Principles of rehabilitation medicine

Zsuzsanna Vekerdy-Nagy MD, PhD

UMCSC

Department of

Rehabilitation and

Physical Medicine,

Debrecen

Hungary

25/Feb/2014

Lesson #1

Definitions

Team work

Lesson #2

Functional evaluation

Rehabilitation

Definition of WHO (1988)

„The use of all means aimed

at reducing the impact of

disabling and handicapping

conditions and at enabling

people with disabilities to

achieve optimal social

integration”

Prevalence of disabling conditions in

European countries is around 10%

„complex rehabilitation”

Medical

Psychological

Social

Vocational

Educational

Comprehensive rehabilitation

WHO ARE IN NEED of rehabilitation??

Persons with

disabilities

Persons who are at

risk (in danger)

At any age with

Functional

limitation(s)

Eligibility for rehabilitation

Persons who are able to participate in a

rehabilitation programme

AIM / GOAL is obligatory

(reimbursement)

Persons with disabilities

Persons with disabilities

include those who have

long-term physical, mental,

intellectual or sensory

impairments which in

interaction with various

barriers may hinder their full

and effective participation in

society on an equal basis

with others.

Convention on the Rights of Persons with Disabilities and Optional Protocol, UN 2006.

http://www.youtube.com/watch?v=wRuOntUbAnQ

http://www.youtube.com/watch?v=A9Z06EeIhFM

http://www.youtube.com/watch?v=wRuOntUbAnQ http://www.youtube.com/watch?v=A9Z06EeIhFM

World report on disability

WHO, 2011 • Understanding disability

• Disability – a global picture (10-15 per cent !!)

• Assistance and support

• General health care

• Rehabilitation

• Enabling enviroments

• Education

• Work and employment

• The way forward - recommendation

http://www.who.int/disabilities/world_report/2011/en/index.html

WHO action plan 2014-2021

„Better health for persons with

disabilities”

Vision: persons with disabilities

and their families enjoy the highest

attainable standard of health.

Three main objectives:

1./ to address barriers and improve acces to

health care services and programs

2./ to strengthen and extend habilitation and

rehabilitation services, inc CBR and

assisstive technology

3./ to support the collection of appropriate

and internationally comparable data on

disability, and promote multi-disciplinary

research on disability

Medical rehabilitation

Includes all

rehabilitative

approaches provided

by health care services

and personnel

Assistive devices

Physical, mental,

psychological assistance

and guidance

Permanent medical

treatment and care

European Board of Physical and Rehabilitation Medicine

Collège Européen de

de Médecine Physique et de Réadaptation

-----------------------------------------------------

European definition of Physical and Rehabilitation Médicine (PRM)

This proposal was set up during the General Assembly of Ljubljana

(March 2003) and validated in Antalya (October 2003)

„PRM is an independent medical specialty concerned with the

promotion of physical and cognitive functioning, activities

(including behaviour), participation (including quality of life)

and modifying personal and environmental factors. It is thus

responsible for the prevention, diagnosis, treatment and

rehabilitation management of people with disabling medical

conditions and comorbidity across all ages.”

www.euro-prm.org

Principles of

PRM

• Learning process

• Aims at reducing the

impairment caused by the

disease where possible

– (1) in preventing

complications,

– (2) in improving functioning,

and

– (3) enabling participation.

• The induvidual’s personal,

cultural and enviromental

context must be taken

account

• Practice is in various

facilities from acute care

units to community

settings

Principles of PRM

• Special diagnostic assessments are used by

PRM specialists

• Treatment facilities include pharmacological,

physical, technical, educational and

vocational interventions which are provided

by multidisciplinary team

• Rehabilitation is a continous and

coordinated process, which starts with the

onset of an illness or injury and goes on

ritght through to the individual achieving a

role in society consistent with his or her

lifelong aspirations and wishes

The rehabilitation team

Team is not simple a group of people who

are working together..

Team work refers to a multi-/interdisciplinary

approach of several people who work

together collaboratively for mutually

accepted goals along with sharing

information and experiences.

The results are more advanced values than

the simple summary of the single efforts

ever might be.

