TREATMENT PROTOCOL CVA/CCM/TBM
Difference between above 3 conditions:
Besides underlying etiology, CCMs and TBMs have a very good recovery- usually with very little residual neurological fallout (if high enough CD4 count). They are usually acutely ill for a week or two (just do bed programmes) but then get them sitting up as soon as they can tolerate it- even if this is with full support- and rehab further. They are usually a bit more ill than an average CVA, so keep their exercise tolerance in mind during rehab sessions.
As soon as either of these conditions are able to sit (even with partial support), bring them up to the physio gym- they will receive much better rehab and it is easier to do weight shifts on a hard surface.
CHECKLIST FOR INVESTIGATION AND REFERRAL:ASSESS / REFER TO
Orientation to person, place time
Insight into condition and limitations
Judgement within various situations
Perceptual tasks, vision and hemi-acknowledgement
Social interaction and behaviour / OT
Speech: receptive and expressive / SLHT and dietician
SLHT, perhaps audio
Medical management: compliance and insight from patient and family / OT, dietician, MO
Care at home:
-who is primary carer? Time available for this person to care? Time that patient will be left alone during the day?
-Who will cook (dietary needs)
-Accessibility within and around (as well as who will assist in transfers)
-Social integration and hobbies/responsibilities prior to CVA- expectations now?
-Are they on a DG/OAP? If not- start with getting an ID and then applying. If yes, see whether they will require permanent care at home and thus qualify for a GIA. / Therapist/assistant
Home affairs, welfare, TU/Social work
If retraining is possible:
-function in ADL such as dressing, cooking, washing (self and clothes), crafts, weeding…
ie, do they need graded retraining as well as an assistive device? / OT
Sitting capacity (aided and unaided)
Standing and transfers
Walking (with/without assistance)
(Any mobility device required? Time for weaning? Repairs? Returns?) / physio
VCT / HIV/AIDS councillor
Principles to be used:
-MOHO or biospychosocial models can be used (others can also be used: holistic care emphasized), as well as motor control theories
-It is important that a prioritized (realistic) list of goals and problems is made WITH THE PATIENT AND FAMILY. Progress to be measured according to these.
-Bobath principles for motor relearning to be used (CVAs NOT to be rehab’ed as if they had musculoskeletal weakness)
-Physio and OT: Patients should be taken to their maximum level of functioning without fixation, and rehabilitated at this level. Emphasis should be on activities (break each activity down into smaller positions/requirements as exercises), and there should not be fixation during these activities (downscale if there is). Concentrate on balance reactions, weight shifts, dissociation (scapulo-humeral, lumbar-pelvic, pelvic, pelvic-femoral) and cross stability. Sensory retraining, coordination and perceptual retraining by OTs.
Frequency of Rehab:
-Patients to be seen daily in wards
-Patients and their primary caregivers should be seen together as often as their carer visits them in hospital. The sooner the education starts, the better the follow up compliance and outcome
-Patients should be seen at least once a month at their closest clinic if possible, until plateau phase- then can be checked by HBC at home.
Tick list for discharge:
- What is a CVA and how to prevent another one
- Family education and support at home (incl accessibility)
- Financial status (DG/OAP/GIA)
- Psychosocial problems and plans for reintegration
- Passive movements and positioning
- Pressure care and identification/Mx of bedsores
- Urinary incontinence (if present)- dangers of staying wet, Sx & Sx of UTI
- HEP and ADL integration
- Use, maintenance, repair and return of assistive and mobility devices
- CRF directions, follow up clinic date and comprehensive treatment plan indicated on patients BLUE card and on case management page.