RainbowVisions - Rainbow Rehabilitation Centers

Transcription

RainbowVisions
A Quarterly News Magazine for Acquired Brain Injury Professionals, Survivors and their Families.
www.rainbowrehab.com
Winter
2006/2007
Rainbow Rehabilitation Centers, Inc.
VOLUME IV
No. 1
Featuring...
Clinical News on Tracheostomy Care
Meet Dr. Perlman
Rainbow’s Medical Director
Medical Care & Active Therapy for
Becky Branscum, TBI survivor
Survivor perspective by
Kara Swanson
Author of I’ll Carry the Fork!
us
Grand
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e
Op
amp
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a
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Neuro
e 15-16
n pag
Details o
What’s
NEWS
in the Industry
RAINBOW IN 2006 & 2007
This program would be a step in the right
Looking Forward
Written by
direction.
Bill Buccalo, President
In that vein, the Michigan providers
Rainb ow Visions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 of rehabilitation services, from hospitals
A
to home care, have the challenge,
s we look back on 2006 and forward
treatment teams. This program will
the opportunity, and I would say the
to 2007, the outlook for Rainbow is
complement our 6 bed model quite well.
responsibility to show the rest of the
bright. Much has been accomplished in
the recent past that leads me to believe that
employee turnover rate in our company’s
under a well funded program (no-fault). A
with continued hard work we will be well
history. In each of the past five years, we
comprehensive outcome study has been
positioned for the future.
have had a decline in turnover and this
discussed among industry leaders. I would
In response to customer feedback, a
We have been blessed with the lowest
country the benefits of rehabilitation
year should be no exception. We are
suggest the time is now.
number of programs have been added in
very proud of this. Rainbow employees
the past year to meet your needs. Early
have participated in a wide variety of in-
their billing requirements in late 2005.
this year, we added a house to serve clients
house and community based continuing
The change called for increased provider
with more behavioral challenges. This has
education programs and team building
accountability. We welcome this change,
been well received.
activities. In addition, we have worked
and I imagine the trend will continue with
We opened the Garden City
diligently to attract new employees to join
other insurance companies as well.
Apartment Program in July for semi-
us when we have the opportunity or when
independent clients in Wayne County and
someone exceptional comes along.
Insurance Workgroup which issued a
to accommodate certain living situations
Our focus remains on providing
report in September 2006. The report
for adults with brain injury. Not every
outstanding care and rehabilitation
called for dramatic changes in the no-
individual we are requested to treat fits
for our clients. We receive Customer
fault law. The goal of the report was to
neatly into a pre-designed program, so our
Satisfaction feedback throughout the
find a way to reduce the cost of insurance
treatment teams individualize client care.
year, both formally and informally. We
in urban centers. The conclusion was to
The same goes for living environments
are not perfect by any stretch, but the
essentially gut the medical benefits out of
and living situations. The Garden City
ongoing encouragement, feedback, and
no-fault to achieve the goal. The anti-fraud
Apartment Program has been set up to
recommendations we receive help to guide
recommendations were positive, but the
accommodate a broad range of needs,
us in our efforts. We cannot rest on our
overall recommendations and arguments
including decreased levels of support at a
successes over the years; rather we have to
were one sided and narrowly focused.
lower cost, providing support for mothers
continue to improve the program, attend to
We must create a more effective means of
with children and for individuals with
our clients and work for a better future for
reducing the cost of insurance aside from
unique needs that don’t fit the criteria for
them.
simply not selling it or short changing
other programs.
future accident victims and their families.
been change. Rainbow’s own Dr. Heidi
The social costs will far outweigh the short-
has been the purchase and development
Reyst is a member of the State of Michigan
term premiums saved.
of our newly established NeuroRehab
task force, which is working to develop
Campus. These facilities will complement
a Traumatic Brain Injury Waiver. A TBI
2007 and the improvements to come with
our current continuum of care by offering
Waiver would allow certain residents
it. Enjoy the holidays and have a happy
another option in addition to our traditional
of Michigan that do not have insurance
new year.
6-bed home. This program will focus on
funding to access much needed brain
maintaining our community integrated
injury rehabilitation service. Expanded
more information on any of these issues,
focus, providing on-site treatment,
access to rehabilitation services is
feel free to contact me at:
activities, nursing and comprehensive
desperately needed across the country.
[email protected] t
An exciting event for Rainbow this year
1
On the industry front, there has also
A major insurance company changed
The state senate put together The
We are excited about our plans for
If you have questions or would like
WINTE R
2006/2007
Table of
Contents
INDUSTRY NEWS
What’s News in the Industry – Looking Forward
1
ABI Clinical News – Tracheostomy Care 3
Survivor Corner – Article by Kara Swanson
7
RainbowVisions
On the
Cover
A Quarterly News Magazine for Acquired Brain Injury Professionals, Survivors and their Families.
Rainbow
Winter
2006/2007
Rehabilitation Centers, Inc.
13
this issue is the
AACBIS Corner – Silent Epidemic
19
Grand Opening
Event Calendar 25
of Rainbow’s
No. 1
Clinical News on Tracheostomy Care
Featured in
Technology Corner – Ultrasound & Electrical Stimulation
VOLUME IV
Featuring...
Meet Dr. Perlman
Rainbow’s Medical Director
Medical Care & Active Therapy for
Becky Branscum TBI survivor
Article by
Kara Swanson
Author of I’ll Carry the Fork!
NeuroRehab
Campus.
RAINBOW CLIENTS
From Rainbow’s Medical Residential Program – Becky Branscum
9
See page
15-16 for details.
pus
g
O p e n in
Grand
GRAND OPENING
Rainbow NeuroRehab Campus – Open House
hab Cam
NeuroRes on page 15-16
Detail
15
INSIDE RAINBOW
Meet Dr. Perlman – Rainbow’s Medical Director
11
Rainbow Visions editor & designer – Kimberly Paetzold
Meet Cynthia Jeffrey – NeuroRehab Campus Executive Chef
17
Staff photographer – Heidi Reyst
Medical Nutritional Therapy – Enteral Nutrition & Tube Feeding
23
TBI Child Focus Series – When Children are Injured / Part 3
27
Employee of the Season – Summer 2006
29
The Last Word – Ina’s Beauty Shop
30
E-mail the editor with comments or questions at:
[email protected]
1.800.306.6406
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just got easier!
A Specialty Transportation Company
We offer personalized, attentive and expert transportation services for
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Call us today for a brochure of our services, pricing or to schedule a ride.
2
ABI
Clinical
News
A LOOK AT
Tracheostomy Care
By Monique Kurkowski, RRT, CBIS
Rainb ow Visions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 Angie McCalla, MS, CCC-SLP, CBIS
T
he tracheostomy is one
of the oldest known
surgical procedures. The first
reference to this procedure
is found in an ancient Indian
book of medicine, the
Rig-Veda, written in 1500
BC. However, Chevalier
Jackson is credited with
describing the modern
day tracheostomy in 1909.
As recently as the mid
1980’s, the percutaneous
tracheostomy was introduced as an alternative to the surgical
technique. This bedside method is considered minimally
invasive and more cost effective than surgery.
Respiratory Therapy in Tracheostomy
Management
When an individual has an obstructed
airway, needs secretions cleared, has
difficulty breathing, needs prolonged
mechanical ventilation (greater than
14-21 days) or has a need to facilitate
ventilator weaning, tracheostomy tube
placement may become necessary. For
individuals requiring long-term ventilation,
a tracheostomy tube has a number of
advantages over translaryngeal intubations,
including: Improved stability (allowing
individuals to have greater participation in
therapy), more discharge options, greater
comfort, and freeing
of the larynx for
speech and eating.
The tracheostomy also
helps avoid trauma to
the teeth, oropharynx,
vocal cords and larynx.
Tracheostomy tubes
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Above: Becky Branscum (right) being assisted with her
tracheostomy by Christine Herdell, RN (left). You can read Becky’s
story of active therapy and tracheostomy surgery on page 9.
are available in a wide range of sizes, shapes and types. They
are made of hard or soft plastic or metal material. The size is
generally determined by the size of the person; both diameter
and the length are considered when determining the appropriate
tube. However, the manner in which the tube will be used is
also a consideration when determining size. A person requiring
full ventilation, for example, may need a larger diameter. Stable
individuals who are ready for weaning may benefit from smaller
tube diameters.
Tracheostomy tubes may be cuffed or uncuffed. A cuff is
used to seal the airway to allow for full ventilation. A cuff can
be filled with air or foam. When a cuff is used, care must be
taken to decrease the risk of tracheal injury. Tracheostomy cuffs
have also been used to decrease the risk of gross aspiration (the
accidental spilling of liquids into the airway). There are conflicting
opinions on the benefits of using inflated cuffs to reduce the risk
of aspiration. In general, unless a person is receiving mechanical
ventilation, the tracheostomy cuff should be deflated, allowing the
client to move air both through and around the tube, decreasing
the work of breathing. If emergency ventilation is required, the
cuff can be re-inflated to allow for full mechanical ventilation.
Some tracheostomy tubes have both an inner and outer cannula.
The inner cannula is designed to be removed for easier cleaning.
The inner cannula may be disposable or non- disposable. The
non-disposable cannulas are cleaned using appropriate technique
and reinserted.
Fenestrated tubes can be used to facilitate speech. These tubes
have single or multiple openings on the outer curve of the tube.
When the tube is capped to occlude the proximal opening, the
fenestrations allow air to flow into the larynx, giving way for the
production of speech.
Tracheostomy tube dependant clients require specialized care
È Uncuffed Trach
Cuffed Trach Î
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and equipment. Because their upper
airway’s natural mechanism for warming
and humidifying inspired air is bypassed,
it is essential to compensate for this via
a moist air setup. This system generally
includes a nebulizer, tracheostomy collar,
compressed air/ oxygen, large bore tubing
and a drain trap. This system
must be closely monitored.
If an individual is left to
breathe un-humidified air,
their secretions can become
thick and dry, which may
cause potentially lifethreatening mucus plugs.
Suctioning the airway
when a tracheostomy tube
is present is essential to
prevent mucus plugs. The
frequency of suctioning is unique to each
individual. Some people have a strong
productive cough requiring less frequent
intervention, while others may have a weak
or non-existent cough which requires very
frequent suctioning. Care must be taken to
ensure proper suctioning technique is used.
Depending on the setting, clean or sterile
technique should be used to decrease the
risk of infection.
Tracheostomy care is essential to prevent
infection and maintain a patent airway.
As in suctioning, the technique used to
provide this care depends on the setting
where it is provided and the type of tube
being cleaned. Care should include the
cleaning of the tube and the stoma (the
surgical opening). The ties used to secure
the tracheostomy tube should also be
changed. Care should be taken to ensure
the ties are tight enough to secure the tube
in the airway, but not so tight as to cause
injury to tissue.
Tracheostomy tubes require changing
from time to time, and a spare tube should
always be on hand. Having a small
diameter tube on hand for difficult reinsertions is recommended. Each facility
has its own protocol on the frequency
of routine changes. Although the
recommended frequency of tube changes
is not clearly documented, in general,
tubes should be changed when cracked,
malfunctioning, or dirty. Special care is
required with mechanical ventilation so the
flow of air is not interrupted for prolonged
periods of time during changes.
As an individual improves in their ability
to maintain a patent airway and their
respiratory status improves, tracheostomy
tube weaning can be considered. This is
typically accomplished by first ensuring the
person can tolerate a deflated cuff. Once
cuff deflation is tolerated, the decision is
made to either cap the tracheostomy tube
or downsize the diameter. In the process
of tracheostomy capping, a plastic cap or
plug is used to occlude the tube opening.