PRM

specialist

Orthotists

prosthetist

Vocational

councellor

teachers

Psychologist Speech

therapist

Social

worker

OT

Occupational

therapist

Physical

Therapists

PT

nurses

Other

physicians

PATIENT

and

FAMILY

Team

members

The rehabilitation

team

• Multiprofessional

• Delivering rehabilitation

in • Organized

• Goal-orinted

• Patient-centered manner

Good communication is a key

issue Typical communication barriers

(Given and Simmons, 1997)

– Autonomy

– Individual members’ personal

characteristics that may

contribute to personal conflicts

– Role ambiguity

– Incongruent expectations

– Different perceptions of

authority

– Power and status differentials

– Varying educational

preparations of the patient care

team members

– Hidden agendas

Team dynamics – 5 ING

F O R M I N G Getting to know one another

S T O R M I N G Dealing with tensions and defining group tasks

N O R M I N G Building relationships and working together

P E R F O R M I N G Maturation in relationships and task performance

A D J O U R N I N G Disbanding and celebrating accomplishment

Styles of team

interactions 1. Medical model

2. Multidisciplinary

team model

3. Interdisciplinary

team model

4. Transdisciplinary

team model

Medical model

• Traditional

• Clear chain of responsibility

• Well respected

• Reinforced medicolegally

Disadvantages:

many professionals doing multiple tasks

paternalistic – „client-centered care”

Medical ethics recently has prioritized patient autonomy

Multidisciplinary team model

Attending

physician

Psychologist Social worker Nurse OT PT

Interdisciplinary team model

Psychologist

PRM spec

OT

PT

nurse

Patient

Transdisciplinary team model

• Beyond communication encourages cross-treatment

between disciplines

• Developped from educational models

• Cross-training / multiskilling

• Example: traumatic brain injury rehabilitation

The five premisses of TD team model:

Role extension (improving discipline-specific knowledge) – role

enrichment (avareness of other’s knowledge) – role expansion

(education others) – role release (incorporating the skills of other discipline) –

role support (support of others and feedback on implementation)

Woodrruff G, McGonigel M. The transdiciplinary model. In: Joordan J, Gallagher J,

Huttenger P, et al., eds. Early Childhood Special Education: Birth to three. Reston

VA: Council for Exceptional Children; 1988.

Core team members involved in

rehabilitation Mobility

Transfers

Positioning

Toilet and hygenie

Dressing

Feeding

Communication

PT

OT

Speech T

Rehab

nurses

Managing team

meetings

Weekly basis

Cost-effectiveness (extended

communication: cost and time!)

Method

Progress reports by each

disciplines

Problem-oriented agenda

(problem list – comments)

Action summary

„Collaborative team work”

• „Today collaborative

team work is no

longer an option: it is

a basic pre-requisite

for effective practice

and quality care”

Different world views

The professional identity

• „the health professional that has a strong professional identity is

more open to different world views” (McCallin 1999, 2004, 2007)

• „clear professional identity reduce role confusion” (Booth, Herrison, 2002)

• Az egyes szakmák építkezésének fő modelljei

Models of world views

PT Bio-psycho-social (Roberts, 1994)

Physiatrist /PRM

spaecialist

Biomedical model of the healthcare

Nurses Bio-psycho-social-spiritual model of the healthcare

OT Holistic approach

Social worker psycho-social model (Burbach et al. 2002)

UEMS recommendations

Professional Practice Committee of Union of European Medical Specialists (UEMS) Physical and Rehabilitation Medicine (PRM) Section recommendation on the basis of the current literature:

Effective team working produces better patient outcomes (including better survival rates) in a range of disorders, notably following stroke*.

There is limited published evidence concerning what constitute the key components of successful teams in PRM programmes.

However, the theoretical basis for good team working has been well-described in other settings and includes agreed aims, agreement and understanding on how best to achieve these, a multi-professional team with an appropriate range of knowledge and skills, mutual trust and respect, willingness to share knowledge and expertise and to speak openly.

