RainbowVisions - Rainbow Rehabilitation Centers
Transcription
RainbowVisions - Rainbow Rehabilitation Centers
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 g n i n e Op amp C b a h e R Neuro e 15-16 n pag Details o www.rainbowrehab.com 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. www.rainbowrehab.com 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 Getting around just got easier! A Specialty Transportation Company We offer personalized, attentive and expert transportation services for individuals with special needs throughout Southeastern Michigan. Call us today for a brochure of our services, pricing or to schedule a ride. 2 ABI www.rainbowrehab.com 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 3 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 WINTE R 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. 4 www.rainbowrehab.com 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 WINTE R 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 www.rainbowrehab.com 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 WINTE R 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 www.rainbowrehab.com 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 www.rainbowrehab.com 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 www.rainbowrehab.com 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 Continued from page 12 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 www.rainbowrehab.com 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 rey and I’m f f e J ia h Cynt Hello, I’m ow’s for Rainb f e h C e xecutiv the new E s. ab Campu he h e R o r u e N ays loved t lw a e v a h I nd 20 years a r e v o r a in o f of Americ d business e t o u o it f t s e h In t linary in I’ve been in hool at Cu c s o t rs degree lo t e n e h c w a I b ! a s rt got Culinary A ichigan and M o t k c a me b niversity. nd then ca U a a k n r n o o Y d a w M Ne agement at d I food man systems, an l o o h c s d an health care , g in r e t a c , . ants vironments els, restaur n t e o h e s e in h t d e ll of I’ve work s! enus for a m d e p erful dishe lo d e n v o e d w e y v n a a h nts m ur new clie o g in v r e s ward to I look for Cynthia 17 WINTE R 2006/2007 u n e M r e n n i D Sample Starters d aesar Sala s Soup & C oodle Chicken N s Option e e r t n E l n with Dil OR Salmo in Lo rk o osemary P Roasted R am ith sour cre d Potato w e k a B R to Patty O Sweet Pota el Sprouts OR Bruss r e p p e P ed Roasted R uash with Yellow Sq Dessert C Fruits e Ch / Sugar Fre Cherry Pie sonal Fresh Sea R Whole erry Pie O 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 www.rainbowrehab.com 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 Continued on page 21 20 www.rainbowrehab.com 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 Continued from page 20 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 e as ise H ea rt D eA nc ta bs Su Br ea st Ca bu nc er im he lz se er ’s n A Re ha bi lit at io n’ s so rk Pa or op ste in os is sC O at ep M ul H ro le Sc tip le tN W es iti sis I TB ile Vi ru s $200 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 www.rainbowrehab.com 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. Continued on page 26 24 www.rainbowrehab.com 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 Applause Banquet Center - Grand Rapids, Michigan “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 Applause Banquet Center - Grand Rapids, Michigan “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 Continued from page 24 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 Continued on page 29 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 www.rainbowrehab.com 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 E-mail: [email protected] 28 www.rainbowrehab.com 1 - 8 0 0 - 9 6 8 - 6 6 4 4 Enteral Nutrition Monitoring for Tolerance Patients must be carefully monitored Continued from page 26 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 E-mail: [email protected] www.rainbowrehab.com P.O. Box 970230 Ypsilanti, Michigan 48197 If you do not wish to receive copies of Rainbow Visions, please e-mail: [email protected]