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