UEMS PRM Section strongly recommends this pattern of working. PRM specialists have an essential role to play in interdisciplinary teams

*Neumann, Guttenbrunner, Fialka-Moser, Christodoulou, Valera, Giustini, Delarque: Interdisciplinary team working in physical

and rehabilitation medicine.

J Rehabil Med 2010 Jan;42(1):4-8.

The field of competence (FOC) of the

specialist in physical and rehabilitation

medicine (PRM). uniform basic principles described in the White Book of PRM in Europe

national traditions, different health systems and other factors, PRM practice

varies between regions and countries in Europe

comprehensive description of the FOC in PRM

PRM interventions include, prevention of diseases and their

complications, diagnosis of diseases, functional assessment,

information and education of patients, families and

professionals, treatments (physical modalities, drugs and other

interventions)

Gutenbrunner, Lemoine, Yelnik, Joseph, deKorvin, Neumann, Delarque: The field of competence of

the specialist in physical and rehabilitation medicine (PRM).

Am Phys Rehabil Med 2011 Jul;54(5):298-318. Epub 2011 Jun 12

Functional evaluation

Rehabilitation evaluation

Patient history

1) Past medical history + present illness

2) Social history (family, home)

3) Vocational history

4) Psychological history

Patient examination 1) Physical evaluation (general condition,

organs)

2) Evaluation of impairments: musculosceletal system (ROM, joint stability, muscle strenght testing), respiratory system, etc.

3) Functional abilities and skills

4) ADL

Individual Rehabilitation Plan

Setting rehabilitation goals

Preparing for discharge

(hospital home)

• Functional gains of the

indivividual

• Evaluation of home

enviroment

(architectural,

transportation,

communication)

Self-care and every-day activities

In developed nations about 30 % of waking hours of a typical person is spent performing self-maintenence activities

Discharge pattern of persons with stroke from rehabilitation inpatient units determined in 70% by the ability to function independently (bathing, toileting, social interaction, dressing and eating)

Mauthe RW, Haaf DC, Hajn P et al. Arch Phys Med Rehabil 1996:77:10-13.

WHO International Classification for Impairment,

Disability and Handicap (ICIDH) 1980

• Impairment

• Disability

• handicap

Health status

International Classification of

Functioning, Disability and Health (ICF)

2001

Enviromental

factors

Personal

factors

Body Functions

and Structures

Activities Participation

Elements of ICF

--------------------------------------------------------------------------------------------------------------------

Body functions Activities Enviromental

& & factors

structures participation --------------------------------------------------------------------------------------------------------------------

Functions (b) Capacity Barriers

(d) (e)

Structures (s) Performance Facilitators

http://www.who.int/classifications/icf/en/

MORE INFORMATION

ICF Checklist

pdf, 200kb

http://apps.who.int/classifications/icf

browser/

ICF severity scale

Extent or magnitude of impairment (b,s)

Performance and Capacity (d)

Barrier or facilitator (e) + -

xxx.0 NO ……. (none, absent, negligible,...) 0-4 %

xxx.1 MILD ………………….. (slight, low,...) 5-24 %

xxx.2 MODERATE ……… (medium, fair,...) 25-49 %

xxx.3 SEVERE …………. (high, extreme,...) 50-95 %

xxx.4 COMPLETE ………………… (total,...) 96-100 %

xxx.8 not specified

xxx.9 not applicable

ADL assessment of

children

Special considerations

• Incorporating

developmental milestones

into the structure of the

assessment

• Interacting with the child

during the assessment

process

• Reporting information to the

parents (involvement of

parents to the assessment)

ICF-YC

• WHO - 2007

• ICF modified in 237

items

• Developmental

issues incorporated

• New issues have

been validated

Examples for the ICF / ICFCY modifications

functions (d)

• d310-d329 COMMUNICATING - RECEIVING

• d310 Communicating with - receiving - spoken messages

• note

• Comprehending literal and implied meanings of messages in spoken language, such as understanding that a statement asserts a fact or is an idiomatic expression . , such as responding and comprehending spoken messages.

