INTERNAL MEDICINE II 11.

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MEDICAL REHABILITATION 1
February 3, 2020 | Ramona Luis Pablo Santos, MD
Transcriber/s: 4Aeeeeyyyy

Italicized text– powerpoint voiceover and lecture recordings.
Subtrans’ note: Make sure to read the handouts, because Doc
emphasized a lot of stuff from the materials.
Figure 1. Scope of Medical Rehabilitation
LEARNING OUTCOME
• Role play as a physiatrist
o Create a plan for the medical rehabilitation of
clients with arthritis
o Write referrals to members of the medical
rehabilitation team
o Develop outcome measures
o Analyze the response to rehabilitation
• Be a positive influence on the QoL of differently abled
persons
WHO-ICF (2001)
• World Health Organization International
Classification of Functioning, Disability and Health
• Source (read this daw for future use):
https://www.who.int/classifications/icf/en/
• Provides common
o Language – provides a universal language in
describing both health and disability
o Framework to assess health and disability
o System to categorize and report disability –
provides a coding
o system that helps categorize and report
disability.
• Uses
o Clinical practice
o Health care planning and development
o Research
KEY TERMS (REFER TO ICF CHECKLIST)
• Impairment
o Anatomic (body structure) or physiologic (body
function) problem (deviation or loss)
o i.e. patients with intellectual impairments, or
communication problems such as patients with
aphasia.
o Most common example of anatomic impairment
is patients with amputated limbs.
o Any problem that is either anatomically or
physiologically.
• Activity
o Tasks made by the individual in a controlled
environment – we evaluate here the capacity of
an individual to do a particular task. Under the
ICF checklist, it falls into several domains (e.g.
Communication Domain, Mobility Domain, Self-
care, etc.)
o Activity limitation → Reduced capacity to do
task
o If unable to perform a task in the best
environment, or ideal environment (e.g. rehab
clinic), then it’s activity limitation.
• Participation
o Involvement in life situations; “lived
experience” - What the patient does outside the
facility. If a patient cannot perform a certain
activity in his environment, it’s called
participation restriction.
o Participation restriction -> unable to perform an
action in person’s own environment (e.g. their
homes, school, church, etc.)
o inability to do an activity that a patient is
capable of doing in an ideal environment
because of environmental obstructions in the
patient’s natural environment
Table 1. Examples of Impairment with their Corresponding Activity
and Participation Limitations
IMPAIRMENT REHAB CLINIC HOME/COMMUNITY
(activity limitation) (participation
restriction)
Paraplegia Can wheel himself Partner wheels him
to go to mall/church
Loss of leg Walks with Social isolation
prosthesis

RA Hand In OT can do all ADL At home assisted in al

 providing a cure for the disease, but the client is
contractures with modified tools ADL by caregiver
having activity or participation limitations.
Expressive Communicates Can go wherever he • Disability can persist even without impairment –
aphasia need with picture pleases, alone effect of contextual factors
card • Focus on FUNCTION, not disability – why we evaluate
capacities and activity.
Behavior Can do chores and Employed in a • “I Can Function”
(Autism) make purchases restaurant • Now emphasizes a positive viewpoint
o When a person is still able to do all the tasks
prior to impairment, the patient is not disabled.
FRAMEWORK FOR HEALTH AND DISABILITY
Table 2. Examples of Assessment of Impairments
Impairment Client 1 Client 2 Client 3

Loss of leg walks out has walks with

secondary to with prosthesis prosthesis
diabetic prosthesis
gangrene Very poor self resumed all
Returned to image and past activities
work as an refuses social but retired
executive contact early since
Figure 2. WHO-ICF Framework (very important, understand this office is in 3rd
through. Bigger picture at the end of the trans) resumed all resigned from floor and
previous life work in call building has
activities center no elevator
WHO - ICF (2001)
• Replaced ICIDH (1980) - International Classification of refuses to
Impairment, disability, and handicap – first version leave the
used house
• Dropped term handicap
o Handicap is the inability to perform your role in Assessment no disability no activity Participation
society due to a disability. This is a term no limitation restriction
longer used. functioning due to
• Disability redefined as impairment, activity participation environment
limitation and/or participation restriction restriction al factors
o Disability is the inability to perform any task that due to
your peers can do such as self-care, walking, and personal
tasks you see in the same peer group. factors
• Used biopsychosocial model of disability
o Relationship of disease, impairment and
MEDICAL REHABILITATION
disability no longer linear – there is no longer a Table 3. Difference Between Medical Practice and Medical
linear relationship between impairment and Rehabilitation
disability.
o Added contextual factors as important cause of MEDICAL MEDICAL
disability PRACTICE REHABILITATION
▪ Contextual factors - environmental and
personal factors Patient- centered Desired, preferable mandatory
• E.g. Absence of wheelchair lifts on a
Priority goal cure - optimal function
bus causes disability or
control disease - best quality of life
participation restriction to patients
in wheelchairs
Client Patient and Patient, family,
decision-maker community, civic
IMPORTANT IMPLICATION OF WHO-ICF society, leaders
• Health is not merely the absence of disease – it is and policy makers
possible to bring back the health of the individual by