This allows the patient to only breathe
around the tube and through their mouth
and nose. Care should be taken to ensure
the diameter of the tube is small enough
to allow for this to occur. In tracheostomy
tube down-sizing, progressively smaller
tubes are inserted into the airway over the
period of a few days, allowing the stoma to
gradually close and encourage mouth/nose
breathing. When the last tube is removed,
a dry sterile dressing is placed over the
2006/2007
stoma. The stoma should close completely
in a couple of days. The weaning process
should be individualized to meet each
individual’s tolerance to the procedure, and
a combination of down-sizing and capping
is the preferred method.
The ultimate goal for a respiratory
therapist is to assist in weaning individuals
from a tracheostomy tube whenever
possible. Some patients will require the
ongoing use of a tracheostomy tubes due
to respiratory muscle weakness and their
inability to maintain a patent airway. For
those that require long-term use, the goal
should be to achieve the greatest amount
of independence while maintaining a high
quality of life. These individuals should
have access to a full therapeutic treatment
team and benefit from therapy as their
physical ability allows. With a coordinated
effort, they may be able to regain the ability
to talk (using the appropriate equipment),
eat, and enjoy social and community
activities.
Article continued on page 5
Monique Kurkowski, RRT, CBIS
Monique is the Admissions Coordinator and
Registered Respiratory Therapist at Rainbow. She
obtained her associate degree from Henry Ford
Community College in Dearborn, Michigan and
has specialized in the field of traumatic brain injury
rehabilitation since 1993. Respiratory therapists
(RT), Registered Respiratory Therapists (RRT) and
respiratory therapy technicians—also known as
Respiratory Care Practitioners (RCP)—specialize
in the assessment and treatment of breathing
disorders. Airway management is the number-one skill needed by a respiratory therapist.
Skill in vascular assessment for intravenous lines (IV) and arterial line or arterial blood
gas (ABG) is also required. RTs work closely with other medical disciplines such as
physicians, nurses, speech therapists and physical therapists. Respiratory therapists only
act on a physician’s order, except where there are written protocols or, in the event of an
emergency, with no physician present. Respiratory therapists are now required to be
licensed by the State of Michigan.
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1 - 8 0 0 - 9 6 8 - 6 6 4 4 Rainb ow Visions
Tracheostomy
Care
Continued from page 4
Speech-Language Pathologist &
Tracheostomy Management
The principal role of the speechlanguage pathologist (SLP) in regard to
patients with tracheostomy tubes is to
optimize speech and swallowing. This
population provides a challenging set of
characteristics requiring high levels of
competency, skill and knowledge in the
basics of speech and swallowing. They
also must be knowledgeable on the
anatomy and physiology of the respiratory
and phonatory systems (normal and
disordered) and understand normal
respiratory and metabolic values, airway
management techniques, and endotracheal
and tracheostomy tubes. These skills
are developed and enhanced with an
interdisciplinary team that includes
physicians, respiratory care practitioners,
nurses, registered dieticians and social
workers. Central to this team is the speechlanguage pathologist. The SLP serves
to enhance and develop the potential
for communication and oral intake by
providing functional outcome-specific
feedback to team members, the patient and
family.
The first and most important function of
the SLP is to assess communication skills in
order to provide an efficient and effective
means of self-expression. To determine
the best system, SLPs must assess an
individual’s cognitive level, physical
limitations and communication needs. Not
all individuals will be a candidate for a
system, but if one is deemed appropriate,
communication may take two forms;
nonverbal and verbal.
Nonverbal communication
includes writing, gestures, lip reading,
communication boards and electronic
augmentative communication systems.
These methods rely on physical movements
to transmit a message. Despite being
viable communication strategies, each
has limitations. Writing requires fine
motor coordination and demands literacy
on the part of both communication
5
5
partners. Gestures limit the number of
messages the person can convey. Lip
reading demands good articulation and an
absence of neuro-muscular involvement.
Augmentative systems can become very
costly to purchase. Despite the limitations,
nonverbal communication may be an
appropriate and effective means of
communication especially for those with
poor articulation.
Verbal methods of communication
utilize a natural or artificial sound source.
Because verbal communication is the
most effective and efficient, it should
be considered first. Speech following
tracheostomy tube placement is affected at
the very basic level. With the presence of
a tube, airflow is diverted away from vocal
cords. With the diversion of air, the cords
no longer vibrate as the air passes through
them to produce sound. The person is
rendered aphonic (absence of voice).
Some air may leak up to the vocal cords
but may not be forceful enough to drive
the cords into vibration, or may only allow
enough force for very short utterances.
Despite the interference with normal sound
production there are a number of options
for speaking with a tracheostomy. Options
include:
• Plugging the tracheostomy tube by
holding a finger/placing a cap over the tube
• Covering the tracheostomy tube with
the chin
• Tracheostomy speaking valve. A oneway valve that allows air in, but not out.
This forces air around the tracheostomy
tube, through the vocal cords and out
the mouth upon exhalation, enabling
vocalization.
• Fenestrated tracheostomy tubes have an
opening allowing air to pass through the
vocal cords.
• Electrolarynx or artificial larynx is
a hand held device placed on the neck
surface that vibrates when activated and
mechanically resonates when words or
sounds are mouthed.
• A talking tracheostomy tube. Speech is
obtained through a line directly above the
cuff. An outside air source is used to force
air through the vocal cords.
• A SpeakEZ that combines a heat
moisture exchanger (HME) with a built-in
speech valve.
Swallowing
The presence of a tracheostomy tube
has the potential to negatively impact
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swallowing and increase the risk of
aspiration. The effects of the tube are not
fully understood, but it is documented
that aspiration risk increases particularly
if there are concurrent structural and/or
neurological difficulties. Incidence of
aspiration was noted at levels of 15-77%.
The most common problems are delayed
swallow, latent glottal closure, poor
laryngeal elevation and reduced or absent
subglottic pressures. Due to the increased
risk of aspiration, SLPs must demonstrate
hypervigilance in regard to assessment and
treatment. Their initial role is to complete a
thorough case history, assess cranial nerve
function in regard to oral motor skills and
then preform a swallowing evaluation. The
swallowing evaluation may take various
forms including:
• A blue dye test. Blue dye is placed on
the back of the tongue every four hours.
Suctioned secretions from the tracheostomy
are monitored for the presence of blue dye.
The presence of blue dye may indicate the
patient is aspirating their own secretions.
2006/2007
The speech-language pathologist
must also manage oral intake. Strategies
used to assist those with dysphagia and
a tracheostomy parallel that for persons
without a tube. However, some special
considerations and strategies are exclusive
to the presence of a tracheostomy tube: Dry
swallows after every bite, a series of single
swallows to allow breathing time between
swallows and frequent rest breaks due to
the extra effort of breathing while eating.
The SLP may recommend occluding the
tracheostomy tube during swallowing to
restore subglottic pressures. This may
improve safety. Both the use of finger
occlusion and a one-way speaking valve
have been shown to effectively decrease
the risk of aspiration. Simple alterations in
diet consistency, for both solids and liquids,
can also reduce aspiration risk.
advances in medical care and the ability
to treat infections and manage chronic
pulmonary conditions. Patients are not
only being treated in acute care settings,
such as hospitals, but also in their homes
or a community based rehabilitation
centers. Care must be tailored to the
individual’s functional outcome and their
environment and these decisions are made
in collaboration with the patient’s treatment
Conclusion
Caring for individuals with
tracheostomies has evolved due to
Eubanks, D.H., Bone, R.C. Comprehensive
Respiratory Care (1985). Mosby.
team. t
References:
“Care of the Patient with a Tracheostomy”
www.orthonurse.org/Education
“Home Mechanical Ventilation: Tracheostomy
Management and Monitoring”
www.chest.net/education/online
“Tracheostomy in Critically Ill Patients”
www.mayoclinicproceedings.com
• Bedside/clinical swallowing
assessment. Different foods and liquids are
presented for oral consumption and the SLP
makes recommendations based on clinical
observations–presence or absence of
coughing, eye watering, reddened face. The
limitation of the test is that the exact cause
of the disorder cannot be determined.
Angie McCalla, MS, CCC-SLP, CBIS
Angie has a Masters of Science in Speech-Language
Pathology from Bowling Green State University in
Ohio and a Bachelor of Science in Communication
Disorders from Central Michigan University. She
has extensive experience in a variety of sub-acute
• Videoflouroscopic Swallow Study. In
settings providing care and rehabilitation including
this method, the SLP uses flouroscopy to
assess the dynamic process of swallowing.
Video recordings of the study are reviewed
to determine the integrity of the swallow
mechanism in real-time.
the University of Michigan Medical Center PM&R
Speech-Language Pathology Department. There
she completed an internship focusing on evaluation
and treatment of neurological trauma patients and
completed an internship at Blanchard Valley Hospital
• Fiber Endoscopic Evaluation of
Swallowing. This method has the SLP using
a fiber-optic endoscope. It makes use of a
flexible endoscope to view the laryngeal
structures before and after the swallow.
The procedure is videotaped to review for
additional analysis.
in Ohio. Memberships include: American Speech Language Hearing Association (ASHA).
Speech-Language Pathology is the study of human communication disorders. These
disorders can be congenital or acquired, and can affect individuals of any age. The practice
of speech-language pathology includes prevention, diagnosis, habilitation, and rehabilitation
of communication, swallowing, or other upper aerodigestive disorders; elective modification
of communication behaviors; and enhancement of communication. This includes services
that address the dimensions of body structure and function, activity, and/or participation. q
6
ABI
Survivor
Corner
REHABILITATION
The Gift Inside the Box
By
Kara Swanson, Author & TBI Survivor
Rainb ow Visions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 Kara is the author of “I’ll Carry the Fork!” and
speaks nationally about brain injury from the
survivor’s perspective
B
ack in September I sat down to watch
Monday Night Football. The New
Orleans Saints were hosting the Atlanta
Falcons and I had looked forward to seeing
the re-opening of the Louisiana Super
Dome after Hurricane Katrina and its
horrific aftermath in 2005.
The big dome looked beautiful on this
night. Gone were the tons of garbage that
had filled it. Gone was the smell. Gone
were the bodies.
It was fixed up and freshly painted
inside and out, and there was a carnival
atmosphere–A celebration with music and
tailgating in the parking lots. Tantalizing
smells of delectable foods wafting through
the crowds. People were walking the
streets with signs and smiles. While
hundreds of thousands of people were
displaced after the hurricane, it seemed
like everyone who remained was in and
around the Super Dome that night. Even
as much as Louisiana and the surrounding
hurricane-devastated region continue
to struggle, there was something sorely
needed and wonderfully tangible on this
night. In this place, it was relief and it was
hope.
During a crucial point in the game, the
raucous crowd was called upon to make
more noise in order to help the Saints’
defense stop the Falcons’ late drive. A
television camera panned the frenzied
crowd and then zoomed in on a man in
a New Orleans shirt and colorful beads,
pounding like crazy on the wall below his
seat.
I half-laughed and shook my head.
Here was this man, one simple man in this
jam-packed stadium, amidst a city that
7
still weeps and limps and struggles. This
man who, after a short four-hour reprieve,
would likely head back into the dark
night through ghost-town neighborhoods
to his FEMA-issued trailer. Here was this
man smiling and hollering and pounding
like crazy. Trying to make a difference.
Believing he was making a difference.
Knowing.
Something about seeing him brought
tears to my eyes.
Rehabilitation after traumatic brain
injury is as concrete as the walls of the
Super Dome and as fluid and changing
as the people who filled it that night. For
the survivors of TBI, rehabilitation affects
and hits and heals on many levels. It can
be, at the same time, the answer and the
question, the hero and the goat, the bottom
of the hill and the top of the mountain.
