WCS 35

WCS 35

REHABILITATION MEDICINE
Dr Leonard SW Li

Medicine

Sat 28-09-02
Rehabilitation

The combined and co-ordinated use of medical, social, educational and vocational measures for training or retraining the individual to the highest possible level of functional ability (WHO 1969)

Rehabilitation Vs Habituation

Rehabilitation: Adaptation of a new set of skills to survive. Change of habits and behaviours - eg. after stroke (new gait, one-hand techniques), cardiac disease (limited exercise tolerance)

Habituation: Accustoming to an environment (not experienced before) e.g. spinal bifidus (LL motor impairment, cannot walk properly) (eg. New-borns - have not experienced life before) (Habituation - more used with paediatrics)

ICIDH

In 1980, the World Health Organisation published the first version of the ICIDH (International Classification of Impairments, Disabilities, and Handicaps) as a classification of the "consequences of disease". Classifications of diseases fail to capture the variety of experiences of people who live with health conditions, and the ICIDH was designed to fill that gap.

Impairment

Any loss or abnormality of a psychological, physiological, or anatomical structure or function

Disability

Any restriction or lack resulting from an impairment of a person's ability to perform a task or activity within the range considered normal for a human

Handicap

A disadvantage for a given individual, resulting from impairments and/or disabilities, in performing a role otherwise normal for that individual

Insufficiency of ICIDH

Demarcation of disability and handicap sometimes is not clear
Difficulty in quantification of handicap
Practical assessment, clinical use and research is limited

ICFDH-2: International Classification of Function, Disability and Health

Social model orientation

Operational definitions given for all categories

Neutral terminology

Structural and functional impairments

'Activity' instead of 'Disability': look at Pt with disease more +vely

'Participation' rather than 'Handicap'

Includes environmental factors: politics in a country that could affect a person with disability, environmental (ramp to MTR, lift in shopping centre)

Impairment

Is a loss or abnormality of body structure or of a physiological or psychological function, e.g. loss of a limb, loss of vision...

An Activity

Is the nature and extent of functioning at the level of the person. Activities may be limited in nature, duration and quality, e.g., taking care of oneself, maintaining a job

Participation

Is the nature and extent of a person s involvement in life situations in relation to Impairment, Activities, Health Conditions and Contextual Factors. Participation may be restricted in nature, duration and quality, eg. participation in community activities, obtaining a driving license…
Note: Contextual: (1) Environmental - political, social (2) Personal - psych issues of Pt

Overview of the dimensions of ICFDH-2

	Impairments	Activities	Participation	Contextual Factors
Functioning	At body level	At person level	At social level	In interaction with Environmental and personal factors
Characteristics	Body function Body structure	Person's ADL	Involvement in the situation	Features of the physical, social attitudinal world
+ve Aspect	Functional + structural integrity	Activity	Participation	Facilitators
-ve Aspect	Impairment	Activity limitation	Participation restriction	Barriers

Examples

Health Condition	Impairment	Activity Limitation	Participation Restriction
Leprosy	Loss of sensation of extremities	Grasping difficulties	Denied employment because of stigma
Panic Disorder	Anxiety	Limitation in going out alone	Restricted involvement in social relationships
Spinal Injury	Paralysis	Limitations in using public transport	Restricted participation in church activities
Juvenile Diabetes	Pancreatic dysfunction	None (controlled by medication)	Restricted participation in food consumption
Vitiligo	Facial disfigurement	None	Restriction in participation in social relations owing to fears of contagion
Former mental Pt with psychotic disorder	None	None	Denied employment because of employer's prejudice

INTERVENTIONS/ APPROACHES

INTERVENTIONS

Impairment interventions: medical interventions to deal with the impairment, and preventive interventions to avoid activity limitation

Activity limitation interventions: rehabilitative interventions and provision of assistive devices and personal assistance to mitigate the activity limitation, and preventive interventions to avoid participation restrictions

Participation restriction interventions: public education, equalisation of opportunities, social reform and legislation, architectural 'universal design' applications and other ways of accommodating activity limitations in major life areas

Medical Therapeutic Models

Biomedical Model: Classical medical therapeutics direct treatment at the cause of disease (senior Dr > Dr / senior nursing staff > junior staff)
Biopsychosocial Model: Rehabilitation produces multiple simultaneous interventions addressing both the cause and secondary effects of injury and illness

Team Approaches

Multidisciplinary Approach

Professionals treat the patient separately, with discipline-specific goals
Various Patient's progress is communicated through documentation or regular meeting

Interdisciplinary Approach

Each distinct profession evaluates the patient separately and then
Team member interacts together at team meeting
Assessments and long-term and short-term goals are shared.
The goals of each discipline are co-ordinated into a unified plan

Transdisciplinary Approach

Cross-training of members and procedure development to allow overlap of responsibilities between disciplines.
Flexibility in problem solving and produces closer interdependence of team members
Disciplines with extensive involvement with the patient may become case managers and co-ordinate team effort

