Autor: Jody Billingsley , DPT





The survival rates after civilian and military trauma have improved significantly over the last fifty years due to a multitude of advances in trauma prevention, the emergency medical trauma system, and acute care hospitalization.  As a result, more trauma victims survive and require admittance to the hospital, many of whom will ultimately need rehabilitation care. Patients with traumatic injuries represent approximately one fourth of the inpatient rehabilitation population in the USA, approximately 164,000 patients. Trauma is a very common cause of significant disability, particularly in younger, productive working-age adults and is of special concern to rehabilitation teams. These special concerns include return to work, fertility, caring for young children, and unique psychological problems.   There are a number of interventions, if appropriately applied early, that will reduce or prevent later disability, identify rehabilitation needs early on, and allow for optimal functioning of the acutely injured individual. Problems such as pressure ulcers, contractures, autonomic dysreflexia, heterotrophic ossification, atrophy, and spasticity may be avoided with appropriate early intervention.  Expertise in all these areas is available in the rehabilitation team. 


Rehabilitation is a dynamic and critical component of the therapeutic continuum, and one that is essential if patients are to regain good quality of life after serious illness or injury.  The rehabilitation paradigm differs from the curative one in many ways.  It is an individualized, patient-oriented activity focused on disability rather than disease.  Rehabilitation moves from impairment towards helping the patient find ability in the presence of obvious disability.  The rehabilitation medicine physician is part of an interdisciplinary team, the members of which have complementary roles. Physical, occupational, speech and language, nutritional, vocational, and recreational therapists, nurses, psychologists, psychiatrists as well as physicians form the rehabilitation team. Rehabilitation specialists can assist the physicians and other healthcare professionals in explaining to patients and their families the significance of their disabling conditions and they can help develop comprehensive treatment strategies to ensure the maximal functional outcome in patients.  The patient and their social support networks should have access to rehabilitation services through their entire course of recovery, which may continue for many years after the injury as services may alter as the needs of the patient change.


The benefits of early rehabilitative interventions are multi-faceted.  Early intervention optimizes functional outcomes, provides thorough patient/family education, and allows opportunity for the ongoing collaboration with bedside nurses to assist in the rehabilitation process.  In addition, specific discipline recommendations can be addressed, complications that could hinder a patient from achieving his or her fullest potential are prevented, and early discharge planning and preparation are facilitated.  This requires a comprehensive evaluation of all systems affected by the disease or injury, as well as an exploration of the psychological and emotional responses of the individual and the family to the disease or injury.


Trauma patients spend extended periods in an ICU setting, unable to actively participate in their care.  Trauma patients may require prolonged periods in bed on bed rest because of medical, surgical, or orthopaedic injuries/issues.  However even small amounts of therapy have proven to decrease post-ICU lengths of stay and more quickly improve a patient’s overall function. Interventions at this stage can help ensure that patients are prepared for a higher level of activity when they are medically stabilized.  Prevention of complications that would inhibit patients from reaching their full potential is the goal of early therapy interventions at this stage of the patient’s care.  Deformity prevention must begin as soon as possible after injury as deforming forces are acting upon patient and can happen quickly.  Deforming forces can include deinervated muscles, muscle weakness, immobility, gravity, and spasticity.  Problems caused by deforming forces include muscle contractures, over stretched muscles, soft tissue tightening, joint instability, and joint misalignment.  Joint contractures can inhibit or make activities difficult, for example, a lack of dorsiflexion prevents anterior movement of tibia over talus, which makes standing impossible.  A lack of flexion at knee will make sit to stand transfers difficult; a lack of extension at knee prevents normal heel strike and effects stance phase of gait; and a lack of range of motion in shoulders, elbows, and hands would prevent patients from completing their activities of daily living, dressing, washing and grooming.  The rehabilitation team can control these deformities by recommending and performing positioning, range of motion, orthotics, splinting, casting, and Toxina botulínica tipo A – BOTOX®