After the car crash in 1996 that
caused my injury, I underwent physical,
speech, occupational, advanced balance,
alternative vocational, driver retraining, and
psychological therapies. Looking back,
I now understand that attending therapy
once or twice or three times a week for an
hour at a time was a lot like that man in
the Super Dome pounding on the wall. No
matter how dismal my situation lingered
and waited and darkened outside, that hour
of therapy made me feel like I was making
a difference. Like I was affecting change.
I was unable to drive for the first
eighteen months after my injury and it took
many months before my insurance would
approve a transportation benefit. I lived
in an area I was told was a “dead zone.”
Cabs wouldn’t answer calls near my home
because they received so few of them that it
wasn’t profitable to wait nearby.
In order to make my eleven o’clock
appointment, I had to get up and get ready
by 6 am, calling the cab company for a
ride. It often took three or four hours for
someone to begrudgingly pick me up and
drive forty-five minutes to my therapist’s
office.
After our session ended close to noon, I
would go to the coffee shop down the street
and wait for one of my friends to get out of
work. They’d pick me up at four or five and
drive me back home. Sometimes we’d wait
until six or seven for the afternoon rush to
ease. My forty-five minute appointment
each week took twelve hours to execute.
But I went. I went because I needed
to feel like I was affecting my recovery.
Physically, emotionally–I needed to feel
like I was doing more than just sitting in
my house waiting for this nightmare to end,
my injury to be cured, and my old life to
return.
Within our complex and oftenconfusing health and insurance systems,
too many survivors are forced to wait
excruciating weeks and months, even
years, between and before they are afforded
much-needed therapies. It is bewildering
and dispiriting. Once we finally gain
access to rehabilitation, far too many of
us are terminated prematurely due more
to insurance parameters than to an actual
measure, or lack thereof, of progress.
One of the most beneficial aspects of
quality rehabilitation is the feeling that
something specific and concrete, regardless
of how small, is being addressed and
improved. When your relationships, your
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career, your financial future and your sense
of self are all swirling around you and
raining down upon you like a hurricane,
you would be surprised at how incredibly
rewarding it feels to walk successfully
between two parallel bars or to be able to
read a simple sentence without messing up
the words.
While I valued most of my therapies
and therapists, I also came to understand
something very important that greatly
enhanced my recovery. It is that we
enjoy only a fraction of our healing and
improving during our time in rehab.
We cannot set aside time to heal.
We cannot allow ourselves to simply
compartmentalize healing within the
confines of our therapists’ offices. Our
injuries are stubborn buggers and we need
to do better than that.
While we are “inside the box” in rehab,
we need to learn to think “outside the box.”
When our therapists give us homework,
we need to require of ourselves even more
than what they require. We need to ask
more than they ask and demand more of
ourselves than they demand.
It took me a while to see my
rehabilitation as more of a starting point
than a finish line. I expected my therapists
to cure me. I expected that, after six
weeks of one-hour sessions every Monday,
Wednesday and Friday, I would be ready
and equipped to return to my life and pick
up where I left off.
It sounded good in theory. It wasn’t
until I started “thinking outside their boxes”
that I began to see improvement. Instead of
simply completing the reading tasks given
to me in speech therapy, I went home and
sang songs over and over to reclaim the
smoothness and ease in my speech. After
walking between parallel bars in physical
therapy, I came home and used the walls in
my hallway to keep me safe as I practiced
turns and bends. When my occupational
therapist used hand weights and rubber
balls to increase the coordination in my
fingers, I went home and molded clay and
threw tennis balls to my dogs.
While many venues of rehabilitation
available to us employ dedicated and
2006/2007
enthusiastic therapists, too often the time
we are allotted to utilize their wonderful
skills is cut short by the limitations of
insurance coverage, finances or our own
potential to improve.
It is crucial that we embrace the idea
that healing is a life-long process that is
not bound by four walls. The end line
for healing cannot be prescribed. The
possibility of healing cannot expire.
We need to listen to and take with us
the advice and direction afforded by the
people charged with our rehabilitation.
They offer seeds that we can plant and
nurture so that we might enjoy their lovely
blossoms every day of our lives.
We are that man in the Super Dome
that night–A year after the storm; five years;
ten. No matter the darkness that remains or
the feeling sometimes that we are forgotten,
we owe it to ourselves to keep pounding
that wall. We need to keep trying to affect
change and improvement in our lives.
Every day. Every day. t
n eCnittsy
Gapradretm
A
ilies,
A place for fam
ome!
a place to call H
Now Open!
Call for a brochure...
1.800.968.6644
8
10
From
Rainbow’s
Medical Residential
Program
TBI SURVIVOR...
Becky Branscum
By
Kimberly Paetzold, Editor
B
Rainb ow Visions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 ecky Branscum came to Rainbow in
December of 1998, almost nine years
after her motor vehicle accident in January
Pictured above: Left - Nurse with Becky on right (year of photo)
of 1990. She was seriously injured and
initially treated at St. Vincent Hospital in
Toledo. The accident had left her with a
motor neuron disturbance (neurological
Above: Becky Branscum–November, 2006.
muscle damage) and a frontal parietal skull
fracture on her right side. Becky lived
in several residential locations after her
closure to prevent aspiration, but Becky’s
pneumonia has not been a major health
hospital discharge. Initially, she weaned
body cannot coordinate these efforts
issue.
from her tracheotomy tube, but because
because she has cranial nerve dysfunction.
of chronic reoccurring pneumonia, she
Her muscles do not move quick enough to
Improved Communications
readmitted to U of M Hospital where a
close her airway, so aspiration results.
tracheotomy tube was reinserted.
and found that she was having difficulty
team made it their primary focus to
with the size of the screen. Her treatment
admission to Rainbow almost eight years
improve Becky’s quality of life. It did
team recommended a ChatBox Assistive
ago has yielded steady improvements. The
not take long before there was marked
Communication Device. At first, the
Rainbow treatment team combined with
improvement in her respiratory system and
ChatBox was unsuccessful, but therapists
residential staff, worked hard to help Becky
cognitive functioning. In 2005, Becky was
recuperate. Following are some highlights
a candidate for the Lindeman procedure
of her therapy gains in various therapeutic
(surgery), which is a laryngotracheal
disciplines.
separation that prevents aspiration by
The rehabilitation process since Becky’s
Rainbow’s interdisciplinary treatment
Initially Becky worked with a DynaVox
physically separating the lower respiratory
Improved Respiratory Status
tract from the upper respiratory and
digestive tracts. During the surgery, Becky’s
When Becky first came to Rainbow
she was quite sick. According to Monique
surgeons also eliminated the need for
Kurkowski, Respiratory Therapist,
a tracheostomy tube by constructing a
Admissions Coordinator, “Becky’s biggest
permanent stoma.
challenge has been her tracheostomy tube,
which has caused constant tissue growth
wonderful. Becky has decreased her work
resulting in airway obstructions.” Another
of breathing, making her more comfortable.
problem for Becky is immobility. Due to
She is working on eating one meal orally
lack of proper movement for so many
each day. Even when she’s not motivated
years, secretions built up and pooled in her
to attend therapy, she always has energy
lungs causing chronic pneumonia. Non-
and interest in eating. The amount of her
injured individuals have seven layers of
secretions has reduced, and the reoccurring
9
The results of this surgery have been
Above: Becky Branscum with a
tracheostomy tube in 2003–prior to the
Lindeman procedure (surgery).
WINTE R
2006/2007
continued to work with Becky, and she
lean forward.
could result in a fracture, and they need to
now uses it with a series of switches called
constantly monitor her breathing. Standing
the pow pad. Becky has three of these
received permission to employ active
exercises were recommended for Becky
located on a wooden tray that sits on her
therapy, a lot of work had to be done
to build bone density and to normalize
table. She is able to activate up to three
regarding her positioning. Her head rested
abnormal muscle tone. Additionally,
of the switches and four different pages
deep into her chest, her left knee was
standing is necessary physiologically
on the ChatBox, giving Becky the ability
contracted beyond 90 degrees of flexion,
for lungs and other organs. It can help
to communicate with her staff. Overall,
and she was unable to stand. In addition,
skin integrity, the digestive system and
When the Rainbow Treatment Team
respiration.
her accuracy rate is 75%––the best
documented results since her accident.
...even though she may never
Becky has also increased her ability
to use yes and no communication. She
fully recuperate from her
uses thumbs up or a head nod for yes,
and thumbs down or head shake for no.
injuries, proper care and active
Combining this with the ChatBox, Becky
has more options for communication and
therapy has greatly improved
can easily draw attention to herself.
Becky’s quality of life.
Occupational & Physical Therapy Gains
Becky Today
Becky has endured and never stops
fighting. She enjoys looking at attractive
young men, likes being around people
and really enjoys her food. Becky loves
attending concerts, and her favorite music
is country. Her disposition is happy,
and even though she may never fully
recuperate from her injuries, proper care
and active therapy has greatly improved
From an Occupational Therapist’s
standpoint, Becky was not in good shape
Becky’s left elbow was seriously contracted.
Becky’s quality of life. According to Lisha
when she came to Rainbow. According
To solve this problem, therapists serial cast
Clevenger, the Medical Program Director
to Becky’s Admissions Coordinator,
Becky’s arm out, with good results. Later
at Rainbow, “I think Becky feels better.
Monique Kurkowski, “When I went to the
they were able to put a semi-dynamic
Her respiratory status is now comfortable;
hospital to evaluate Becky, I was surprised
elbow brace on her arm. However, it took
before she was always fighting. She feels
to see the severity of
a long time to work the contracture out
better, so she’s more alert and able to
her contractures.” Her
of Becky’s knee because of her serious
participate. She’s had a really great team
occupational therapist,
osteoporosis. With the fear of being too
of therapists who worked together and it
Kathy Grace recalls, “I
aggressive, Kathy Grace (OT) spoke with
helped her immensely. It has been a slow
think her case manager
Becky’s family in a team meeting about
and long process to work out many of her
was afraid we were going
the risks involved in rehabilitating her
problems, but it’s been successful.”
to be unrealistic with our
knee. Together with the treatment team,
active therapy goals, but
they decided that the gains outweighed
process, residential staff diligently watched
when we started Becky’s
the risks and proceeded with aggressive
over her and reported any concerns they
treatment, our goal was
therapy. Slowly the contracture of Becky’s
observed. Aside from all of her basic
to help her posture.”
left knee was worked out, and she is now
care and positioning requirements, her
Becky had aggressive
at 0 degrees. She is able to stand at the tilt
assigned house staff attend to little things
osteoporosis due to
table with amazing extension.
that help build self worth, such as matching
hormonal disturbances
her outfits right down to her socks and
from the injury and from
her surgeon requires she stand three times
making sure she has plenty of social
non-weight bearing for
a week. This can be a challenge for her
interaction. This attention to detail makes
several years. She had not
treatment team; her positioning on the tilt
a big difference in Becky’s life. It provides
been sitting in a proper
table has to be perfect. It takes quite a
not only a warm and caring environment,
wheelchair, which resulted
bit of time for two professionals to get her
but gives Becky a sense of dignity and
in bad posture (thoracic
standing, and the procedure requires a high
belonging. t
curvature), causing her to
level of concentration. Any wrong moves
As part of Becky’s physical therapy,
Throughout Becky’s rehabilitation
10
Meet
Dr. Owen Perlman, M.D.
