Physical Medicine and Rehabilitation

Physical Medicine and Rehabilitation Physicians or Physiatrists are nerve/nervous system, muscle, and bone experts who treat injuries or illnesses that affect how you move and manage everyday tasks that may have been affected by disease and trauma. Rehabilitation physicians are medical doctors who have completed training in the medical specialty of Physical Medicine and Rehabilitation (PM&R).

Specifically, rehabilitation physicians:

• Diagnose and treat pain
• Restore maximum function lost through injury, illness or disabling conditions Treat the whole person, not just the problem area Lead a team of medical professionals such as Jesse Brown VA Medical Center Comprehensive
• Integrated Inpatient Rehabilitation Program (CIIRP)
• Provide or refer for a large array of non-surgical treatments
• Explain your medical problems and treatment/prevention plan
• The job of a rehabilitation physician is to treat any disability resulting from disease or injury, from sore shoulders to amputations. The focus is on the development of a comprehensive integrated program for putting the pieces of a person's life back together after injury or disease with an integrative and interdisciplinary approach.

Rehabilitation physicians take the time needed to accurately pinpoint the source of an ailment. They then design a treatment plan that can be carried out by the patients themselves or with the help of the rehabilitation physician’s medical team. This medical team might include other physicians and health professionals, such as neurologists, orthopedic surgeons, and physical therapists. By providing an appropriate treatment plan, rehabilitation physicians help patients stay as active as possible at any age. Their broad medical expertise allows them to treat disabling conditions throughout a person’s lifetime. Both inpatient and outpatient physiatry consultation services are available. Additionally, physiatrists are the primary treating physicians when patients are enrolled in our Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP).

Physical Therapy

Provides services to veterans who have experienced changes in physical function and health by developing an individualized treatment plan which may include prescribing exercise and activities to improve movement, facilitate independence, and regain quality of life.

Kinesiotherapy

Provides treatment programs to improve patient function through the use therapeutic exercise and mobility training.

Outpatient and inpatient physical therapy services are available. Additionally, there is a kinesiotherapist involved in Jesse Brown’s Home Based Primary Care (HBPC) Program and Physical therapy is also available in the home for veterans who are home bound under Community Health Nursing Services.

Occupational Therapy

Provides goal-directed treatment utilizing a variety of techniques and activities to improve functional daily skills, upper extremity range of motion, muscle strength, coordination, balance, endurance, visual-perceptual, and cognitive skills.

Outpatient and inpatient occupational therapy services are available. Occupational  therapy is also available in the home for veterans who are home bound under Community Health Nursing Services.

Jesse Brown offers some medical treatments that are considered to be non-standard, falling into the category known as Complementary and Alternative Medicine or Integrative Treatments (CAM) in the Jade Clinic or directed from the Jade clinic menu through other departments. These treatments are available when it is safe for veterans and does not interfere with standard of care treatments. The list below is currently what is available:

• Acupuncture
• Aromatherapy
• Craniosacral therapy
• Functional Medicine Consultation
• Healing Touch
• Integrative Medicine Consultation
• Meditation
• Osteopathic Treatments
• Tai Chi
• Yoga

Hospitalized patients typically spend most of their time in bed.   Lack of movement leads to problems in all parts of the body (heart, lungs, stomach/intestines, muscles, etc).  These problems lead to longer lengths of stay in the hospital, weakness, and problems with both physical and mental functioning.  Moving and exercising in the hospital is key to preventing delirium, improving mental health and cognition, and maintaining optimal physical functioning in our hospitalized patients.
 

Some benefits of participating in an exercise program in the hospital include:

• Shorter time requiring a ventilator (breathing machine) by 1-2 days
• Shorter time in the ICU (1-2 days less) and in the hospital (3-4 days less)
• 25-30% reduction in the incidence of delirium
• 25-35% of patients with increased functional independence when leaving the ICU and the hospital

PICs is short for Post Intensive Care Syndrome. PICs may include: ICU Acquired Weakness, Cognitive (brain) dysfunction, and mental health problems.

ICU-Acquired Weakness:  Muscle weakness commonly develops during an ICU stay.  The weakness can make activities such as grooming, dressing, feeding, bathing, and walking difficult.

Cognitive (brain) Dysfunction:  Problems with memory, ability to pay attention and concentrate, difficulty solving problems, and difficulty thinking about more than one thing at a time (organizing complex tasks).  This type of brain problem may affect whether you can return to work, balance your checkbook, or remember to take your medicine. 