Prevention of joint contracture and skin breakdown is the key to maximizing long-term functional outcomes and this can be achieved through splinting and positioning interventions.  Turning and out-of-bed positions allow circulation to pressure-bearing areas and improved vascular flow to skin.  Trauma patients are at risk for skin breakdown for many reasons.  Examples include immobility, sensory impairment, muscle weakness and atrophy, spasticity, fractures, contractures, orthotic pressure, compromised peripheral circulation, skin changes over time, exposure to shearing/friction forces, incontinence, nutritional deficits, psychological factors, smoking, non-compliance, and medications.  Eachempati et al. found that “most ulcers developed in patients with an ICU stay >7 days” and that “increased age, non ambulatory status, prolonged time without any nutrition and an emergent ICU admission” were the greatest risk factors in development of decubitus ulcers.  The most common locations for pressure sores to occur are the sacrum, heel, ischium, foot, and trochanter.  The best treatment for pressure sore is prevention. 


It is important to mobilize a patient as soon as they are medically able.  Studies show that pulmonary complications are a cause for mortality and/or increased length of stay on acute care; mobilization improves pulmonary function.   Mobilization also decreases the risk of decubitus ulcers.  A patient’s ability to progress with rehabilitation can be delayed because of skin breakdown problems.  An example would be that a spinal cord injury patient could not sit due to a decubitis ulcer.  Mobilization also assists with strengthening, decreases the risk of muscle atrophy, and improves circulation and cardiac function.  Mobilization may begin with a tilt table or standing frame and progress to standing and ambulation.


In conclusion, early rehabilitation interventions are crucial to patient care success.  When appropriate “team” therapy interventions are provided early in the care of traumatic injuries, improvement occurs in length of stay, patient outcomes, and family satisfaction.  Early mobilization with therapists will prevent a multitude of medical complications that are associated with bed rest i.e. DVT, atelectasis, and muscle atrophy.  Therapists are able to identify a mode of communication for patients that will best allow an active intervention and interaction.  Therapists help to determine an adequate source of nutrition thereby improving a patient’s medical condition and energy level.  Therapists provide family training that allows families and patients to be prepared to assist with discharge.  There is improved patient and family satisfaction through the appreciation of the holistic approach of therapy.  Skilled therapists who educate and train families in their specialty areas ensure that patients are getting the most thorough and efficient methods of care and training.


Acute inpatient rehabilitation is a continuum of the acute care phase of therapy with a focus on patient independence and transfer back to community.  Specialty programs exist for the care of the brain injury, spinal cord injury, amputation, multiple trauma and burn patient to address their specific and unique needs.  Each program with their unique characteristics that are unable to be addressed in a discussion of this short length.


The AutoAmbulatorTM is a step forward for rehabilitation; it is a piece of equipment that incorporates body weight supported treadmill training (BWSTT) with robotics.  Body weight supported is a gait training strategy that involves the unloading of the lower extremities by supporting a percentage of a patient’s body weight.  The strategy involves an overhead suspension system to support a percentage of the patient’s body weight as the patient walks on a treadmill.  In 1986, Finch first proposed the use of a treadmill and body weight supported for gait training in the human population.  Preliminary studies demonstrated favorable effects on the gait pattern of patients with neurologic conditions.  Body weight supported walking may assist with regeneration of the primitive stepping reflex.


There are multiple benefits to BWSTT.  It allows the therapist to safely initiate gait training earlier in the rehab process.   It provides a dynamic and task specific approach, that integrates essential components of gait including upright posture, weight bearing, swing phase (stepping), and balance.  It also facilitates symmetrical gait patterns, discourages development of compensatory strategies that are often seen in gait training with walking aides, and it provides immediate feedback to patients and often increases motivation and participation.


During initial clinical studies of the AutoAmbulator, patients showed a dramatic improvement in gait, a reduced or eliminated need for constant use of crutches or canes, significantly improved balance, which should reduce the number of falls.  They experienced pain relief in affected joints and limbs, reduced dependence on others, reduced incidence of complications usually associated with spinal cord injury, and improved the quality of patients daily lives.  The indications for BWSTT include cerebral vascular accident, spinal cord injury, brain injury, multiple sclerosis, orthopedic conditions, and debilitated patients from deconditioning or prolonged illness.


In conclusion, no one individual member of a health care team can do everything necessary for patients, coordination among all elements is critical for minimizing time to recovery and producing the best outcomes.



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