RAINBOW REHABILITATION
Medical Director
Interview by
Heidi Reyst, PhD, CBIT
Kimberly Paetzold, CBIS, Editor
1 - 8 0 0 - 9 6 8 - 6 6 4 4 Written by
D
r. Owen Perlman is the Medical
Director at Rainbow Rehabilitation
Centers and the cofounder of Associates
in Physical Medicine and Rehabilitation,
P.C. He has a long history of involvement
in the development and implementation
of quality rehabilitation programs for brain
injury survivors. Well-known in Michigan
for his clinical skills in treatment and
management of the full spectrum of brain
injury, Dr. Perlman is a creative, dedicated
and tireless advocate for his patients and
their families.
Dr. Perlman obtained his undergraduate
degree in Psychology and his medical
degree from the University of Michigan.
During his residency at U of M, he served
as the Chief Resident. He is board certified
as a specialist in PM&R.
In 1984, Dr. Perlman joined the St.
Joseph Mercy Health System in Ann
Arbor as Medical Director of the inpatient
What is
PM&R?
Physical medicine and rehabilitation
(PM&R) or physiatry is a branch of medicine
dealing with functional restoration of a
person affected by a physical disability.
The major concern of a physiatrist is to
help patients function optimally within the limitations placed upon them by a disease
process for which there is no known cure. It is a relatively young specialty and was
recognized as a medical specialty in 1947.
Physical medicine and rehabilitation involves the management of disorders that alter
the function and performance of the patient. Emphasis is placed on the optimization of
function through the combined use of medications, physical modalities and experiential
Rainb ow Vis ions
training approaches. Electrodiagnostics are used to diagnose and provide prognosis for
various neuro-muscular disorders.
Common conditions that are treated by physiatrists include traumatic brain injury,
amputation, spinal cord injury, sports injury, stroke and musculoskletal pain syndromes
such as low back pain and fibromyalgia. Chronic pain management is achieved through
a multidisciplinary approach involving psychologists, physical therapists, occupational
therapists and interventional procedures when indicated. q
11
Rehabilitation Unit. He collaboratively
developed CARF-accredited programs that
include inpatient Brain Injury, the postacute Joyce M. Massey Traumatic Brain
Injury Day Treatment Service and McAuley
Work Advantage. He was the Department
Director and the Program Director
responsible for all rehabilitation services in
the system until 2001.
Thank you, Dr. Perlman, for interviewing
with Rainbow Visions. People come from
all over the state to have you treat them.
Could you tell us how you became an
expert in the field of brain injury?
In college, my friends and I used to talk
about having an in-depth knowledge in a
specific treatment area. This would allow
us to become experts in that chosen field.
I made the decision to help individuals
with traumatic brain injury and went into
practice because it combines everything
I like to do. I have a background in
psychology, and I’m interested in both
acute and chronic care. I particularly
enjoy working with teams and could never
work alone–Teamwork gets a lot more
accomplished.
In addition to being an expert in the
field, I now realize that part of my role is
being a patient advocate. I know what my
patients needs, what will happen if they do
or don’t get the appropriate treatment, and
WINTE R
how they will progress. Therefore, I feel
an obligation and try to advocate fairly and
strongly. I do believe this is another reason
I have become well regarded.
rehabilitation to make sure the appropriate
splints and seating systems are ordered,
and to provide adequate family education
before people leave.
With your vast experience in PM&R
and specifically treating individuals with
traumatic brain injury, do you see patients
transferring into acute rehabilitation
quicker?
The real question here is the ability to
certify somebody for an acute rehabilitation
unit, and there clearly have been changes.
Essentially, there are ten conditions that
a patient now must meet in order to be
admitted, and it follows the 75% rule. Each
acute rehabilitation unit, over a period
of one year, must have at least 75% of
patients meet set diagnosis criteria. If the
rehabilitation unit fails to meet this, they
can loose certification. Because of this,
many individuals now transfer directly into
sub-acute settings.
Technology that helps individuals with
traumatic brain injury has vastly improved
over the years. What has been your
perspective on this trend?
I began treating individuals with TBI in
the late 70’s/early 80’s, and we did not have
the tools for treatment that we do today.
One example is Intrathecal Baclofen. Oral
Baclofen was available in the early 70’s,
but it’s only been over the last ten years that
Intrathecal Baclofen has been an accepted
treatment modality, and approximately
When an individual incurs a TBI and has
a low Rancho level, how do you feel these
individuals should initially be treated?
Individuals with a TBI and Rancho level
of I, II, or III should initially be treated
on an acute rehabilitation unit. It’s not
a question of coma stimulation for these
patients, but rather coma and medical
management. In order to properly treat
these individuals, you must have a good
understanding of their injuries, look for
any seizure potential and treat accordingly,
assess their respiratory and swallow
status, have a feeding tube placed (if
necessary) and look at the prospect of oral
feeding. We must evaluate for heterotopic
ossification and provide the appropriate
prophylactic treatment (preventative
measures or medications). It is practical
to do neuro-stimulant medication trials
in a unit where you can actually see the
response. For example, when patients are
bedridden for long periods of time, helping
them overcome balance reaction problems,
blood pressure problems and autonomic
storming problems would be an example of
treatment provided in acute rehabilitation.
I like patients to have a 30 day trial in acute
2006/2007
150-200 patients from our practice use it.
For individuals with severe spasticity, this
modality is an extremely effective treatment
option that eliminates side effects that
impair cognitive status. In our practice, we
track outcomes, such as skin breakdown, as
well as complications. There are limitations
when using Intrathecal Baclofen. The
implants are battery operated and only
useful for the lifetime of the battery; maybe
five years. Newer units are better, with an
extended battery life, and the volume of
Intrathecal Baclofen they store is doubled
from 20 cc’s to 40 cc’s. This decreases the
need to come into the Doctor’s office to
have the nurse refill the pump.
Continued on page 14
Baclofen
Baclofen is a muscle relaxant medicine commonly used
to decrease spasticity related to neurological diseases.
Spasticity is a motor disorder characterized by tight or
stiff muscles that might interfere with voluntary muscle
movements. Spasticity is caused by an imbalance of
excitatory and inhibitory input in the spinal cord. This
imbalance causes hyperactive muscle stretch reflexes
that result in involuntary spasms and increased muscle
tone. Baclofen works by restoring the balance of excitatory and inhibitory input to reduce
muscle hyperactivity, allowing for more normal motor movements.
Baclofen can be taken orally or delivered into the intrathecal space containing the
cerebrospinal fluid (fluid surrounding the spinal cord and nerve roots). Oral baclofen causes
side effects that might limit its usefulness. When oral baclofen is delivered throughout
the body, only a small portion goes to the spinal fluid where it is needed. An intrathecal
delivery system, which provides the baclofen to the target site in the spinal cord, is a more
effective way to deliver the medicine.
The baclofen pump system is the intrathecal (directly into the spinal fluid)
method of delivering the medicine. The system consists of a catheter (a small,
flexible tube) and a pump. The pump (a round metal disc, about one inch thick
and three inches in diameter) is surgically placed under the skin of the abdomen near the
waistline. The pump stores and releases prescribed amounts of medicine through the
catheter. The pump is refilled by inserting a needle through the skin into a filling port in
the center of the pump. With a programmable pump, a tiny motor moves the medicine
from the pump reservoir through the catheter. Using an external programmer, your
treatment team can make adjustments in the dose, rate, and timing of the medicine. q
Source: The Cleveland Clinic Health Information Center, www.clevelandclinic.org
12
ABI
Technology
Corner
THERAPY & TECHNOLOGY
Ultrasound & Electrical Stimulation
Written by
Rainb ow Visions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 I
Kristine Woodson, OTR
Occupational Therapist
n today’s world of changing technology it
can be difficult to keep up with the latest
healthcare trends and have a thorough
understanding of available services. There
are several modalities utilized by therapists
to enhance functioning; the two that will
be discussed in this article are ultrasound
and electrical stimulation.
Ultrasound & Electrical Stimulation
Although many people are familiar with
the term ultrasound, there are a myriad
of applications for its use. In the realm of
therapy, ultrasound is used during treatment
sessions to reduce edema, promote tissue
and fracture healing, reduce pain, decrease
muscle tone/muscle spasms, increase
range of motion, increase circulation and
remodel collagen.
Therapeutic ultrasound uses high
frequency sound waves to generate
tissue vibration that creates heat in the
treatment field. Secondary effects from
the production of heat include increasing
blood flow to tissue, which delivers
important nutrients and removes waste.
When receiving ultrasound, the therapist
uses a coupling medium (gel or water) to
transmit sound waves to the treatment area.
Another common modality is electrical
stimulation. Electrical stimulation is the
application of electrical currents to specific
muscles through strategic placement of
electrodes. It is often used for neuromuscular reeducation and decreasing pain
through nerve blocks, atrophy and muscle
spasms while increasing range of motion.
It also reduces edema through sensory
stimulation.
Often, therapists use combined
modalities to maximize results. Four
specific results that are often strived for
through the use of ultrasound and/or
13
electrical stimulation include: Managing
contractures/increasing range of motion,
managing pain, increasing strength and
training muscles to increase continence.
Contracture management:
Abnormal tone decreases an
individual’s ability to move muscles
through the full range of motion and often
leads to contractures. Individuals with
limitations in their passive range of motion
can receive a combination of ultrasound,
electrical stimulation, orthotic use and
a range of motion program to decrease
the risk of future contractures and/or
increase their passive range of motion.
In this scenario, ultrasound can apply
deep heat to the muscles with limited
range, as well as stimulate the Golgi
Tendon Organs to activate the Protective
Relaxation Reflex. Electrical stimulation in
this type of situation can be used to either
reeducate muscles or perform a nerve
block to decrease pain during treatment.
Orthotics are utilized to perform a gradual,
prolonged stretch over a longer amount of
time than what can be completed during
individual therapy sessions. It is also
important that patients and caregivers are
aware of the range of motion programs
that need to be carried out throughout
the day and fully understand the splinting
schedule to maximize benefits.
If a patient has full passive range of
motion, but a limited active range of
motion, typical use of electrical stimulation
will focus on increasing muscle strength
and will be combined with therapeutic
exercises and activities to retrain the
muscles for proper movement patterns.
When electrical stimulation is coupled
with exercises, the muscles strengthen and
the active range of motion increases.
Pain Management
Both ultrasound and electrical
stimulation can be used to decrease pain.
Ultrasound can increase circulation and
blood flow to effected areas, decrease pain,
as well as edema and muscle tightness.
Electrical stimulation can be used for
similar symptoms and for completing a
nerve block. This reeducates the sensory
systems to interpret input properly and
reeducate pain receptors.
One important consideration when
using electrical stimulation is to be aware
of pain medications that a patient may be
taking. Some medications decrease the
effectiveness of electrical stimulation. To
implement treatment successfully, adjust
the timing of session to occur when pain
medications are least present in the system,
or have the prescribing physician select
an alternative medication. One long-term
benefit of electrical stimulation can be
the decreased reliance on certain pain
medications.
Increasing Strength
With the variety of impulses used
during electrical stimulation, electrodes
can be placed on weak muscles that
need strengthening. This application
is frequently used in sports medicine
rehabilitation to increase muscle strength/
power or to maintain muscle strength
during inactivity due to injury.
Continence Training
Another application is managing
continence. The use of electrical
stimulation combined with an exercise
regime can aid in the reeducation of the
bladder muscles, decreasing the frequency
of incontinent episodes. Before using
this treatment, patients need to relay their
medical history so proper precautions
can be taken. It is recommended that a
physician prescription is obtained prior to
beginning this modality so that there are
clear communications regarding treatment
protocols and any potential concerns can
be discussed. t
WINTE R
2006/2007
Dr. Perlman
Another wonderful technology is the Lite Gait, which is a suspension harness
patients wear to progressively increase their weight bearing. This mobility device
helps promote proper posture, balance, coordination, trunk and lower extremity
strength, and endurance required for standing and walking.
