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Rehabilitation
Dr J Hobart
Rehabilitation - definitions Rehabilitation is a process of active
change by which a person who has become disabled acquires the knowledge and skills needed for optimum physical, psychological and social function.
Rehabilitation is the application of all measures aimed at reducing the impact of disability and handicap and improving quality of life.
Rehabilitation is… For people with achievable goals
Rehabilitation is about changing one or more of…
The person
The way they do things
The environment
Rehabilitation is not…. Respite Suitable for all disabled people
Neuro-rehabilitation
Assessment Measurement Planning Treatment Evaluation Reassessment
Assessment
Multidisciplinary team
Identification of the problem
Measurement of the problem
Assessment frameworks
ICIDH World Health Organisation International
Classification of Impairment, Disability and Handicap
PILS Prevention, Independence, Lifestyle, Social
resources
WHO ICIDH (1980)
Pathology
Impairment
Disability
Handicap
WHO ICF (2001)
Pathology
Impairment
Activity limitations
Participation restrictions
Pathology
A pathological diagnosis is vital in rehabilitation the most effective management is to stop
the pathology effective management demands a
knowledge of the natural history and prognosis of the disease
key role for the doctor
Impairment
the direct neurophysiological consequences of the underlying pathology sometimes pathology is silent
signs used to deduce underlying pathology
Disability - activity
any restriction or lack of ability (resulting from impairment) to perform an activity within the range considered normal for a human being difficulty walking difficulty dressing/walking difficulty hearing or speaking
Handicap – participation
a disadvantage for a given individual, resulting from an impairment or a disability that limits or prevents the fulfilment of a role that is normal for that individual
handicap reflects the cultural, social, economic and environmental consequences for the individual that stem from impairment and disability
History Taking
Pathology Diagnosis
Impairment Examination
Disability Review Function based
Handicap Review Daily routine
PILS
Prevention What future adverse events can be prevented
Accidents, Broken Skin, Contractures, Diet.....
Independence How is it reduced? How could it be increased?
Lifestyle Goals, Roles and Soul
Social resources Who can help?
Rehabilitation
Assessment
Planning
Treatment
Care
Evaluation
Planning
Multidisciplinary problem analysis
Identify areas of potential functional improvement
Setting goals
Goal Setting
Terminology Short term goals Aims for patient Long term goals Objectives for patient Action plans Team tasks
A goal should be specific, time limited, easily measured and patient centred
Treatment
Drug management Control of pain, spasticity, bladder problems,
constipation, impotence Physical management
physiotherapy, occupational therapy, nurses Cognitive management
psychologist, occupational therapist, nurses
Evaluation
Checking on the effectiveness of any intervention
Define criteria
Measure success/failure against criteria
Evaluation
Process Goal achievement Integrated care pathways
Outcome Impairment Disability Handicap Quality of life
Integrated Care Pathways
Document which details the expected interventions during an episode of patient care
Departures from the pathway are documented (variances)
Analysis of the variance allows audit refinement of the pathway improved patient care
Helpful (?) advice for primary care
Try to identify goal/s Think: person, strategy,
environment Don’t underestimate cognitive
problems Try to understand why rehab may
not be suitable
Spasticity
Spasticity
A motor disorder characterised by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neurone syndrome
Spasticity is associated with.. Soft tissue changes and contractures
Resists muscle stretch and lengthening Spasms – flexor/extensor/adductor Abnormal postures and mechanical
problems Severe disability, handicap, reduction in
QoL Pain
Spasticity management
Drugs
Therapists
Continence advisors
Social services
Therapists
NEURO – physios, OTs, hand therapists
Intensive hands-on therapy Home exercise programmes Mobility aids and seating Beds and bed positioning
Continence advice
Impact of UMN syndrome on sphincters
Impact of sphincter probs on spasticity
Bladder management Strategies, drugs, catheters
Bowel regimens Diet, drugs
Social services
Impact of environment on spasticity
Optimise aids Optimise care package
Anti-spasticity drugs
Baclofen Tizanidine Dantrolene Diazepam Cannabis Botox Intrathecal baclofen Intrathecal phenol
Helpful (?) advice for primary care
Keep it simple MDT approach Dynamic problem that may change Re-evaluation often required With drugs:
Start low go up slow