• d3100 Responding to the human voice

• d3101 Comprehending simple spoken messages

• d3102 Comprehending complex spoken messages

• d3108 Communicating with - receiving - spoken messages, other specified

• d3109 Communicating with - receiving - spoken messages, unspecified

• d315 Communicating with - receiving - nonverbal messages

Evaluation of results of rehabilitation

Types of functional tests

• Classify /categorize

– GMFCS / ASIA

• Admission / discharge / Follow-Up

– FIM / Barthel / 6MWT/ TUG / GCS

• Outcome measures

– GOS / GAS

International Classification of

Functioning Disability and Health

Gross Motor Functional Classification System (GMFCS)

I independent walking indoors,

outdoors, jumping, climbing stairs

II independent walking indoors, limited outdoors, holds on while climbing stairs

III may walk short distance indoors, using assistive mobility device

IV may need adative equipment for sitting, propels WCh

V no self mobility needs assistance for moving

I

III

II

IV

V

Palisano R, Rosenbaum P, Bartlett D, et

al: Content validity of the expanded

and revised Gross Motor Function

Classification System. Dev Med Child

Neurol 2008;50(10):744

4 to 6 y

Manual Ability Classification

System (MACS)

• Not a test

• Parents teachers or the child itself could

be asked

• Questions have the focus on the child’s

ability to handle objects in important daily

activities

Grade Definition

A Complete. No sensory or motor function is preserved in the sacral

segments S4-S5

B Incomplete. Sensory but not motor function is preserved below the

neurological level and includes the sacral segments S4-S5

C

Incomplete. Motor function is preserved below the neurological level,

and more then half of key muscles below the neurological level have

a muscle grade less then 3 (Grades 0-2).

D

Incomplete. Motor function is preserved below the neurological level,

and at least half of key muscles below the neurological level have a

muscle grade greater than or equal to 3.

E Normal. Sensory and motor functions are normal.

ASIA CLASSIFICATION

The ASIA (American Spinal Injury Association) assessment protocol consists of two sensory examinations, a motor examination and a

classification framework (the impairment scale) to quantify the severity of the spinal cord injury.

Tests evaluate changes /progress of

patients’ functions

Manual Muscle Test Grades

Grade 5 (Normal; 100%) The patient or subject can complete the whole range of motion (movement) against

gravity with maximum resistance applied by the therapist at end-of-range.

Grade 4 (Good;75%) The subject can complete the whole range of motion against gravity with moderate

resistance applied by the physical therapist (PT) at end-range. Testing the uninvolved

limb should always be considered to know whether you are applying too much force on

the involved limb or not.

Grade 3 (Fair;50%) The patient can only complete the range of motion against gravity. When external

(outside) force is applied by the PT, the patient gives way.

Grade 2 (Poor;25%) Your patient cannot perform the movement against gravity. But patient can do complete range of

motion when pull of gravity is eliminated. No resistance is applied.

Grade 1 (Trace) Patient is not able to move the joint even with gravity eliminated. However, closer examination by

the therapist would reveal slight muscle contraction through palpation.

Grade 0 (Zero; No trace) No contraction is noticed, even with physical therapist's palpation (touch).

Ashworth Scale for grading Spasticity

1) no increase in muscle tone;

2) slight increase giving a catch when part is

moved in flexion or extension;

3) more marked increase in tone but only after part

is easily flexed;

4) considerable increase in tone; and

5) passive movement is difficult and affected part

is rigid in flexion or extension.

Function to assess: walking

Ability independent / with

assisstive aids

Speed

Quality

Observational

http://www.youtube.com/wa

tch?v=N0JNxFI3dUY

Computerized

http://www.youtube.com/wa

tch?v=MON0b3z_qCs&list=

PL1E01B66745EFABD6

Purpose: To assess mobility

Equipment: A stopwatch

Directions:Patients wear their regular footwear and can use a walking

aid if needed. Begin by having the patient sit back in a standard arm

chair and identify a line 3 meters or 10 feet away on the floor.

Instructions to the patient:

When I say

“Go,”

I want you to:

1. Stand up from the chair

2. Walk to the line on the floor at your normal pace

3. Turn

4. Walk back to the chair at your normal pace

5. Sit down again

On the word “Go” begin timing.

Stop timing after patient has sat back down and record.