Common technologies that individual’s with TBI can effectively use are PDA’s
(personal digital assistants), digital recorders and alarms, GPS systems and Bluetooth,
which connects and exchanges information between devices such as PDAs,
mobile phones, laptops, PCs, etc. These items have become assistive technology.
Computers are a great tool allowing individuals with TBI to easily and safely
research/learn. Many find it advantageous to purchase on-line, especially those that
are house bound or have inappropriate behaviors. There is a downside as well, such
as the ability for easily overspending or logging on to inappropriate sites. We handle
this by putting in appropriate controls and blockers, establishing people as computer
administrators to determine what sites are appropriate.
Dr. Perlman’s Family
Wife: Sheila
Children
Sarah (26)–lives in Chicago
Alex (15)–High School sophomore
Jacob (2- 1/2 years old)
Rachel (5 months)
These are some examples of the technology improvements separate from the
obvious as it relates to traumatic brain injury diagnosis: MRI’s, CT Scans, the
vocational potentials and certainly the improvements in the surgical techniques,
monitoring techniques, etc. These technologies have all helped with diagnosis and
treatment. Braces and wheelchairs have improved, going from reclining wheelchairs to
the tilt and space wheelchairs.
With regard to TBI, do you foresee a point where technology reduces the severity of
injury and life-long care needs?
We are still trying to find the emergent or acute care markers that would enable us
to determine the various types of injury located in different areas of the brain. The
key is to treat the injury on-site and in the ER; to avoid anoxia (lack of oxygen) and
to keep the vital signs and homeostasis under control. I think the future is looking at
medications that might help neuro-recovery mentally, neuro-stimulation and neurorepair. This means looking at some of the neuro-protective medicines, neuro-stimulant
medications, and neuro-protective procedures that might be able to help a person
long-term.
I’m sure our readers would like to know how you balance everything to maintain
your success.
I balance my life by working hard, and it takes lots of energy. I have a picture in
my office of a bee in midair given to me by a patient. A bee moves quickly to stay
afloat, but at any given moment, it looks like it’s standing still. I find the key to success
is making every patient feel that I have nothing else to do but to talk with them, treat
them, and help with their issues.
When I do go home, I focus on my family and give them my all. As they say about
anybody that is successful, you never do it by yourself. You have to be surrounded by
really incredible people, and I am. We are fortunate in Michigan to have outstanding
professionals providing excellent treatment and quality care. t
14
NeuroRehab Campus
Grand Opening
Open House
December 13, 2006
11:00 am - 3:00 pm
Join us for refreshments, lunch and tours of our new facility
from 11 am until 3 pm on Wednesday, December 13, 2006.
The official Grand Opening Ribbon Cutting Ceremony is scheduled for 12 pm.
Please R.S.V.P.
by phone: 1.800.968.6644 ask for Mary Mitchell ext. 153
Fax: 1.877.624.6269
•
E-mail: [email protected]
Rainbow NeuroRehab Campus
25911 Middlebelt Road
Farmington Hills, MI 48336
23
15
Clinical Programing:
The NeuroRehab Campus for adults
with brain & spinal cord injuries offers
Rainbow’s full Continuum of Care including
active therapy, community outings and
supported living for individuals with medical needs.
Some of the unique features offered through the residential portion of the campus include...
• Two 20-bed facilities with private bedrooms and private baths.
Each room offers optional cable TV, internet access, telephone access
and call light/intercom system access.
• Physician visits on-site
• Nursing services available on-site 24/7
• Executive Chef
• Professional Treatment Team on-site
16
Meet
CynthiaJeffrey
NOTABLE CHANGES AT RAINBOW
Executive Chef – NeuroRehab Campus
Kimberly Paetzold, Editor
Rainb ow Vis ions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 By
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17
WINTE R
2006/2007
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ynthia, the new Executive Chef for Rainbow’s NeuroRehab Campus, is
looking forward to preparing and serving many great meals. She will be
preparing menus with several incredible options and will talk with clients to get
a feel for their likes and dislikes. Cynthia will prepare a couple of hot entrees for
each meal–breakfast, lunch and dinner– that taste great!
Dining at the NeuroRehab Campus will be cafe style and Cynthia will be
working with Catherine (Rainbow dietitian) to meet individualized dietary
needs. The menus will all be heart-healthy, and for clients with aspiration
issues, specialized meals will be prepared. q
18
AACBIS
Corner
BRAIN INJURY SPECIALIST
Silent Epidemic
Rainb ow Visions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 By Heidi
I
Reyst, PhD, CBIST Systems Director
f we collectively want to eliminate
the Silent Epidemic moniker from our
vernacular, then we must arm ourselves
with knowledge about brain injury. Let’s
begin by taking a moment to examine
the phrase “Silent Epidemic” and most
importantly, the implications of remaining
silent. An epidemic is defined as “affecting
or tending to affect a disproportionately
large number of individuals; excessively
prevalent.” By virtue of this definition, one
would expect widespread understanding
of brain injury, given its pervasiveness. Yet,
this really is not the case.
If you compare the incidence of other
maladies such as breast cancer and heart
failure to TBI, it is hard to understand the
general public’s lack of knowledge, given
TBI’s higher relative rates of incidence and
prevalence (see sidebar for definitions).
Figure 1 presents the overall incidence
and prevalence of TBI1, Breast Cancer2 and
Heart Disease3. Figure 2 presents death
rates for TBI1, Breast Cancer2 and Heart
Disease3, and Figure 3 presents incidence
rates per 100,000 people for TBI1, Breast
Cancer2 and Heart Disease3. These figures
highlight that while other diseases or
conditions may have lower or equivalent
rates of incidence, prevalence or death,
many have a higher public profile. I would
argue that the lack of public knowledge
lies not solely in the breadth (or amount)
of the general public’s knowledge of brain
injury, but also in its depth (or quality) of
understanding.
Today, brain injury is a topic discussed
in the popular press more than ever. Just
last month, on both ESPN and ESPN Radio,
there were stories regarding the NFL’s (mis)
handling of athletes with concussions.
The nightly news is even more profound
in its coverage of soldiers returning from
Iraq and Afghanistan with brain injuries.
19
A particularly disturbing fact is that TBI
is now considered the signature injury of
the Iraq war. Words like “polytrauma”,
where soldiers return with brain injuries
along with a host of other injuries like
amputations, burns, auditory and visual
impairment, post traumatic stress disorder,
spinal cord injury and depression,
have begun to seep into our collective
vocabularies. The breadth of information
is increasing–and that is a good thing. But
I am not ready to declare success because
I believe the depth of knowledge has yet to
keep up.
Many of you will recall the news of
CBS anchorman Bob Woodruff who was
critically injured by a roadside bomb
in Iraq in January, 2006. Woodruff was
embedded with troops when their convoy
was hit. It was widely reported that he
suffered serious injuries, including a
traumatic brain injury. As time passed,
fewer news cycles reported on Woodruff
and his cameraman Doug Vogt, who was
also injured. While some of that may
be due to privacy concerns for these
gentleman and their families, some was
surely due to the fact that newer stories
started to take precedence.
To the general public, Bob Woodruff’s
story was a sound bite amidst the constant
bad news that permeates our coverage
of this conflict on television, radio and
the Internet. For those familiar with the
recovery process after TBI, there was a tacit
understanding that Mr. Woodruff and his
family had a long road ahead of them. I
am quite sure the general public did not
lay claim to such knowledge.
So as my argument goes, such stories
have certainly increased the breadth of
knowledge–more people are aware of
Epidemiology – The branch of medical
science dealing with the incidence,
distribution & control of disease in a
population4.
Incidence – The number of cases of
a disease having their onset during a
specified period of time. It is expressed
as a rate and is a measure of morbidity4.
Example –Every year in the U.S., 1.4
million people sustain a Traumatic Brain
Injury1.
Every year in the U.S., 506 people per
every 100,000 sustain a Traumatic Brain
Injury1.
Prevalence – The number of cases of
a disease present during a particular
interval of time4.
Example – In 2005, there were 5.3 million people living with a brain injury in
the United States5.
TBI as a substantial issue–but the depth
of knowledge is still lacking. Few are
aware of the often debilitating or life
long consequences that come with brain
injury. For the silent epidemic to no longer
be silent, we need to increase both the
breadth and depth of understanding. How
do we make this happen and why is this so
important? Let me tackle both separately.
How do we increase the public’s
knowledge of the consequences of ABI?
For families and survivors–your stories
are compelling, and they need to be
told. As the saying goes; brain injury
doesn’t discriminate. But for a variety
of reasons, we don’t expect harm to
come our way. Our psyches have built
in protection systems allowing us to see
the world through rose-colored glasses.
Studies that have compared depressed
people to “normal” people have shown
that depressed people may actually have
WINTE R
6M
Figure 1. Overall Incidence and Prevalence for
TBI, Breast Cancer & Heart Disease
5M
Incidence
Prevalence
4M
3M
2M
1M
0
70,000
2006/2007
TBI
Breast Cancer
Heart Disease
Figure 2. Overall Death Rates for TBI, Breast
Cancer & Heart Disease
60,000
50,000
40,000
30,000
20,000
10,000
TBI
Breast Cancer
Heart Disease
Figure 3. Overall Incidence per 100,000 People for TBI,
Breast Cancer & Heart Disease
a more accurate view of the world. This implies that
non-depressed people utilize some protective factor
to shelter oneself from the pain of reality. Perhaps this
is a case where the truth may in fact hurt. Akin to this
protective factor is the widely held idea that bad things
won’t happen to me–they happen to other people.
There are at least 5.3 million people currently living
with a brain injury who likely believed that it wouldn’t
happen to them. They are evidence that this theory is
a bad theory.
There are some very good memoirs by people with
brain injuries. Some of these include Kara Swanson’s
I’ll Carry the Fork, Dr. Claudia Osborne’s Over My
Head, and Tricia Meili’s I am the Central Park Jogger.
But you don’t have to write a book to tell your
story–every day opportunities present themselves,
and a message coming from someone who has been
there is often the most powerful. Credibility is not in
question–it’s a given. Some Rainbow clients have
spoken at local high schools, to let people know first
hand the real consequences of drinking and driving.
You couldn’t hear a pin drop in a gymnasium full of
teenagers. Personal experience is powerful and people
will listen. In the spring of 2007, Bob Woodruff and
his wife will air a special to present their story. I will
be watching.
For professionals in the field, use every day
opportunities to educate. Whether its done formally
by speaking to a conference or to your local church
group, or informally by talking to your neighbors about
the newest concussion information or the benefits of
side curtain air bags, (I think my neighbor will buy her
next car based solely on whether it has side curtain air
bags) there are countless opportunities.
At worst, we risk coming across as pious; at best our
education may save a life, or prevent a brain injury. I
think I’ll take my chances at being perceived as selfrighteous. It’s that important. But why?
Why is increasing the public’s knowledge of the
consequences of ABI so important?
In a nutshell, it’s all about funding. Prevention
efforts require money. Research into neuro-protective
factors requires money. Research to improve trauma
care requires money. Rehabilitation requires money.
Long-term care requires money. The Brain Injury
Association of America estimates that of individuals
with severe brain injuries, only five percent have the
TBI
Breast Cancer
Heart Disease
20
1 - 8 0 0 - 9 6 8 - 6 6 4 4 Rainb ow Visions
Table 1
Budget 2006
Federal Spending Budget8
Department of Health & Human Services
TBI Act7
Silent Epidemic
By Heidi Reyst, PhD, CBIST
funding needed to care for long-term
treatment. I often wonder what percentage
of that five percent is the result of our Auto
No Fault system here in Michigan. We are
blessed with a system that works.