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Team approach Occasionally Necessary insufficiency
Metastasis

Modalities Surgical, Same, except

pharmacologic, surgical PLUS Other effects
health education physical agents,
and promotion, assistive Muscle spasm reduced increased
counseling technologies,
mobility devices, Nerve Conduction Enhanced Decreased
functional and Velocity
vocational training,
environmental Pain relief Yes Yes (apply for 20
modification min)

MEDICAL REHABILITATION TEAM • Use of ice or warm compress is just for adjunct for
• Physiatrist (Rehab Med Specialist) management of pain relief (it’s not the definitive
• Physiotherapist treatment, especially for patients who don’t want to
• Occupational therapist take too many medications
• Speech therapist/ pathologist • ICE is the best for inflammation
• Rehabilitation nurse o Only given for 5-10 mins to produce
• Psychologist vasoconstriction
• Vocational counselor o We avoid heat because it will cause
• Social worker vasodilation thus propagating inflammation
• patient o There should always be a 2-hour gap in
between ice compress
PHYSICAL MODALITIES o For pain: 20 mins
▪ Primary goal is not anymore
• Thermal agents (heat and cold)
vasoconstriction but to slow down nerve
• Electrical stimulation
conduction
• Exercise
o >30 mins it will cause reflex vasodilation
• Others
• Rest
o Ultrasound
o Most important treatment for acute
o Traction - the main effect of traction is reduced
inflammation
muscle spasm, which results in less pain in
o If you mobilize an injured tissue, it will just
persons with cervical and lumbosacral strain. The
promote inflammation
amount of force needed to increase the disc
o There should be balance between rest and
space will usually cause discomfort and excessive
movement
pressure in the harnesses
▪ You can start moving but if it begins to
o LASER (Light Amplification of Stimulated
hurt again, you rest it
Emissions of Radiation)
o Analgesia masks the pain thus allowing further
injury
ICING VS WARM COMPRESS
o May utilize splints
Table 4. Heat Vs Cold Compress
• Healing:
HEAT COLD o Skin: 3 weeks
o Bones, Ligaments, Tendons, Muscles, Nerve
Main Physiologic Vasodilation – in Vasoconstriction cells: 6 weeks
effect the subcutaneous (reflex dilates ▪ Time when tissues can take in the usual
vessels only after 10 min) stress
▪ 12 weeks before they can take more than
Main use Improve blood Decrease acute the usual stress
flow inflammation ▪ Before this, reinjury may occur
Main Acute Cold
contraindication inflammation hypersensiivity
Vascular infection