PHASES IN REHABILITATION PROCESS

Phase I : Evaluation

Phase II : Treatment to arrest pathophysiology

Phase III : Therapy to enhance organ function

Phase IV : Task Reacquisition

Phase V : Environmental modification

Rehabilitation Process: Phase I

Evaluation

Knowledge of patient's personal life tasks, roles and aspirations
To quantify individual effects of disablement

Functional Assessment

"Any systemic attempt to measure objectively the level at which a person is functioning, in any of a variety of areas such as physical health, quality of self-maintenance, quality of role activity, intellectual status, social activity, attitude toward the world and self, and emotional status" (Lawton)

Activities of Daily Activities (ADL)

Basic ADL: e.g. Personal hygiene, Grooming, Feeding, Toileting, Transfer, Ambulation, Stair climbing. (FIM, Barthel, WeeFIM)

Basic = minimal activity a person has to do to survive

Diag: modified Barthel Index 100 - personal hygiene, bathing self, feeding, on and off toilet, stair climbing, dressing, bowel control, bladder control, chair/bed transfer, ambulation, total score/ 0-100

Advanced ADL (Instrumental ADL): e.g. Shopping, Driving, Gardening. (FAM, PEDI) (culturally dependent - no gardening in HK)

Usefulness of Functional Assessment

Cannot be used as a medical diagnosis (Pt should have medical Dx before functional assessment)
But, once diagnosis is established, can provide indication of impact on the individual's ability to live and function independently (degree of disability)

Reduction in Disabilities = Improvement in Function
Rehabilitation Process: Phase II

Treatment to arrest the pathophysiologic process causing tissue injury

Eg. Spasticity - botulinum toxin injection, phenol motor point block (motor point = where n enters m; phenol causes chemolysis of motor point)

Rehabilitation Process: Phase III

Therapeutic exercise (physical medicine)

To focus on enhancement of organ performance

Exercise Training

Muscle strengthening ® (1) Isometric exercise (2) Isotonic exercise (3) Isokinetic exercise

Isometric - Generation of m force with no visible jt movt; External resistance is not overcome by internal force generation; eg. Carrying shopping bag, push against wall (benefits Pt with jt immobilised in cast; Caution in HT: contract muscle, veins collapse, increased resistance, BP = CO x TPR, therefore BP increases)
Isotonic - Generation of m force with visible jt movt; At variable speed; With constant external force; eg. Push-up, Thera-band (home exercise prg)
Isokinetic - Generation of m force with visible jt movt; At constant speed; With variable external force; Use machine - can generate maximal force throughout its length-tension curve; eg. Cybex machine (great benefit if equipment available)

Cardiovascular conditioning

Supervised by therapist
Teach proper techniques: incl. monitoring HR, RPE (rating of perceived exertion)
All individuals older or with risk factors such as HT, smoking, hypercholesterolaemia, history of CHD should first undergo graded exercise test
Type of activity - the participate can enjoy
ACSM (Am College Sp Med) Guideline - 3-4x/wk, duration 20-30 min, intensity 50-85% VO2 max or 50-85% max HR (HR max = 200 - age)
The following components should be included in any exercise programme

Warm-up 5-10 min
Stretching
Cool down 5-10 min

Pacing in Exercise

To avoid problems of muscle fatigue, rest between bouts of exercise can be added
Esp. important in elderly (decreased exercise tolerance)
Ex performed in bouts of 2-5 min then 1 min rest breaks
Exercise for 15-30 mins per session

Rehabilitation Process: Phase IV

Task Reacquisition

Total person adaptive techniques
Compensation techniques - eg. Hemiparesis
Adaptive devices
Orthosis - external appliance to enhance Pt's function
Prosthetics - eg. Fake leg

Rehabilitation Process: Phase V

Environmental Modification

Environmental enhancement (physical, psychological, social and political) to reduce handicap

CLINICAL REHABILITATION

APPROACH

Evaluation (Assessment)
Planning (Goal-setting)
Intervention (Care and Treatment)
Re-evaluation
Discharge planning

CONFLICTS

Disagreement of the goals
Disagreement of the suitable clients to enter the service (rehab process expensive)
Disagreement of the final aims before discharge from the service
Disagreement between purchasers (Pt) and providers (Dr, therapist)

OBJECTIVES

To maximise the patient's independence within any environment

To optimise the patient's physical environment

To provide the level of personal support needed (when Pt returns home, can family provide support? Community nurse?)

To achieve the wildest range of role behaviours possible

To optimise the level of social interaction

To provide the patient with opportunities to occupy him/herself (day centres)

To maximise the patient's ability to adapt to change (eg. Main issue for young person with disabilities may be employment \ provide training)

To modify the patient's expectations in term of future positions

To modify behaviour and expectation of family and significant others

PHASES: CONTINUUM OF CARE

Medical: acute > rehab > community
Mobility/ Cognitive/ Self-care: acute < rehab > community
Vocational/ Sexual: rehabilitation < community
Psychosocial: acute < rehab < community

REFERENCE

www3.who.int/icf/icftemplate.cfm

J.A. DeLisa. Rehabilitation Medicine: Principle and Practice 3rd edition. Lippincott