In the year 2000, Traumatic Brain
Injuries in the United States cost more
than $60 billion, and the expected lifetime
costs were estimated at $406 billion6. The
need for money is clear. Where it will
come from is not so clear. A key point
of departure for this discussion lies with
the Traumatic Brain Injury Act of 1996;
it focused on 3 key areas: Prevention,
research and improved service delivery. It
appropriated funds for the CDC to establish
TBI surveillance and prevention projects,
the National Institutes of Health to award
grants for TBI research, and the Health
Resources and Services Administration to
$35,000,000
award grants for the creation of programs
that provide comprehensive, coordinated
TBI services for states5. Figure 4 presents
the amount of appropriations by fiscal
year7.
To put this in context, in 2006 the annual
budget for the United States included 2.6
trillion in spending dollars8. The budget
included $4.4 billion for the Department
of Health and Human Services, which
includes the Centers for Disease Control,
the National Institutes of Health (NIH)
and the Human Resources and Services
Administration among others8. Table 1
(above) presents this data. It is, as they say,
the proverbial drop in the bucket.
When it comes to appropriations in
Congress, the squeaky wheel gets oiled
and numbers speak volumes. The more
we can educate about the incidence and
Funding Amount
$2,500,000,000,000
$44,000,000,000
$14,210,000
prevalence of brain injury, the more people
will understand that a disproportionate
number of people are affected. Figure 5
highlights the disparity that exists in NIH
grant awards across different health issues9.
Again, despite the overall incidence of TBI
relative to other health issues, the funding
is disproportionately low.
We need to use these disproportionate
numbers to show that TBI is grossly under
funded. We also need to ensure that
we help people realize these “numbers”
are far more than statistics used to get
powerful people’s attention–they are all
people. They are individuals with families
who need more than good will gestures
from politicians. They need the results of
research that show best practices in trauma
care. They need funding for programs that
provide comprehensive, high quality care.
Figure 4. TBI Act Appropriations by Year
(Requested)
$30,000,000
$25,000,000
$20,000,000
(Expected?)
$15,000,000
$10,000,000
$5,000,000
$0
21
27
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2007
2006/2007
WINTE R
Figure 5. National Institutes of Health Grant Awards by Disease/Condition
(from 1972 to present - dollars in millions)
$2,000
$1,800
$1,600
$1,400
$1,200
$1000
$800
$600
$400
They need prevention programs that work and reduce the incidence
and prevalence across all groups. They need research that examines
ways to lessen injury effects and provide better long-term outcomes.
They need funding that doesn’t place the burden of care solely on
families. They need care in settings of choice that are appropriate for
individual needs.
The list of needs is long, but the silence can be broken. We
need advocacy that is loud and consistent. You can write your
Congressperson. There is a quick and convenient way to do this
via the Internet. Go to: www.biausa.org/policy and legislation/
legislative action center to find your legislators.
You can also support your local Brain Injury Association through
volunteering or donating much needed money. I also strongly
recommend supporting the Brain Injury Association of America. We
need a strong and consistent voice holding Congress accountable to
our constituents–individuals with brain injuries and their families,
providers of care, and future brain injury survivors. This organization
is committed to keeping brain injury awareness a constant. They are
the voice in Washington that we all rely upon every day whether we
realize it or not. They have strong leadership and are committed to
ensuring that every dollar they spend is spent well, and they need
our help to do that. Every dollar will count; whether you can afford
$1 or $100, it will make a difference. Please consider helping
this organization if you have the means. It may go a long way in
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References
1. Langlois JA, Rutland-Brown W, Thomas KE (2006). Traumatic
Brain Injury in the United States: Emergency Department Visits,
Hospitalization, and Deaths. Atlanta (GA): Centers for Disease
Control and Prevention, National Center for Injury Prevention and
Control.
2. American Cancer Society - Cancer Facts & Figures 2006.
www.cancer.org/downloads/STT/CAFF2006PSSECURED.PDF
3. American Heart Association - Heart Disease and Stroke Statistics - 2006 Update. www.americanheart.org/downloadable/heart/
1140534985281statsupdate06book.PDF
4. National Center for Health Statistics.
www.cdc.gov/nchs/datawh/nchsdefs/incidence.htm
5. The Essential Brain Injury Guide. The American Academy for
the Certification of Brain Injury Specialists. Manuscript to be
published in 2006.
6. Finkelstein EA, Corso PS, & Miller TR (2006). Incidence and
Economic Burden of Injuries in the United States. Oxford press.
7. TBI Act and Related TBI Apporpriations - Fiscal Year 1997 to
2007. Brain Injury Association of America.
www.biausa.org/elements/policy/tbiactappropriations2007.pdf
8. Budget of the United States Government: Fiscal Year 2006.
www.gpoaccess.gov/usbudget/fy06/pdf/budget/tables.pdf
9. National Institutes of Health Funding Research Areas - Estimates
of Funding for Various Diseases, Conditions, Research Areas
www.nih.gov/news/fundingresearchareas.htm
stopping the silence. t
22
Medical
Nutritional
Therapy
H E A LT H WAT C H
Enteral Nutrition & Tube Feeding
Written by
Rainb ow Vis ions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 &
Catherine Hahn, MS RD, Dietitian
Vicky Scott, RNC, NP, Nurse Practitioner
T
raumatic Brain Injury can result in
many physical, cognitive, and sensory
issues that impede nutritional intake
such as dysphasia (difficulty swallowing),
problems with appetite, attention,
concentration and taste. Adequate
nutrition is extremely important to maintain
health and promote healing, so Medical
Nutrition Therapy (MNT) is often necessary.
MNT is a general term for medically
addressing the needs of people at
nutritional risk. At risk individuals undergo
screening assessments and based on the
screening, a registered dietitian (RD)
works with the interdisciplinary team to
develop a plan of care, implement the plan
and evaluate the results. One of the most
important goals for Rainbow’s dietitian,
Catherine Hahn, is to assure that all clients
are adequately nourished either by tube
feeding recommendations or by counseling
on daily food choices.
Nutritional Considerations
Nutritional requirements are important
factors and are affected by disabilities.
For example, cardiopulmonary stress may
increase calorie needs, while decreasing
tolerance to fluid volume. Infection or
stress from surgery may increase both
calorie and protein needs and certain drugs
may increase the requirement for specific
vitamins or minerals.
Energy or caloric needs are calculated
for normal growth and development. If
caloric intake is inadequate, weight and
height gain will be poor. If caloric intake
is excessive, weight gain will be higher
than desired and Body Mass Index Ratings
(BMI) will be excessive. Factors that may
change caloric needs include illness or
inflammation, increased seizure or physical
23
activity, surgery, increased therapies or
changes in medication. Immobility will
decrease calorie needs.
Protein requirements also vary between
individuals and may increase due to illness,
infection, trauma, pre- and post-surgery,
sepsis or major burns. Estimates of protein
requirements are based on height and
weight (or ideal body weight). Disease related requirements are also a
considerations, such as renal or hepatic
conditions. RD’s use nitrogen balance to
determine the amount of nitrogen (byproduct of protein metabolism) required to
maintain equilibrium by assessing urinary
nitrogen losses. Some factors affecting
nitrogen balance include the biological
value of protein ingested, growth of the
individual, renal function, fecal and skin
losses, and anabolic/catabolic hormones.
Fluid requirements can be estimated
based on weight, height, and age and
depend on the following variables: Urine
output, sweating, vomiting, fever, stool
pattern, environment, renal disease,
cardiac anomalies, tracheostomies and
medications. Constant drooling may
also contribute to fluid loss. Signs of
dehydration include: Constipation,
decreased urine output, strong smelling
or dark urine, crying without tears, dry
lips and skin or sunken eyes. Electrolyte
imbalances must also be monitored along
with fluid intake, as they may cause serious
medical complications, such as hypo- and
hyper-natremia (low or high sodium),
hypo- and hyper-kalemia (low or high
potassium) and cardiac arrhythmias.
Vitamin and mineral needs are mostly
determined by Recommended Dietary
Allowances (RDA) for age, unless growth
is markedly delayed by illness. For a child
with growth delay, the RDAs for height age
can be used. Individuals with inadequate
caloric intakes, decreased absorption and
increased caloric needs should consider
supplemental vitamins and minerals.
Vitamin and mineral requirements can be
altered by medications, disease, previous
medical/dietary history and other factors.
In general, it is a good idea for most people
to take a daily multivitamin to ensure
adequate nutrient intake.
Inadequate Nutrition
Under nutrition is often the result of one
or more of the following: Decreased dietary
intake, increased nutritional requirements
and the impaired ability to absorb or utilize
nutrients. If untreated, the effects are not
limited to loss of weight, body fat and
body tissue, but can have physiological
and functional effects as the body attempts
to adapt to nutritional deficiencies and
starvation. These effects may include:
• Impaired immune function
• Delayed wound healing
• Increased risk of tissue breakdown
• Muscle wasting and weakness which
may effect respiratory and cardiac
function and mobility
• Altered structure of the small intestine
which may result in malabsorption
• Increased risk of post-operative
complications
• Apathy and depression
Individuals at high risk for inadequate
nutrition may include:
• Patients unable to consume at least
WINTE R
Fluid Needs
Fluid needs are important to
consider for tube fed clients. Specific
water needs for an individual can be
calculated as 1 ml/kcal or 35 ml/kg
usual body weight (UBW). Clients
who have large water losses through
perspiration or oozing wounds may
require more fluid intake.
Most Enteral formulas contain
80-85% free water, and fluid needs
can be met with a small amount of
additional water. However, calorically
dense formulas contain as little as 60%
free water, so failure to supplement
with water can result in dehydration.
One way to assess fluid intake is to
monitor urine output. Obligatory
fluid output is the minimum output of
urine necessary to remove waste and
is estimated to be 700 ml per day or 30
ml per hour. q
75% of energy needs by mouth
• Patients with total feeding time of more
than four hours per day
• Young children/infants with weight loss
or no weight gain for three months or
longer
• Weight for height or length less than
fifth percentile for age and sex
• Triceps skin fold less than fifth
percentile for age
• Severe hypoalbuminemia (low protein)
Enteral Nutrition and Tube Feeding
Many clients at Rainbow have physical
and cognitive problems, making it
impossible to get proper nutrition through
normal eating. Enteral nutrition, or tube
feeding, is a way to feed these individuals.
Enteral feeding refers to the delivery of
liquid feedings through a tube. It is a means
of providing carbohydrates, proteins, fats,
vitamins and minerals to people who are
unable to eat orally. Conditions that may
require enteral feeds may include:
2006/2007
• gastrointestinal (GI)disorders of
When selecting a formula, factors to
absorption, digestion, utilization,
secretion and storage of nutrients
• neuro-muscular disorders, such as
muscular dystrophy, spinal cord defects
and cerebral palsy or damage to the
central nervous system
• Cardiopulmonary disorders and other
conditions of hyper-metabolism, such
as burns and some types and stages of
cancer, HIV/AIDS
• Failure to thrive and/or infant
prematurity
consider are:
1. Protein and calorie requirements
2. Age and medical condition
3. History of food intolerance or allergy
4. Intestinal function
5. Route of delivery
6. Specific formula characteristics
Osmolality of a formula has a
direct influence on the GI side effects.
