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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