Mental Health Problems:  Problems with sleep, depression, anxiety, and post-traumatic stress disorder.  These symptoms may include avoiding things that remind them of their ICU stay, nightmares, flashbacks or disturbed thoughts, and becoming easily startled or jumpy.

• Helping the patient to stay “oriented” is important.  Talk about things, people, and events they know about.  Talk about the day, date, time.  Bring in items from home.  Read aloud at the bedside.
• Keeping a diary or journal may help patients later understand what happened to them and reduce stress.
• Early mobility and work with therapists can prevent weakness, delirium, and cognitive dysfunction .  Learn how to help the patient move!
• During or after the ICU, a specialist may help.  Specialists that may help the patient or family recover from PICs include:
• Physiatrist (Rehabilitation Specialist): coordinating the patient care by leading a team of professionals to diagnose and treat pain and restore function lost through injury, illness, or disabling condition
• Occupational therapist: re-learning life skills such as activities of daily living, balancing a check book, managing finances and helping with cognition (thinking).
• Speech therapist: re-learning speech, address problems with swallowing
• Physical therapist: restoring function and independence after injuries to the muscles,  bones, tissues, and nervous system
• Psychologist/Psychiatrist: treating problems with thoughts, emotions, and coping

• 1/3 of family members may experience mental health problems including depression, anxiety, and post-traumatic stress disorder. 
• It is important for family members to understand the disease and illness and all treatment options to be able to decrease stress.
• Whenever possible, it is important to know the patient’s wishes, values, and preferences so that decisions are made according to the patient’s values and wishes
• Helping with a family member’s medical care is one way to reduce stress for those who wish to do so.  Your nurse can help you with appropriate ways to assist with care.

During our therapy sessions, we follow the following safety criteria:

Exclusion Criteria for out of bed mobility, reviewed daily for each patient:

Vitals/Patient Assessment:

• Resting Heart Rate <50 or >130
• Resting SBP <90 or >200 (exception: dialysis patients more than 10mmHgb below their resting BP), MAP <65 or >120
• Respiratory Rate < 10 or > 30 bpm
• SpO2 <88% or 10% below baseline SpO2
• Temperature >103 degrees Farhenheit
• Vent Patients:
  • PEEP>10cmH20
  • FIO2 > or equal to 0.60
  • High frequency oscillator
  • Marked ventilator dysynchrony
  • Requiring prone positioning
  • Intubated within 24 hours
• Sedation: RASS Scale <-2 or >+2
• Delirium: CAM positive for delirium and unable to follow commands (less than 2 of the De Jonghe criteria)

Labs:

• Hemoglobin is acutely < 7.0 g/dl or Hematocrit <25%
• Platelet count is <20k for out of bed exercises, ok for in bed exercises down to 5k
• Potassium < 2.5 mmol/l or > 6.5 mmol/l
• Sodium is < 120 mmol/l
• Glucose acutely < 70 mg/dl or > 350 mg/dl
• Lactate (Lactic Acid) >4mmol/L
• INR >4
• aPTT >130 seconds
• pH <7.25

Medical Conditions:

• Ruling out for DVT or PE (Dopplers, CT of chest, D-Dimer, VQ Scan ordered and pending)
• Acute DVT or PE w/o first treatment dosage of LMWH or IV heparin and no IVC filter
• Concern for spine Instability, concern for fracture, or metastatic lesions to the spine: Imaging required prior to initiation of therapy and precautions must be confirmed by physician following obtaining imaging
• Fractures: imaging must be performed and physician clearance is required prior to moving patient
• Cardiac Precautions
  • Ruling out for acute MI (Troponins, EKG)
  • New arrhythmia or angina
  • 3rd degree heart block
  • Awaiting Pacemaker
  • Receiving prostacyclin or nitric oxide
• Escalating vasopressive support over the past 2 hours
• Comfort care without goals for going home
• Stroke
  • Ruling out for acute stroke (CT, MRI brain)
  • Stroke within the past 24 hours
• Patient refusal
• Actively having a seizure
• Known uncontrolled active bleeding
• Active hypothermia management
• Lumbar puncture within 4 hours following procedure
• PICC line placement: no therapy within 4 hours following procedure, no lifting >10 pounds on PICC side, and no BP recordings on PICC side
• Cardiac catheterization: no therapy within 4 hours following procedure; ensure femoral sheath has been removed prior to starting therapy

Other Precautions:

• Total Hip Arthroplasty—Strict hip precautions (no bending forward, no bending to side, no lifting lower limbs above 90 degrees, no crossing the lower limbs) for 6 weeks, no hip internal rotation for the rest of their lives.
• Hemiarthroplasty Hip—Strict hip precautions for 6 weeks, no hip internal rotation for the rest of their lives.
• Hip fractures status post ORIF, typically are partial weight bearing, surgeon dependent how much weight-bearing is allowed and surgeon must comment on precautions prior to moving patient
• Total Shoulder Arthroplasty—No range of motion or weight bearing for 2 weeks, surgery and surgeon specific protocol determined as an outpatient after the 2 weeks.
• Ankle fractures (bimalleolar) –non-weight bearing for 6 weeks
• Tibial plateau fractures -- non-weight bearing for 12 weeks
• Pilon (A.K.A as Plafond fracture)— non-weight bearing for 12 weeks
• Quad or Patella tendon rupture, absolutely no knee flexion of any kind for 6 weeks after surgical repair, either a cast or a knee immobilizer will be used.
• Sternotomy: Sternal Precautions for 12 weeks; no lifting more than 8 lbs. (e.g. a gallon of milk) including weight bearing through the upper limbs such as using a cane or walker, no shoulder abduction past 90 degrees, no overhead activities, no driving for two weeks
• Spine precautions after surgery: no excessive bending or twisting of the spine, no lifting greater than 10 lbs. for at least 6 weeks postoperatively, beyond 6 weeks it is surgeon specific. If the surgeon orders a TLSO brace or a cervical brace, then brace must be donned when out of bed at all times until the surgeon states it is okay not to use. If brace is not ordered by surgeon, than a brace is not needed. Most surgeons do not require braces after spine surgery.
• Wounds: These areas are always non-weight bearing until completely, 100% healed but weight can be applied to areas on the limb that do not have any wounds. For example, if a patient has a heel wound, the heel is non-weight bearing but the forefoot is weight bearing as tolerated. If a patient has a sacral wound, weight-bearing may be performed on ischial tuberosities. Stage III and IV wounds: therapy is okay but no activity that could cause shear forces across the wound. Open abdominal wounds: speak with physician prior to initiation
• Cardiac pacemaker placement: No lifting >10 pounds on left side x 6 weeks, no shoulder abduction >90 degrees for 6 weeks, no driving x 2 weeks

Things that are Ok for therapy out of bed:
NG tube, central venous catheter, pleural drain, wound drain, intercostal catheter, urinary catheter, venous and arterial femoral catheter, continuous renal replacement therapy including femoral dialysis catheters, open abdominal or chest/sternal wound performing in bed exercises

Reassessment Criteria during therapy session:

MAP <65 mmHg or >120mmHg
MAP >10mmHg drop from baseline in dialysis patients
Drop in SBP or DBP >20% during exercise
SBP>180
HR <50 beats per minute or >150 beats per minute
HR greater than 70% age-predicted maximum HR (0.7 x (220-age))
HR drop more than 20% during exercise
Respiratory rate <5 or >40 breaths per minute, or increase of >20 BPM from resting
Pulse oximetry, SpO2 <88%, or >4% decrease in SpO2
Marked ventilator dysynchrony
Patient distress
New arrhythmia
Chest pain
Concern for airway device integrity or endotracheal device removal
Fall to knees
Patient refusal

To restore maximum function and independence in veterans lost to disabling injury, disease, and pain, utilizing a holistic, non-surgical, interdisciplinary approach and employing a broad range of therapeutic methods.

1. The patient should be eligible to receive health care from Veterans Health Administration Facility. For more information regarding patient eligibility to receive VA health care, please call: Call our toll-free number at 877-222-VETS (8387).
2. The patient should be medically stable and have enough endurance to attend and to be able participate in a minimum of 15 hours of therapy per week.
3. The patient has to agree and to be willing to participate in a minimum of 15 hours of therapy per week.
4. Any patient on antibiotics, oral/parenteral, for infection will be observed post therapy and will remain normothermic without the use of antipyretic agents for at least 48 hours prior to transfer without evidence of active infection.
5. The patient and family will become part of the interdisciplinary rehabilitation team and participate actively in setting goals and establishing treatment objectives. If extensive diagnostic testing or treatment is needed or concurrent illness arises, the patient will be transferred to the appropriated service. Once the patient is stabilized and can resume the rehabilitation therapeutic regimen, he/she will be returned back to the PM&R bed service as appropriate.
6. The patient must be able to participate in the rehabilitation process and demonstrate potential for improvement with identifiable goals in at least two of the following:
   • Self care
   • Mobility Bowel & Bladder management
7. Screening for admission will be conducted by a PM&R physician.
8. Prior to acceptance of the patient, the admitting PM&R physician will ensure that an appropriate medical record precedes or accompanies the patient.
9. Outside referrals: Referrals from other VA facilities, community hospitals, and private care facilities require the verification of eligibility and must proceed through the transfer coordinator (Lisa Bell, ). Once the patient’s eligibility is verified, the patient’s medical records must be forwarded to a PM&R attending physician. If the physician deems the patient to be appropriate for our program, the Transfer and Admission processes will be initiated.

