1. PHYSIOTHERAPY FOLLOWING DISCHARGE Sally Emery Advanced Physiotherapy Practitioner Spinal Outpatient Department

2. Introduction Goals for inpatient rehabilitation - skill development - maximise independence - minimise complications - prepare for discharge back into the community Handover to Spinal Outpatients on discharge

3. Maintenance in the community Need to maintain skills in order to fully function in the community Reliance on relatives and carers for assistance Support Network - teaching prior to discharge - outpatient therapist - community therapists

4. Care of the joints and soft tissues Stretching exercises Positioning Standing frames Splints/Orthoses

5. Why stretch? To prevent stiffness To maintain flexibility and suppleness in the muscles To minimise the effects of ongoing spasm/spasticity To prevent contractures of the joints To maintain optimal levels of function and independence

6. Stretching exercises Aim to take the joints through their full available range of movement Most important muscles include - calf muscles- pecs - hamstrings- biceps - hip flexors- wrist/hand Be careful not to overstretch the joints and soft tissues

7. Positioning Aims to - maintain symmetrical postures - encourage stretching - reduce spasm - minimise adaptive shortening of the muscles - prevent complications, e.g. contractures

8. Why stand? Benefits include - effective stretching - reduction in spasm/spasticity - maintenance of bone density - improved bladder and bowel function - psychological effects

9. Standing Frames Tilt Table Oswestry Frame

10. (cont’d).... Iper Granstand Assessed for appropriate frame prior to discharge Requisition made for funding from local Primary Care Trust Varying level of assistance required to use frame at home

11. Splints/Orthoses Upper Limb Splints Lower Limb Orthoses Corsets/Braces/Binders Variety of types May require assistance to use

12. Chest Care Assistance with coughing Assistance with nebulisers Suction for the patient with a tracheostomy Assistance with ventilatory machines

13. Why cough? Build up of secretions can affect the ability of the oxygen breathed in to reach every part of the lungs Excess secretions increases the risk of bacterial growth Increases the risk of chest infection and pneumonia which can be fatal in serious circumstances

14. Coughing When coughing, the stomach muscles expel air forcefully from the lungs clearing the passages of secretions or any other obstruction When the stomach muscles are paralysed the cough is weak and ineffective therefore assistance is required to provide the force behind the cough

15. Assisted Coughing Technique using the arm or hands to strengthen the cough Performed independently or, more frequently, by somebody else Needs to be practised in order to be effective as timing and coordination are key factors

16. (cont’d) Patient takes a deep breath in then pressure is applied as they cough out Direction of the pressure is ‘inwards and upwards’ on the stomach muscles, just below the ribs The sound of the cough can be used as a guide for effectiveness Rests should be taken between continuous coughs

17. (cont’d) Lying Sitting

18. Nebulisers Variety of medications Saline helps loosen the secretions so that it can be coughed up more easily Other drugs (bronchodilators) help widen the passages of the lungs to reduce wheezing and allow the phlegm to pass more freely Patients who have problems clearing their secretions may be prescribed nebulisers to take daily

19. Suctioning and tracheostomy care Tracheostomies provide a more effective means of clearing secretions for patients with ongoing chest problems May require suctioning using a small catheter attached to a suction unit Tube also needs to be looked after to prevent infection and blockages Procedures need to be in place in case a blockage occurs

20. Ventilated patients Small number of patients Continuous invasive ventilation via a tracheostomy Intermittent ventilation or overnight support via a tracheostomy or a face mask Basic knowledge of the machine’s components and settings is required

21. Summary Once discharged a patient needs to maintain the skills they have learned as an inpatient to prevent any complications This will enable them to maximise their quality of life As their relatives, you can help them to do this by assisting them in their maintenance exercises and daily régime

22. But remember! Help is at hand! - engage in your relative’s therapy sessions to learn the skills required to help them - once home, contact the Spinal Outpatient Service for further advice and support as needed - alternatively, assistance from a community therapist can be arranged if appropriate - support from a variety of sources exists for you as well as your relative