This is an excerpt from Rehabilitation of Musculoskeletal Injuries 5th Edition With HKPropel Online Video by Peggy A. Houglum,Kristine L. Boyle-Walker & Daniel E. Houglum.
Ella is in a sling after sustaining a fracture to the greater tubercle and neck of her right humerus. Ella thinks she needs a better story about how she broke her humerus because the actual story is embarrassing. She was riding her bike with some friends on a challenging trail, and she fell off her bike—not on the trail, but at the stoplight by her house when she was coming home. She reached for the crosswalk button and missed the stoplight post altogether. She fell on her outstretched right arm, and she could tell immediately that she had a problem.
Ella’s friends took her to the immediate care facility around the corner from her house where she was examined by the physician assistant, Rebecca. After her evaluation, which included several X-rays, Rebecca determined that while Ella had two fractures, surgery wasn’t needed. She gave Ella a sling with an abduction pillow and a prescription to begin rehabilitation next week.
Ella decided to go to a rehabilitation clinic on the recommendation of one of her riding buddies, where she met Tyler, her rehabilitation clinician. Tyler is an experienced clinician who understands how frustrating it can be to have an injury to the right shoulder. Since Ella is right-handed, several of her daily tasks will require new strategies. In addition to the range-of-motion, pain management, and strength objectives of her rehabilitation program, there are other daily activities that Ella is struggling to perform without pain in the injured shoulder. While she is still trying to come up with a better story for her injury, Ella’s foremost challenge at this point is improving her ability to perform basic daily tasks.
A rehabilitation clinician must often wear many hats over the course of the rehabilitation process. However, different patients may require the rehabilitation clinician to wear different hats for similar experiences. In addition to physical rehabilitation, the rehabilitation clinician may need to offer emotional assistance as well.1 Emotional assistance can take many forms;2 just listening to your patient is a powerful tool in recovery, as is encouragement, respect, and motivation.1
In our opening scenario, after Ella’s fall and subsequent right humeral fracture, many of her normal daily functions will be affected for the next several weeks because she cannot use her dominant arm as usual. These common activities that we perform during our normal daily routines are called activities of daily living (ADLs). These are basic things that most people do without thinking about them. ADLs are performed independently as self-care skills and include activities such as dressing, bathing, eating, and moving from one location to another. Other ADLs may include activities such as cooking, shopping, driving, stair climbing, and any other activity that is routinely performed each day.
Putting on a pair of pants before leaving the house is a functional task, and Ella must regain her proficiency with that activity before she can return to her previous level of function. This essential level of function is also known as self-care or household tasks. Recovery of these functional activities is especially urgent for someone like Ella, who has temporarily lost the function of her dominant arm. She needs to learn how to get dressed, prepare food, and perform hygiene tasks independently, without help from other people, and without the use of her right arm.
Ella’s first visit with Ty will undoubtedly include instruction in how to perform ADLs without suffering additional stress that could jeopardize the healing process in her right arm. Patients often present for their first visit knowing that the injury or surgery has turned their lives upside down, and many formerly easy and mindless ADLs are now very difficult to perform without help and pain.
The hats the clinician must wear in this scenario are those of encourager, confidant, and advisor. As a rehabilitation clinician, you will have professional experience in helping others deal with these ADL issues, or you may have had personal experience with a similar situation after an injury to yourself or a family member. Your personal and professional experience is what the patient will find very useful in this phase of the rehabilitation process.
The functional tasks discussed include sleep and bed mobility, sit to stand, general personal hygiene, donning and doffing a shoulder sling, self-dressing, and meal preparation.
Specific ADL Considerations
A number of considerations must be mentioned before specific ADL issues are discussed. The first and most obvious consideration is what segment of the body is affected by injury or surgery. The act of getting out of bed will be different for a spinal surgery patient than for a patient who had shoulder surgery. The second consideration is the type of surgery or injury to that region. Ligament reconstruction of the lateral ankle comes with different functional considerations than a grade II ankle sprain. Similarly, shoulder surgery and hand surgery present different obstacles to the patient’s ability to perform ADLs. Likewise, it makes a difference if the injury or surgery occurs to the dominant or nondominant arm. The third consideration is the amount of assistance the patient has at home. If the patient has enough help from friends and family, the stress of performing ADLs is lowered. However, many patients do not have help at home, or help is only available on a part-time basis. It may be uncomfortable for a patient to rely on a friend or neighbor for assistance, especially in self-care tasks. Some older or more disabled patients need assistance to perform most basic functional tasks; in these cases, in-home nursing care may be the best option, or a short time in a rehabilitation facility may be warranted.
Most patients prefer to be as independent as possible after surgery or injury. Therefore, the purpose of this chapter is to give the rehabilitation clinician a few ideas and techniques for instructing patients on how to perform basic functional tasks on their own. An often-overlooked aspect to performing ADLs without help is how much time they will require. Patients should be advised that previously quick, simple tasks can become arduous and can take minutes rather than moments to perform. The patient may experience fatigue, frustration, and possibly anger during the time when the injured segment must remain inactive to allow healing.3
When patients feel that their independence is threatened, which it certainly will be after most severe injuries or surgeries, emotional distress is common.1, 3 The hat the clinician will likely wear during this time is one of encourager. It is difficult for patients to see an end to their situation while they are struggling to perform simple ADLs. The clinician can play a significant role in reducing patients’ frustration by teaching them to perform ADLs independently and without irritating the healing structures.
One of the primary objectives in the inactive and early active phases of rehabilitation is to protect the injured area to promote healing. If the patient is in a sling or a brace and is using the involved extremity too often, healing will be slowed.4 During your career as a rehabilitation clinician, you will see many patients unwittingly, often very creatively, putting their injured segments in harm’s way during functional tasks.
During the early phases of healing, reducing the stress to the involved area allows the body to progress through the inflammatory and early proliferation phases more smoothly, which allows the entire process to follow a more predictable recovery time frame.5, 6 The hat the rehabilitation clinician wears at this point is advisor as you offer the patient ideas of how to reduce inflammation and stress to the injured region during basic functional tasks. This results in reduction of the patient’s pain, discomfort, and swelling, which helps the patient to rest and sleep, and these are all important factors in healing.
As an example, after shoulder surgery, the patient is instructed to wear a sling for a time to allow the repaired tissue to heal before stress is applied to the shoulder. The patient is not to use the shoulder because active muscle contraction during the inactive phase of rehabilitation is counterproductive. Patients may know that they should not use the injured arm to cut a piece of steak, but they may not know that using the injured arm to hold a fork in the steak to keep it still while cutting it with the other arm is also counterproductive. When patients are told not to use a body segment, they often are not aware when they are actually using it. In this example, rehabilitation clinicians know that the shoulder muscles work to stabilize the shoulder when the patient is actively holding the arm still to prevent movement. But the patient may think that as long as he does not move the shoulder away from his body, he is not using the shoulder muscles. This is a common mistake. Therefore, rehabilitation clinicians should take the time to instruct and guide patients on proper adaptations and functional ways to perform their ADLs without endangering their healing tissues.
Patients need the rehabilitation clinician to play different roles at different stages of the rehabilitation process. The roles, or hats, vary depending on the patient and the injury. The hats a rehabilitation clinician wears for one patient may not be the same hats he or she wears for another. The hats may include encourager, motivator, advisor, and confidant. Emotional guidance is often needed to help with physical recovery.1