Medical Services:

Jesse Brown VA Medical Center has a 200 bed capacity and the following services below are available within 24 business hours on a consultative basis.

Your Physical Medicine and Rehabilitation (PM&R) doctor requests these services as needed and the treatment recommendations are communicated directly to him or her within 24 business hours of requesting the services.

• Addiction/Chemical Dependency Treatment
• Cardiology
• Dental and Oral Surgery Services
• Dermatology
• Endocrinology
• Ethics Consultation
• Gastroenterology
• General Surgery
• Geriatrics Home Care Services (Therapy, Nursing, Infusion, and Homemaker Services)
• Home Based Primary Care (HBPC) Program
• Hematology and Oncology
• Infectious Diseases
• Laboratory Services
• Low Vision
• Therapy
• Military Sexual Trauma
• Nephrology and Dialysis
• Neurology
• Optometry
• Ophthalmology
• Orthopedic Surgery
• Otolaryngology (Ears, Nose, and Throat)
• Palliative Care
• Podiatry
• Psychiatry
• Pulmonary
• Rheumatology
• Sleep Medicine
• Smoking Cessation
• Thoracic Surgery
• Urology
• Vascular Surgery
• Weight Loss Services (Move Program and Bariatric Surgery)
• Wound and Ostomy Care
• Women’s Health/Gynecology
• Medical Services available to you at other Institutions

Medical Services available to you at other Institutions:

University of Illinois at Chicago (UIC)
Radiation Oncology services are available to you at one of our academic affiliates, the University of Illinois at Chicago. If needed during your comprehensive integrated inpatient program stay, transportation to and from UIC for radiation oncology services will be provided. For more information, please visit:

https://hospital.uillinois.edu/primary-and-specialty-care/cancer-services-at-ui-health/treatment-options/radiation-oncology

Hines VA Medical Center, Maywood, IL
Neurosurgery and Cardiac Surgery Jesse Brown has an arrangement with Hines VA Medical Center to provide neurosurgical and cardiac surgery services up to a capacity of 200 inpatients on a routine and emergent basis. Routine evaluations are performed on an outpatient basis and your PM&R doctor can request these services if you need prior to your discharge. If these services are needed emergently as determined by your PM&R doctor, then immediate transportation is provided to you from Jesse Brown to Hines VA Medical Center. To learn more about Hines VA Medical Center, please click on the link below: https://www.va.gov/hines-health-care/

Pharmacy Services:

Inpatient pharmacy services are available 24 hours a day for the 200 inpatient beds. After your doctor orders a medication for you, a pharmacist varies the medication and provides the medication to the nurse who then administers the medication to you.

Diagnostic Imaging (Radiology):

Comprehensive diagnostic imaging services including plain films, ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI), and nuclear medicine (e.g. bone scans) are available 24 hours a day for a capacity of 200 inpatient beds. Emergent (STAT) diagnostic imaging services are obtained and the results are communicated directly to your doctor in most cases within a couple of hours. Routine (non-urgent) laboratory results are often obtained and the results communicated to your doctor within 1-2 business days.

Laboratory Services:

Laboratory services are available 24 hours a day for a capacity of 200 inpatient beds. Emergent (STAT) laboratory are obtained and the results are communicated directly to your doctor in most cases within a couple of hours. Routine (non-urgent) laboratory results are communicated in most cases to your doctor within the same day.

Peer and family/caregiver support services:

The following organizations provide support for both patients and their families/caregivers. Please contact the organization directly for more information:

Paralyzed Veterans of America
https://pva.org/

National Stroke Association
https://www.stroke.org/

Spiritual Services

Chaplain services are available to you as well. At your time of your admission to CIIRP, your doctor will ask you if you would to see a chaplain and he/she will arrange for a chaplain to see you within 24 hours of your admission. These services are available to you, however, during your entire stay.

Cultural Services

At the time of your admission to the CIIRP, your team of providers will ask if you have any cultural preferences and we will follow and implement your preferences during your stay. Cultural preferences can include but are not limited to dietary preferences and language preferences.