Osmolality refers to the concentration of
osmotically active particles per liter os
solution (expressed as mOsm/L) and is
Some contra indications for enteral
feeding would include:
• a malfunctioning GI tract requiring
bowel rest, such as a mechanical
obstruction in the intestines,
• insufficient absorptive capacity of the
intestinal tract
• severe diarrhea or intractable vomiting
• GI bleeding or severe enterocolitis
(intestinal infection)
• When harm may exceed the benefit of
alternative feedings, such as clients with
an end-stage illness, or when anticipated
benefits may be uncertain or against
the client’s best interests with a lack of
advance directives.
affected by the concentration of amino
acids, carbohydrates and electrolytes
in the formula. Formulas with higher
osmolality produce an osmotic effect
in the stomach and small intestine. The
hyperosmolality draws water into the GI
tract to dilute the formula concentration.
The influx of water into the GI tract may
cause diarrhea, nausea, cramping and
distention. Isotonic formulas are designed
to alleviate these problems. The osmolality
of full strength isotonic formulas is similar
to the osmolality of normal body fluids,
approximately 300mOsm/L.
The required formula volume is
determined by calculating the energy and
There are pros and cons to tube
feeding. Advantages can include improved
growth and nutritional status, reduced
anxiety and improve quality of life,
prevention or reduced risk of aspiration
and improved hydration. Disadvantages
can include increased risk of aspiration
or vomiting with aggressive feeding,
diarrhea and skin breakdown or anatomic
disruption. Metabolic risks include
hyperglycemia (high blood sugar), hyperphosphatemia (high phosphate) and
improved bowel function. Physical risks
include dislodged or occluded feeding
tube.
protein needs of the client. If additional
energy or calories are needed, fat and or
calories can be added. Water must also
be provided to meet fluid requirements
to avoid dehydration. Formulas should
be administered slowly at first; about 50
ml per hour, then increased by 25 ml per
hour every 8-12 hours as tolerated until the
required volume is met. A typical final rate
is 100-125 ml /hr.
Administration of Tube Feeding
Tube feeding may be administered by
bolus feedings, continuous drip feedings or
a combination of the two. Bolus feedings
Tube Feeding Formulas
A variety of commercial formulas are
are delivered four to eight times per day,
each lasting about 15-30 minutes and are
available for tube feedings and most are
similar to normal feeding patterns provided
complete and balanced to meet nutrition
at mealtimes.
requirements for specific populations.
24
2007
Conference
& Event Schedule
January–March
RINC Meetings
Rehabilitation & Insurance Nursing Council
Members Only
Registration begins at 11:30 am
Followed by lunch / presentation at 12:00 pm
For more information contact
Adrienne Shepperd: (248) 656-6681
February
February 7, 2007
Central Michigan Adjusters Association’s Seventh Annual
Vendor Night at Holiday Inn Lansing South at 4:00 pm
For info call Michelle Clark (517) 622-2433
January 19, 2007
February 16, 2007
March 16, 2007
Topics & Locations TBD
February 26, 2007
1 - 8 0 0 - 9 6 8 - 6 6 4 4 December 15, 2006
Garan Lucow Breakfast Seminar at the Lansing Sheraton
For info call Beth Bezenah (248) 641-7600
Or e-mail: [email protected]
March
March 14 - 17, 2007
Contemporary Forums Spinal Cord Injuries: Issues &
Advances at the Intercontinental Boston in Boston, MA
For info log on to www.contemporaryforums.com
MBIPC
Michigan Brain Injury Providers Council
Learn over Lunch
Scheduled meeting times are 12:00 - 2:00 pm
Log on to www.rainbowrehab.com for conference updates!
Cost: Member $20 / Non-member $50
For further information e-mail:
[email protected]
CMSA
Case Management Society of America
Detroit Chapter
For further information log on to:
www.cmsadetroit.com
January 23, 2007
5:00-9:00 pm
Novi Crowne Plaza
For more info call: (248) 443-9890
March 30, 2007
Rainb ow Visions
Day Long Conference
at Burton Manor in Livonia, MI
Save the Date Dinner Conferences
Burton Manor in Livonia, MI
June 5, 2007
September 11, 2007
November 13, 2007
25
December 12, 2006
Applause Banquet Center - Grand Rapids, Michigan
“ABI–Treatment from a Psychiatry Perspective”
January 9, 2007
Holiday Inn West - Livonia, Michigan
Topic-TBD
February 13, 2007
“Brain Injury, Substance Abuse
and Pre-Injury Functioning”
March 13, 2007
Holiday Inn - South Lansing, Michigan/Topic-TBD
April 10, 2007
Holiday Inn West - Livonia, Michigan/Topic-TBD
May 8, 2007
“Predictors of Depression After Mild–Moderate TBI”
June 12, 2007
Holiday Inn West - Livonia, Michigan/Topic-TBD
Watch your mail for confirmed dates, topics & locations!
WINTE R
2006/2007
Enteral Nutrition
They are convenient, less expensive
(if a pump is not required), and allow
freedom of movement because the patient
is not attached to a feeding bag. Some
disadvantages include easier aspiration
compared to continuous drip feedings,
bloating, cramping, nausea and diarrhea.
This method may not be practical for
individuals requiring large volumes or
frequent administration of formula.
Continuous drip feeds infuse formula
without interruption. They are more
expensive because they use a pump and
additional feeding supplies, and limit
mobility because the patient is attached
to the equipment. A continuous feed may
consulted. Liquid medication should
elevate insulin levels contributing to hypo-
be used over pills or capsules, but if not
and hyperglycemia. Continuous drip feeds
available, some tablets/pills can be crushed
are typically used for 8 to 10 hours during
and dissolved in 30-50cc’s of water.
the night for volume sensitive individuals
Formula, juice or milk may be used if the
and smaller bolus feeds can be used
medication does not dissolve. Gel caps
during the day. Continuous drip feeds are
can be cut open and the contents squeezed
delivered by a gravity drip or an infusion
out and most can be dissolved in very hot
pump, which is a better method because
water, then cooled with ice cubes. Highly
gravity drips can be inconsistent and need
viscous liquids (sticky, gummy, gelatinous
frequent checks.
liquid) should be diluted with water prior to
administration.
Medication Administration
NOTE: Certain medications should
Medications may be administered
NOT be crushed or dissolved and certain
when using the bolus feeding method,
medications should not be mixed. Some
but a physician or pharmacist should be
Tube Feeding Formulas
Many companies produce nutritionally complete standard
more viscous and may clog
formulas made of complex proteins, fats, carbohydrates, vitamins
narrow feeding tubes. Milk
and minerals. These formulas are designed for patients who have
or infant formulas can serve
normal digestion but cannot orally consume adequate calories
as a base for the blenderized
and nutrients. They generally have low osmolality and are usually
diet, but a dietitian should
lactose-free, palatable, sterile and easy to use. Some formulas have
carefully monitor these
added fiber to promote regular bowel movements.
formulas.
Elemental formulas are made from predigested nutrients
including amino acids or hydrolyzed protein, carbohydrate and
fat in the form of medium-chain triglycerides or essential fatty
acids. They contain all essential vitamins and minerals. The major
advantage of elemental formulas is that little or no digestion is
required, so stool volume is low and bile/pancreatic secretions are
minimal. The disadvantage is that they are hyperosmolar and may
cause cramping and osmotic diarrhea. Elemental formulas should
be used for individuals with short gut syndrome, malabsoption
syndromes, inflammatory bowel disease, gastrointestinal fistulas,
nonspecific maldigestive and malabsorptive states. They are not
appropriate for people with functioning gastrointestinal (GI) tracts.
Blenderized home-prepared formulas are time consuming,
but less expensive than commercial formulas. When preparing a
homemade formula, sanitary precautions are necessary to prevent
contamination and supplements may be needed to meet nutrient
requirements. In addition, home blended formulas tend to be
Modular formulas are
not complete formulas.
They contain only specific
nutrients and can be
added to commercial or
home-prepared formulas.
Examples include medium
chain triglycerides (MCT
oils), which are easily
digested additional calories
and protein and specific amino acid preparations (Casec or
Promod) used for additional protein.
Specialized formulas are available for special needs such
as diabetes, renal or hepatic disease. Other conditions may
include trauma or severe stress states, or respiratory conditions. A
physician or a dietitian who is familiar with products should select
these formulas and their particular uses. q
26
ABI
ChildSeries
Focus
WHEN CHILDREN ARE INJURED
Children 4 to 5 years of age
By
Dr. Mariann Young, Ph.D.,
Rainbow Pediatric Program Director
Child Focus Series - Part 3
Rainb ow Vis ions
1 - 8 0 0 - 9 6 8 - 6 6 4 4 4 Years of Age:
Knock. Knock
Who’s there?
Anita.
Anita who?
Anita new bike.
And so goes the humor of a four year old!
our year olds discover humor and
spend a great deal of time telling
adults in their world “jokes.” They enjoy
rhyming and will laugh at words that they
have made up. For example, four-year-old
conversations may go like this, “You’re a
boo-boo. You’re a poo-poo” followed by
peals of laughter. This is the time when
children may try a “bad” word, too. Try
not to overreact if your child does this.
Remember that they are trying to make
sense of the world around them, and it is
very hard to understand why adults can say
some words but they
cannot. Give them
a different word
if they are
using words
that you do
not like.
F
27
At this age, children are often great
conversationalists and love to talk about
scientific details and how things work.
They ask a lot of questions, and some may
be difficult to answer. Try to respond as
simply and honestly as you can. Four
year olds can tell long stories, some of
the details are true and some are made
up. They understand the concept of past,
present and future. They also begin to
recognize cause and effect relationships.
Four year olds have a lot of energy.
They are able to control their bodies better
so that running, stopping, starting and
turning are skills that they can manage.
They can turn somersaults, hop on one
foot and gallop away. They can play
catch, throw and bounce a ball, climb,
ride tricycles and try bicycles. Four year
olds are developing confidence in their
physical ability, and at the same time, their
imagination develops. They may be too
bold or timid and need to be supervised in
physical play.
During this stage of life, children are
learning to understand about the feelings
and needs of others. Their behavior shows
that they can feel sympathy, take turns,
share and cooperate–at least part of the
time. They can use words to express anger
rather than act on this emotion. Four year olds can sometimes feel jealous. Parents can help children by reassuring
them how important they are. Four year olds will continue to occasionally tantrum when they don’t get what they want. They can be bossy, and sometimes their behavior is over the top.
Four years olds love adult interaction,
so it is important to provide lots of positive
attention. Parents can play word games
or sorting, matching, and counting games.
Talk to your child, listen to their stories
and tell them stories about what it was
like when you were growing up. Provide
play space and play time and opportunities
for your four year old to play with other
children. Supervise their activities and
show them that you can set limits so the
world is not a scary place for them. Smile
and hold them and tell them that you love
them. They will respond similarly!
5 Years of Age:
A five year old is typically more
energetic, cheerful and responsible than
a four year old. This is a big year, as they
will likely start kindergarten. School may
be an extension of childcare for your child,
or it may be a first separation for a stay
at home parent. You can help ease them
into kindergarten by going to the school
before they start, buying a new book bag,
and listening to all the stories about the
wonderful new world of school.
Five year olds enjoy planning and
spend time discussing who will do
what. They like dramatic play and enjoy
mimicking adult roles and playing dress up
or make believe. Five year olds know right
from wrong and honest from dishonest.
They enjoy showing off how strong they are
and how well they can play games. They
are not really emotionally ready for all the
rules of competition and may have trouble
being good sports.
By the time children are five, they
typically speak fluently and correctly
use plurals, pronouns and tenses. They
are able to use complex language and
understand about 13,000 words! Good
luck to all caregivers because 5 year olds
talk frequently and like to argue and reason
using words like “because.” They are able
to memorize their address and phone
numbers, know the days of the week, and
can name coins and money.
