Function to be Addressed
DOES FUNCTIONAL RETURN DEPEND ON THE DEGREE OF NEUROLOGIC RETURN?
The quantitative amount of functional return and the qualitative lifestyle status are only partially dependent on neurologic return.
Should the patient experience a significant neurologic return during the rehabilitative care process, the patient will have a much better chance of experiencing true self-sufficiency by the end of that process. If the patient has experienced rehabilitative therapy and then experiences neurologic return, the quality and quantity of his or her functional return are aided. Should the patient, however, develop such complications and sequelae as contractures, severe deconditioning, or decubitus ulcers, the patient would probably not realize his or her full rehabilitation potential, even if the patient sub-sequently experiences neurologic return. Legal implications, how-ever, are ever present, and the onset of any of the complications or sequelae named above could be considered part of the error of prac-tice.
Two examples illustrate the daily reality of this type of medical care.
1. A patient with hemorrhagic stroke of the dominant middle cere-bral artery territory and global aphasia can be taught nonverbal meth-ods of self-care even if the global aphasia only evolves to a dense receptive aphasia.11–13,17In fact, teaching activities of daily living to a nonverbal patient with global aphasia is often less difficult than teach-ing those tasks to a patient with dense receptive aphasia. If those patients can be taught to transfer and to groom themselves, they then require much less care and are easier to place with a relative or friend.
Should neurologic return then occur, these patients are that much more likely to become fully functionally independent.
2. A patient with stroke hemorrhages into the territory of the ante-rior cerebral arteries bilaterally and experiences cerebral paraplegia. If 68 ORGANIZATION OF THE ACUTE REHABILITATION SERVICE
this patient’s sensation deficits and bilateral leg, ankle, and foot weak-nesses remain unchanged, orthoses can be provided as well as inten-sive gait and transfer therapy. With adequate treatment on the ward and follow-up after discharge, safe limited ambulation may be achieved.14,16,20 The patient needs to be able to respond to sensory retraining techniques. If neurologic return occurred, therapy would be made much easier and much more effective. The partial contributions of rehabilitative team therapy and neurologic return toward full patient self-sufficiency in his or her community generate the following sig-nificant corollaries:
a. Rehabilitative therapy tends to produce patients who are more emotionally stable, mentally adaptable, and physically fit. Those patients will be better able to use their musculoskeletal system.
b. Rehabilitative functional progress is frequently not an equal, steady, or orderly progression toward self-sufficiency. Progress is irreg-ular and is monitored by functional outcome scales.
c. The progress of rehabilitation is most often slow at the beginning and slows again toward the end of the rehabilitation stay.
d. Activities of daily living, housekeeping, transfer activities, wheel-chair/standing/gait activities, equipment needs, communication needs, and socialization needs are usually included.
Even under optimal circumstances, broadly based progress in all of these areas is usually uneven and lower than expectations, barring neurologic return.11–16 There are well over 50 functional outcome scales in regular national use today. Many scales are digital, computer friendly, national, and broadly applied. Some scales are specific to a few diseases or disorders.
The majority of functional outcome scales consist of equivalent intervals, even though functional progress does not usually resemble that model.15,18,21–24Ordinal intervals could be transformed to resem-ble the nonequivalent data of most rehabilitative processes. Equivalent interval data itself can be analyzed using exponential statistical methodology. At least one national organization has encouraged this modification. Rehabilitative progress is unique and inimitable to each patient’s situation and to each rehabilitation team’s condition. The fol-lowing should be kept in mind when measuring functional outcomes:
1. Whatever functional outcome system is used, the rehabilitation team should take into account patient safety, human error, and human variability.
2. Patient progress estimation should be accurate and realistic.
DEFICITS OF FUNCTION TO BE ADDRESSED 69
3. Are these patients or their families ready and able to participate in a rehabilitation program? Rehabilitation is an elective medical ser-vice.
4. Has effective, efficient communication been established between these patients/families and the rest of the rehabilitation team?
5. Is the rehabilitation team ready, willing, and able to accept this participation and communication, even though that participation con-sumes time and energy?
When functional outcome measurement began, one viewpoint applied a national standard (NS).16–20Those generally subscribing to this view have succeeded in generating functional outcome scales used on a national context. In the process, these scales have been used to limit the amount of funding for the rehabilitation of patients based essen-tially on a national data pool for each condition by establishing “win-dows” of cost-effective rehabilitation for each condition.
Difficulties with NS scales abound. If rehabilitation enhances hygiene and bed mobility and thus prevents decubitus ulcers, this reha-bilitative process is worth funding even if it does not generate many units on NS functional outcome scales. The alternative viewpoint con-cerns itself with the practical goals of each inpatient rehabilitation team’s effort. This relative standard (RS) was initially supported by the American Medical Association. Each devolved unit would contend for itself how much functional outcome could be generated for each unit of cost. This RS viewpoint contends that each rehabilitation team should monitor its goals in its own setting in an analogue, narrative manner during rehabilitation.12–14So far, health maintenance organi-zation (HMO) funding for rehabilitation medicine clinical service has relied on the NS positions rather than those of RS. The rehabilitation process, however, must still be characterized. The following may be used to define rehabilitation progress:
1. Logical inconsistencies frequently trap many well-meaning attempts to fully characterize the rehabilitation medicine process.
2. Applying objective research methods to a process or entity that is basically subjective leads to misleading results. Much literature on chronic pain syndrome falls into this disadvantage. But NS methodol-ogy also contributes, as it applies national and regional objective, dig-ital techniques to measuring a process that is relatively analogue or subjective.
3. Neurologic progress is not necessarily fully documented through serial magnetic resonance images. One way of addressing these types of debates regarding functional progress of inpatients is through the documentation of regular, serial neurologic and functional assessments.
70 ORGANIZATION OF THE ACUTE REHABILITATION SERVICE
Inpatients on an acute rehabilitation unit should be team evaluated in this way on at least a weekly basis. The team conference membership should consist of those therapists, nurses, and aides who are actually working with that particular patient. Substitutions should be kept rare and by prior agreement. Nonessential but interested bystanders should be discouraged from attending by the team facilitator, as confidential-ity of these team proceedings is important. Videotaping or audiotaping of a rehabilitation team conference would generate the same concerns.
To build a team consensus and communication, these patients and their families might be brought in to participate during parts of the con-ference. Many times, the same goal can be achieved by separate fam-ily conferences. Too many conferences (e.g., admitting, discharge, and family) are commonly resented by the rehabilitation team.
Results, however, of the rehabilitation team consensus and com-munication should be documented. Narrative notes should be in place when or shortly after events occur in a readable, thorough, accurate manner. Because these notes are carefully examined by HMOs, word-ing of these notes to capture the spirit and the letter of the team inter-action is vital. Notes taken during the meeting can be dictated later.