++)and extension (++).

(d) Forearm fracture



Shoulder, fingers.If internal fixation (after 2 weeks): wrist(flexion-extension) and elbow (flexion-extension)

Strengthening If cast: isometric contraction wristflexors-extensors and elbow flexors-extensors

Duringimmobilization

(1 month ifinternal fixation/ 3 month if

cast)

No pronation-supination!!!!!

All upper limb (no resistance, then lightresistance for elbow and wrist in flexionand extension).After

immobilizationActive mobilization andstrengthening After 8 weeks: active mobilization

pronation-supination forearm (noresistance then light resistance)

(e) Wrist fracture


Duringimmobilization(3 to 6 weeks)


Shoulder, elbow, fingers.

Afterimmobilization Active mobilization andstrengthening

All upper limb (hand, elbow +++)

Wrist (flexion-extension). No resistance,then light resistance


43/138

Page - 43

EARLY

REHABILITATIONP

ROTOCOLS

FOR

VICTIMS

OFNATURAL

DISASTER

(g) Pelvis fracture

With pelvic fractures, the time of immobilization might vary a lot depending on the stabilityof the fracture (which part of the iliac bone is fractured) and the type of immobilization (castor internal fixation).


Massage Both lower limbsChest therapy Refer to chest therapy protocol.Active mobilization andstrengthening.

Both upper limbs.Ankle, foot, toes.Isometric contractions (back, abdominalmuscles, hip extensors and abductors, kneeextensors and flexors except the musclesthat have insertion on the fractured part ofthe iliac bone).

Passive

Early Rehabilitation Protocols Eng_light

Documents

Transcript of Early Rehabilitation Protocols Eng_light