At this age, it is important to give your
child the chance to make choices, when
appropriate. Try to limit television time
WINTE R
When children have a brain
injury impairment in function
may occur in one or more of the
following areas:
Arousal – ability to awaken/show action
Information processing – the ability to
understand the meaning of written, verbal, or
visual communication
Orientation – knowing your place in time
(day, hour, month & year) and space
Difficulties paying attention
Short and long-term memory
Reasoning – logic and planning
Emotional growth – child may be “stuck”
emotionally at the age of injury
motor abilities
Social behavior – lack of certainty about how
to behave in society
Sensory abilities – difficulty with one or more
of the senses (touch, taste, smell, hearing,
seeing)
Problems with mood – increased sadness
or irritability
2006/2007
to one to two hours per day and encourage conversation, storytelling, cutting,
drawing and active play. Provide lots of praise and verbal encouragement so that
pro-social behaviors are reinforced. Most of all, have fun with your five year old.
Children with traumatic brain injuries
Every year traumatic brain injuries result in 300 deaths, 29,000 hospitalizations
and 400,000 emergency room visits for children between the ages of birth to 14
years. You can help to prevent injuries by making sure that your child wears a
helmet for bike riding, roller blading and other sports activities, assess your house
for hidden dangers such as loose carpeting or objects that are not balanced and
can fall. Make sure that your child is in the car seat or booster, and supervise
sledding, skating, skiing and other winter sports.
Beyond infancy, children may survive head injury in larger numbers than
adults and may experience good physical recovery. However, they may have very
serious cognitive and behavioral difficulties. When treating children, it is very
short sighted to think in terms of the here and now, because there is so much more
growing and developing to be done. It is very important to try to project the future
needs of the child.
Young children with brain injuries may have injured a part of the brain whose
functions are not seen until later in life. For example, the frontal lobe is the center
for executive functions. This area controls judgment, decision-making, planning,
organizing and attention. A young child may not show signs of serious difficulty in
the executive functions until they reach adolescence where these qualities become
evident. Emotional difficulties and trying to make and maintain friendships may
also become obvious as an injured child reaches adolescence. t
References:
“National Network for Child Care: Ages and Stages – Five Year Olds” http://www.nncc.org/
Child Dev/ages.stages.5y.html
“School Aged Children” http://www.cincinnatichildrens.org/health/info/growth/wel/schoolage/4-5-years.htm
“Developmental Milestones: Ages 3 through 5”
http://www.schwablearning.org/articles.asp?r=324
Ylvisaker, Mark (1998) Traumatic Brain Injury Rehabilitation (second edition) Boston, MA
Butterworth-Heinemann. “Healthy.” www.keepkedshealthy.com/toddlerdiscipline.html
After School & Saturday Day Programs
Created by Pediatric Rehabilitation Specialists, Rainbow’s After School & Saturday
Day Programs are structured around the needs of children & teens with brain injuries. Our
Programs integrate structure, group or individual therapies, individual tutoring, group academic
support, recreational activities and social skills training. To receive an After School & Saturday Day Program brochure,
call Rainbow’s Admissions Department at:
1.800.968.6644
28
1 - 8 0 0 - 9 6 8 - 6 6 4 4 Enteral Nutrition
Monitoring for Tolerance
Patients must be carefully monitored
for tolerance of formula, hydration status
medications can be added to the tube fed
formula, but drug-nutrient interactions
may occur. Some drugs can cause the
formula to clump and clog the feeding
tube. Also, placement of the feeding
tube can affect drug action. Some drugs
require the acidic environment of the
stomach to be dissolved, and therefore
may not be well absorbed if the feeding
tube is placed in the intestine.
adequacy of calories, unless the individual
is retaining fluid.
and adequacy of nutritional support.
Always look for symptoms including
Summary
diarrhea, nausea, cramping, constipation
A multidisciplinary treatment team
and aspiration. Hydration status can be
approach is essential for the effective
monitored via daily weights, hematocrit,
planning, administration and monitoring of
blood urea nitrogen (BUN) and electrolytes
a client’s nutritional status. Tube feeding is
High values for the above parameters
one very safe and effective treatment option
indicate dehydration. Nutritional
for those clients’ who are otherwise unable
assessment indicators of protein status can
to meet their nutrition needs. t
be used to determine adequacy of protein
Employee of the Season - Summer 2006
Rehabilitation Assistants
Ann Arbor Apts: Jessica Beaton Gee &
Marlon Hill
APFK I: Mable Spencer
Rainb ow Vis ions
intake and weight can be used to determine
APFK II: Simone Haney
Arbor: Kristi Vaupel
Belleville: Leslie Thomas
Bemis: Janifer Eddins
Briarhill: Kim Hillie & Tina White
Brookside: Duane Jones, Justin Wargo
& Lehman Powell
Crane: Judy Hartman-Brown
Paint Creek: Maureen Hartigan
Denton: Jennifer Miles
Shady Lane: Johnnie McCall &
Elwell: Anders Oygarden & Jessie Hawkins
Garden City Apts: Marocca Davis
Southbrook: Candice Nelson &
Barbara Dooley
Glenmuer: Bridget Miller
Stoney Creek: Sonja Ross
Golftside: Tami Brooking
Summer Programs: Kecia Dixson
Highmeadow: Sherrie Porties
Talladay: Lori Baleczak
Home Health: Sandy Haygood, Jackie Dunn,
Textile: Dawn Lewicki
Chris Gibson, Jennifer Lynch
Maple: Evelyn Williams
Carpenter: Francis Nzau
Chikeia Brown
Page: Yinka Egbeleye
Townhouses: Joyce Williams
Westmoreland: Cheryl Hunt
Whittaker: Michelle Murphy
House Managers
Professional Therapy Staff
Administration/OEI
Gwen Washington
Pam Boykin • Joe Welch
Tiffany Alexander
Congratulations to our Outstanding Staff! 29
WINTE R
The
LastWord
IN MEMORY OF
Ina’s Beauty Shop
Written by
M
Buzz Wilson, CEO
y mom died October 11,2006. She
was 88 and lived a full life, but her
passing etched so many memories in my
mind that I feel I need to tell her story. It is
emotional for me. Describing the birth and
life of my beloved Rainbow brings forth
some of the same emotions. My mother
formed me, and Rainbow is as much about
her as it is about anyone else.
Ina Louise Morse was born April 1, 1917
in Breedsville, Allegan County, Michigan to
a tenant farmer and his wife who cooked
for the laborers working West Michigan
orchards. My grandmother Morse never
stopped cooking (in later years, I looked
forward to the rhubarb pie she made for
me each spring). In those days, women
cooked and the men worked the fields.
My mother’s birth on April Fool’s Day
set the stage for one of the three tenets
under which Rainbow is chartered; have
fun. Mom tormented us with jokes on her
special day—sugar replaced salt; wax paper
was carefully inserted into sandwiches, etc.
She worked every day of her life, making
things better for my brother, two sisters
and me. She had a special language all
her own –thingamajig, whatchamacallit.
Things were described by the letter Y as in
hurt your yegg? Her sense of humor and
her sense of playfulness are today counted
as the strength of Rainbow. Have fun.
My grandparents moved to Oceana
County, Michigan. Sometime in the
1930s, in the heart of the depression, my
grandfather borrowed from a program
established by the Federal Government and
bought his own small farm. During those
years, mom walked about two and half
miles each way to Peach Ridge School, in
the shadow of the Silver Lake Sand Dunes.
She was eighth grade spelling champ,
and we all learned to spell at the evening
dinner hour. Later, when my grandparents
moved to their new farm, she walked three
miles each way to Shelby High School
and graduated in 1936. When the snow
was too high to walk, she stayed with
families in Shelby. When she graduated,
my grandfather would not send her to
college. Instead, he sent her to beauty
school in Grand Rapids–Women needed a
profession, not schooling.
One of the great things about being
poor is that if other equally poor folks
surround you–you don’t consider yourself
poor. We never dreamed about having a
“better” life because it never occurred to
us that there was life outside of our little
town.
Ina’s beauty shop was the product of my
mom’s entrepreneurial spirit, and for 50
plus years it was the center of commerce in
our little village. My mom was religious—
everyone was back then, but she didn’t
wear it on her sleeve. It was and it wasn’t
a way of life. She believed in what she was
taught: Work hard, do well and do what is
right. It was well known in our town that
you didn’t use intolerant talk in our house. It never occurred to us to use the “N”
word, or to disparage folks of a different
social or ethnic background. When she
married my father, she inherited a gay
brother-in-law who adored her. She was
his protector and his nurse. My Uncle Lew
introduced me to my first restaurant meal
(Lakos Restaurant, Muskegon Michigan,
circa 1953, perch dinner costing about
$1.50) and to Duke Ellington. I learned
about the world outside of Shelby.
So now, perhaps you understand that
Rainbow is the product of her bringing me
up. Rainbow is a special place for people
2006/2007
of ordinary upbringing and are as diverse a
bunch as there ever will be. Try to do well
for yourself, but also do well for others and
have fun. God bless the Ina’s of this world.
To her dying day, as grey a day as there
ever could be, she couldn’t understand why
the religious people whom she carefully
attended to every day for fifty years in
Ina’s beauty shop, would oppose the very
research that might lead to the cure of
her oldest son’s Parkinson’s—embryonic
stem cell research. In one of life’s ironies,
an exchange student from Sweden who
lived with her for a year has helped build
a society in which such research can be
carried out. Think about it. Eliminating
some types of blindness, spinal cord
injuries, diabetes, Alzheimer’s, the list is
endless. The cure, when it comes (and
it will) will come about because religious
fervor is considered a private thing. I am
writing this tribute to my mom on Sunday,
two days before the election. We are
arguing about basic research, which will
lead to life—the true right to lifers.
Ten days after my mom’s passing, my
colleagues at Rainbow honored me with
a fundraiser with contributions going
to the Michael J. Fox foundation. This
coming Saturday, I am attending an event
raising funds for the foundation, and I will
present the funds raised at my event to
Michael. At my table will be a Swedish
researcher and his wife. He is conducting
trials and experiments in stem cell
research–Embryonic, not adult stem cells
that will take decades longer to utilize, if
ever. Sadly, the fundamental research is
being forced abroad. This is essentially a
recent phenomenon. In a small town you
held your faith close to your vest and never
forced your will on others.
I am glad of my good fortune; to be
surrounded by such talented and caring
folk at Rainbow. I was honored by the
turnout at the fundraiser held in my honor
and I will forever be indebted to Bill (I am
still teary eyed by his speech), Sherri, Colin,
Greg, Gordon, Sean, Chad, Susan, Heidi,
Lisha, Pawan, Vicky, Mark, Laurie, Mariann,
Laura and so on. May the list never end.
May my mom rest in peace knowing
that one company lives by her ideals.
Thank you all for listening and caring. t
30
Rainbow Rehabilitation Center
Locations:
Ypsilanti Treatment Center
5570 Whittaker - PO Box 970230
Ypsilanti, MI 48197
734.482.1200
Oakland Treatment Center
32715 Grand River Avenue
Farmington, MI 48336
248.427.1310
NeuroRehab Campus
25911 Middlebelt Road
Farmington Hills, MI 48336
248.471.9580
For more information call toll free...
1-800-968-6644
P.O. Box 970230
Ypsilanti, Michigan 48197
If you do not wish to receive copies of Rainbow Visions, please e-mail: [email protected]

RainbowVisions - Rainbow Rehabilitation Centers

Transcription

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