A few days ago I was looking through news articles on strokes and ran across a headline stating that the purpose of rehabilitation is to return lost abilities. The first thought that went through my head was “kinda”, as in that is really only “kinda” the purpose of rehabilitation. This reaction certainly has potential to strike those reading it as odd. Because really, if regaining abilities lost due to injury isn’t the entire point of rehabilitation then just what might that point be? In a post-acute rehabilitation facility there are several other vitally important aspects of rehabilitation that prove equally essential in a patient’s journey to long-term success in his or her home environment.
To be sure, getting back lost abilities after a stroke or traumatic brain injury sees a majority of the focus directed by any therapy regimen. After all, patients want to regain their skills and therapists are committed to helping those patients regain lost skills. But there are other issues to keep in mind. When patients come to a post-acute facility, as a general rule of thumb they have already concluded treatment at a hospital and an acute care facility yet continue to have multiple areas of need. Many patients will have long-term (if not permanent) loss of certain skills due to the severity of injuries suffered. These patients have usually spent several months, and sometimes even years, coming to terms with deficits acquired as the result of an injury or stroke event. Post-acute rehabilitation is typically their last stay in an inpatient rehabilitation facility prior to returning home. Therefore, therapists need to work with patients on how to live a successful life at home in spite of those acquired deficits.
The focus on successful life at home as an adaptation to deficits is sometimes hard for patients and their families to understand. Many patients are perfectly content to do drills for hours and hours on end in an attempt to improve core skills. However, planning realistic strategies with which to approach post-injury life is just as, if not arguably sometimes even more, important. For instance, a patient may want to spend as much time as possible each day doing hand exercises to get back his or her fine motor skills. But if the hand is clearly not coming back to full functionality quickly enough and the patient will likely be discharging with hand deficits, how will that patient put on his or her clothing at home with one good hand? How will he or she cut foods without having a second hand to stabilize the food? How will he or she open up jar lids with one hand or tie his or her shoes? If a facility sends the patient home without having put focus on addressing necessary adjustments that need be made in the application of these practical life skills, then the facility has done a disservice to the patient.
This issue sees a comparable expression in the realms of cognitive and speech skills. A patient may want to practice solely on exercises designed to improve memory or those similarly aimed at regaining speech and oral motor capacity. But if a patient is likely to contend with long-term memory deficits, how will that patient ensure that bills are always paid and that doctors’ appointments are not forgotten? What steps need to be taken in order to ensure that stoves or ovens are not left on? If the patient is likely to have long-term speech deficits, how will he or she contact 911 in the event of an emergency? Clearly, planning for the future while affording full consideration to post-injury deficits’ impact is necessary even for day to day safety and health.
There are also emotional and behavioral areas that need to be explored and sufficiently appreciated. For example, what kind of state is the patient’s self-image in following his or her injury? How does he or she feel about interacting with old friends, family or the general public given the inevitable shift in perspective that accompanies a dramatic change in health status? If the patient has anger or impulsivity issues, how can these best be managed in his or her discharge environment? Again, efforts to adequately understand these emotional and behavioral areas are extremely important in setting the stage for long-term patient well-being and successful, healthy relationships with others.
Preparing for a life operating under the constraints of long-term effects of an injury is comprised of multiple facets which are often worked on simultaneously. The following is not an exhaustive list but does highlight many of the prime targets for a sufficiently comprehensive therapy regimen:
1. Learning new methods to engage activities perhaps previously taken for granted, such as learning how to tie a shoe with one hand or learning a new method to transfer into a car.
2. Identifying and practicing with equipment to make up for deficits, such as using a daily planner to help remember a schedule or a sock-aid to help put on socks.
3. Discussing thoughts and feelings about the real and concrete effects of having injury deficits, such as mourning the loss felt due to an inability to return to a previous job.
4. Identifying potential problem areas in a discharge environment and problem-solving through those areas, such as pre-recording a message for a survivor suffering from aphasia to play on the phone for a 911 operator in case of a fire.
5. Learning and practicing mood and behavioral management techniques such as relaxed breathing.
6. Creating a daily schedule that honestly reflects real-life changes experienced in post-injury life.
7. Identifying and planning activities that can still realistically support participation by a survivor in spite of injury deficits and recognizing those activities that should no longer be engaged in, such as identifying a trip to a ball game as an activity that can still be enjoyed just as capably.
8. Articulating all aspects of a long-term health regimen necessary to satisfactorily maintain health, such as taking medication for seizures or chopping food into smaller-sized bites so as to avoid choking.
9. Identifying and locating specific people/resources needed to promote success, such as deciding which family member is most able to help with managing finances or submitting an application for accessible busing.
In summary, since post-acute rehabilitation will generally be a patient’s last opportunity to experience inpatient rehabilitation and many patients face long-term deficits, it is crucial during post-acute rehabilitation to focus not only on rehabilitating lost skills but also to focus on how to manage life at home while affording sufficient consideration to those inevitable deficits wrought by a traumatic brain injury or stroke.
Learn about brain injury treatment services at the Transitional Learning Center: http://tlcrehab.org/