_________

Time: seconds An older adult who takes ≥12 seconds to complete the TUG is at

high risk for falling. Observe the patient’s postural stability, gait, stride length, and sway

The Timed Up and Go (TUG) Test

http://www.youtube.com/w

atch?v=s0nqzvt9JSs

Six Minute Walk Test Key Points

The 6MWT must be performed twice to account for a learning curve

Required Equipment Walking Track or Area

The track or area should be flat with no blind turns, traffic or obstacles.

The minimum walking length of 25m (82 feet) should be marked in meter (feet)

increments. Stethoscope , vital sign equipment, pulse oxymeter, Stop watch, Portable

oxygen delivery system Chairs in position for the patient to rest, Dyspnea scale

Record:

blood pressure

heart rate

oxygen saturation

dyspnoe score (Borg Scale)

Norm values depend on the age, disability severity, etc.

http://www.youtube.com/watch?v=ixxKBm-kl0M

Functional Independence Measure FIM

Contains 18 items composed of:

– 13 motor tasks

– 5 cognitive tasks (considered

basic activities of daily living)

• Tasks are rated on a 7 point

ordinal scale that ranges from total

assistance (or complete

dependence) to complete

independence

• Scores range from 18 (lowest) to

126 (highest) indicating level of

function

• Scores are generally rated at

admission and discharge

• Dimensions assessed include: 1. Eating

2. Grooming

3. Bathing

4. Upper body dressing

5. Lower body dressing

6. Toileting

7. Bladder management

8. Bowel management

9. Bed to chair transfer

10. Toilet transfer

11. Shower transfer

12. Locomotion (ambulatory or wheelchair

level)

13. Stairs

14. Cognitive comprehension

15. Expression

16. Social interaction

17. Problem solving

18. Memory

FIM Scoring Criteria:

No Helper Required

Score Description

7 Complete Independence

6 Modified Independence (patient requires use of a

device, but no physical assistance)

Helper (Modified Dependence)

Score Description

5 Supervision or Setup

4 Minimal Contact Assistance (patient can perform 75%

or more of task)

3 Moderate Assistance (patient can perform 50% to 74%

of task)

Helper (Complete Dependence)

Score Description

2 Maximal Assistance (patient can perform 25% to 49%

of taks)

1 Total assistance (patient can perform less than 25% of

the task or requires more than one person to assist)

0 Activity does not occur

score description

1 DEAD

2 VEGETATIVE STATE

Unable to interact with environment; unresponsive

3 SEVERE DISABILITY

Able to follow commands/ unable to live

independently

4 MODERATE DISABILITY

Able to live independently; unable to return to work

or school

5 GOOD RECOVERY

Able to return to work or school

Glasgow Outcome Scale

How to evaluate the results of the rehabilitation

process?

1. Monitor functional changes – ICF / FIM / Barthel / any

tests on the level of impairment etc.

2. Demonstrate improvement by raw scores (+ 25 points),

categories, per cent values, etc.

3. Evaluate patient satifaction (questionnaires)

4. Evaluate costs of care (typical indicators: LOS, number

of therapy hours/day or week, need for basic care, etc.)

and calculate cost/benefit

5. Indirect impacts (distal impacts – usually by FU) –

return to work / school; QOL; long-term-care needs etc.

Goal Attainment scale

-3

-2 basic skill

-1

0 the aim / skill to attain

+1

+2

+3

active and passive goals

Active goal

<20m

Walks with cane 20 m

21-34 m

35-40 m

41-50 m

51-60 m

>60 m

goal Attainment Scale

• Active/passive goals

Krasny-Pacini A, Hiebel J, Pauly F, Godon S, Chevignard M.

Goal Attainment Scaling in rehabilitation: A literature-based update Ann Phys Rehabil Med. 2013 Apr;56(3):212-30.

we applied active goals mostly

Examples:

holding the head unsupported

keeping balanced when standing

unsupported

Placing the foot on a foot-plate

without help

transfer from/to wheelchair

stand-ups and sit-downs under a

certain period

standing supported / unsupported

increase walking distance

sitting without support

Improve distance during the 6MWT