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PHYSICAL MODALITIES: USES
Table 5. Physical Modalities and its most common uses
Modality Most Common Use/s
Icing Decreased pain and swelling in acute
inflammation
Warm Decreased muscle spasm; relax muscles
compress
Electrical Pain relief (TENS)
stimulation Delay muscle atrophy
Decrease dependent edema and
improve venous return when combined
with compression and elevation
• Electrotherapy and ultrasound have been used to
facilitate absorption of medications (Ex.
iontophoresis) but the evidence for this is still lacking
• Cost and the accessibility to frequent and regular use
of the modality by the client is important
EXERCISE: PURPOSE
• Improve cardiovascular endurance (aerobic exercise)
– part of the management for cardiovascular
disorders
• Restore skeletal muscle balance (strengthen agonist
and increase flexibility of antagonist) - – e.g. sprain
and strain problems such as in athletes or working
people (those who use gadgets for a long fixed time)
• Increase tolerance of muscles for repetitive work
• Meant to prevent deformity
o Most patients when in pain are in a flexed
position - the position of comfort
o Goal is to go against the position of comfort as
long as it does not go against function
▪ E.g. Elbow extension exercises
• If you do not constantly use a muscle, it becomes
shortened and contracted
o E.g. When you are always looking down on your
gadgets, the neck extensors are perpetually
stretched while the flexors are contracted which
makes it comfortable to just always maintained
that position (this impairs your posture)
TYPES OF EXERCISE
• Strengthening (focus on resistance or intensity)
o Skeletal muscle - progressive resistive exercise
o Cardiac muscle - aerobic exercise
o A muscle that is constantly stretched (such as
the neck extensors in the examples above) will
weaken
o Needs to be done thrice a week on an
alternating basis
• Stretching
o Increase flexibility of muscle/tendon
o Prevent or reverse soft tissue contractures
o Must be prolonged and frequently done
o Must be done as often as possible and prolonged
to sustain the stretch
o Refer to the example above: the neck flexors has
to be stretched to counteract the contraction
• Endurance (focus on repetitions)
o Increase tolerance for prolonged muscle activity
o Also focuses on skeletal muscles, but focuses
more on repetition with the same intensity to
increase the tolerance for prolonged activity.
• Fundamental principle of exercise:
o Unwanted positions and poor posture will
always cause a muscle imbalance between the
agonist and antagonist, and therefore the
exercise will always be to stretch that side which
is shortened and to strengthen the muscle side
that is stretched out
STRENGTHENING EXERCISE: PRINCIPLES **
• Adaptation
o Gains in exercise due to anatomic, biochemical
and physiologic changes over time –
▪ Fast twitch muscles – for power
▪ Slow twitch – for endurance
▪ If you keep doing endurance exercises,
your fast twitch muscles begin to undergo
physiologic changes that are similar or
have some of the characteristics of slow
twitch muscles that would enable them to
tolerate endurance activity.
▪ In aerobic exercise, your heart muscles
uniformly hypertrophies, and then allows
the heart to eject a greater cardiac output
or stroke volume
o Takes 8-12 weeks; at least at least 3x / week –
these changes are not immediate
• Overload
o Gains only if muscle is overloaded so need
resistance
o Resistance in aerobic exercise is based on heart
rate
o Even if you exercise, your muscles will not gain
strength if you don’t overload it with work. To
overload, you have to adjust resistance and
intensity.
• Reversibility
o By 2 weeks of not exercising the gains will begin
to disappear
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 o Retain effect with continued exercise
o Once you stop exercising, after the 2nd week,
everything that you gained (months, years) will
begin to gradually disappear. For you to retain
adaptive changes occurred, you will have to
continue exercising (i.e. decreasing intensity)
• Specificity
o Gains vary depending on nature of the exercise
o I.e. → best aerobic exercise for a runner is to
run; for a swimmer, is to swim
** applies to both skeletal and cardiac muscle

FUNCTIONAL OUTCOME MEASURES

• Outcome measures
o Assess response to treatment plan (positive or
negative outcomes)
o Scoring system (measurable)
o Show progress across time
o Easy reporting
o Standardized, tested for validity and reliability
o Facilitate research especially best practice and
EBM
• Functional outcome measures - focused on
impairment, activity and participation

FUNCTIONAL INDEPENDENCE MEASURE (FIM)

● Internationally known standardized functional
assessment tool; Applies to any disorder; Mainly
adults (WEE-FIM for pedia)
● 18 items in 6 domains (self-care, bowel-bladder
control, locomotion, transfers, communication and
cognition)
● Best score 126 →> independent without devices in all
domains; Lowest score 18 → maximally assisted in all
domains
Figure 3. Functional Independence Measure (bigger picture at the
end of the trans). Lowest score (1) – the client needs to be assisted at
all times. (2-5) needs devices, while highest score (7) – patient has no
device and can do activities independently by himself.
WHO -QUALITY OF LIFE BREF
• Shorter version of the WHO-QoL 100
• 26 questions only
• Assess four domains (physical health, psychological,
social relationships and environment)
• Use this tool for family members or close friends who
has a chronic condition or impairment.

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 ▪ SLE
o Wear and tear/Degenerative
o Trauma
o Repeated microtrauma
o Infection
▪ TB
▪ Bacterial arthritis
• Inflammation - main pathology of arthritis
o Also the first step to repair
o “Damages” the area to clear debris in order to
allow proper repair
o Uncontrolled inflammation is pathologic
o Symptoms are pain and swelling, which leads to
impairment of movement
Figure 4. WHO-QoL BREF (bigger picture at the end of the trans) o We cannot stop inflammation, but we control
the degree of inflammation and its symptoms
RHEUMATOLOGIC DISEASE: OVERVIEW
RHEUMATOLOGIC REHABILITATION
Table 6. Rheumatologic Rehabilitation

