Rehabilitation

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Rehabilitation

• Dr J Hobart

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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.

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Rehabilitation is

• For people with achievable goals

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Rehabilitation is about changing one or more of

• The person
• The way they do things
• The environment

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Rehabilitation is not.

• Respite
• Suitable for all disabled people

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Neuro-rehabilitation

• Assessment
• Measurement
• Planning
• Treatment
• Evaluation
• Reassessment

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Assessment

• Multidisciplinary team
• Identification of the problem
• Measurement of the problem

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Assessment frameworks

• ICIDH
• World Health Organisation International
  Classification of Impairment, Disability and
  Handicap
• PILS
• Prevention, Independence, Lifestyle, Social
  resources

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WHO ICIDH (1980)

• Pathology
• Impairment
• Disability
• Handicap

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WHO ICF (2001)

• Pathology
• Impairment
• Activity limitations
• Participation restrictions

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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

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Impairment

• the direct neurophysiological consequences of the
  underlying pathology
• sometimes pathology is silent
• signs
• used to deduce underlying pathology

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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

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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

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History Taking

• Pathology
• Diagnosis
• Impairment
• Examination
• Disability
• Review Function based
• Handicap
• Review Daily routine

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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?

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Rehabilitation

• Assessment
• Planning
• Treatment
• Care
• Evaluation

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Planning

• Multidisciplinary problem analysis
• Identify areas of potential functional
  improvement
• Setting goals

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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

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Treatment

• Drug management
• Control of pain, spasticity, bladder problems,
  constipation, impotence
• Physical management
• physiotherapy, occupational therapy, nurses
• Cognitive management
• psychologist, occupational therapist, nurses

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Evaluation

• Checking on the effectiveness of any intervention
• Define criteria
• Measure success/failure against criteria

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Evaluation

• Process
• Goal achievement
• Integrated care pathways
• Outcome
• Impairment
• Disability
• Handicap
• Quality of life

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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

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Helpful (?) advice for primary care

• Try to identify goal/s
• Think person, strategy, environment
• Dont underestimate cognitive problems
• Try to understand why rehab may not be suitable

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Spasticity
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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

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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

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Spasticity management

• Drugs
• Therapists
• Continence advisors
• Social services

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Therapists

• NEURO physios, OTs, hand therapists
• Intensive hands-on therapy
• Home exercise programmes
• Mobility aids and seating
• Beds and bed positioning

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Continence advice

• Impact of UMN syndrome on sphincters
• Impact of sphincter probs on spasticity
• Bladder management
• Strategies, drugs, catheters
• Bowel regimens
• Diet, drugs

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Social services

• Impact of environment on spasticity
• Optimise aids
• Optimise care package

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Anti-spasticity drugs

• Baclofen
• Tizanidine
• Dantrolene
• Diazepam
• Cannabis
• Botox
• Intrathecal baclofen
• Intrathecal phenol

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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