DISABILITY REHAB APPROACHED USED

GOALS

Deformity prevention * client and family education

correction * exercise
Contractur
es → LOM
adaptation * proper positioning
* splints – to properly modify
Figure 5. Summary of Principles of Rehab Medicine concerning
movement
Rheumatologic Diseases
* joint protection and work
3 common pathologies in rheumatologic diseases simplification
• immune system disorders – autoimmune (rheumatoid
arthritis, SLE, Sjorgren) – management is related to *environmental modification -
the immune system problem to prevent further stress on the
• Conditions secondary to infection – bacterial arthritis, affected joints
TB arthritis • Deformities and Contractures are the most disabling
• Degenerative, overuse injuries, and repetitive stress problems on a long-term process when it comes to
Regardless of what causes, it presents with inflammation rheumatic diseases. Therefore, priority should always
(acute, subacute, or chronic) and then affects articular and be given to anticipate what kind of deformity is going
periarticular structures. to happen and plan for its prevention. If it’s already
present, then immediate correction is critical.
MOST COMMON PROBLEMS IN RHEUMATIC DISORDERS • Prevent deformity – most important to avoid
• Pain o Deformity and contractures happen due to
• Swelling repeated inflammation, eventually resulting
• Impaired joint function (movement and weight into narrowing of joint spaces, tightening of the
bearing) due to periarticular structures
o Pain and/or swelling o 2nd goal of rehab
o Instability ▪ No contracture happens, but if it does,
o muscle/tendon tears they will not impair function
o Contractures (soft tissue and bony) o Problem: immobilization of joint causes joint
• Rheumatic conditions only differ in etiology damage and contraction
• Arthritis causes: o Functional position
o Immune system disorder ▪ Wrist is dorsiflexed
▪ Rheumatoid arthritis ▪ Thumb and index finger are in opposition

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 ▪ Fingers are slightly flexed
▪ Allows fine movements and precision grip
▪ With the knees, we preserve the full
extension of the hip and the knee, and the
ankle joint in neutral position to allow
walking
▪ Tip toeing (in patients with achilles
tendon shortening) causes bending of the
knee and hip flexion
• Most basic activities are:
o Self-care
o Walking - lower extremities
o Posture and ability to sit – Trunk
CLIENT EDUCATION: ESSENTIALS
• Patho-mechanism of rheumatic disease – it is always
important to explain to the client their rheumatic
disease
o Effect of lifestyle – the effect of their lifestyle,
weight, habits, etc on the joints
o Role of medications – role and limitations of
meds, because like in autoimmune disorders,
medications can’t really cure the disease, but only
control it. Care of the joints should be lifetime.
o Risk of deformity and disability - so they can
cooperate well in the preventive care program
• Control of inflammation
• Joint care
BASIC GUIDELINES IN JOINT PROTECTION
• Respect pain
• Properly pace activities. Take rest breaks.
• Plan each day’s activities
o Alternate heavy and light tasks
o Breakdown long and complex tasks
o Avoid overworking
o Prioritize task/activities
JOINT PROTECTION
• Use stronger and bigger joints for heavy tasks
• Avoid positions of deformity
• Use each joint in its most stable and anatomic plane
• Change positions frequently
• Use assistive/adaptive devices to prevent joint stress
• Planning movements to reduce the amount of load in
their joints esp. the lower limbs when walking
• Ideal footwear is 1inch to 1.5inch
o More than 1.5 is bad for your back
o Less than 1 inch is bad for the arch of your foot
o It has to be snug
• The wider the thing you grip onto, the less stress on
the hand
• In essence, use of a bigger joint is better than use of a
smaller joint
o E.g. Shoulder bags are better than and bags
• Lower extremity - use of a cane to reduce weight
bearing
• Never do full extension of an elbow with weights, it
should always be slightly flexed
• Positions of deformity
o Wrist - when extremely palmar-flexed or
extended/dorsiflexed or when deviated
especially ulnarward
▪ In RA patients the postural deviation of the
wrist is ulnarward
• Environmental modification
o Use of modified equipment to keep the stress
minimum and the joints in anatomical and non-
damaging positions
MUST READ!!! (all handouts are uploaded in the gdrive)
WHO-ICF REFERENCES
• ICF Beginners Guide
• ICF Checklist
• https://www.who.int/classifications/icf/en/
PHYSICAL MODALITIES
Cifu, David (2016). Braddom’s Physical Medicine and
Rehabilitation. Philadelphia: Elsevier, Inc..
• Chapter 17: Physical Agent Modalities, section on
cryotherapy, superficial heat and electrotherapy
(TENS)
OUTCOME MEASURE
Cifu, David (2016). Chapter 7: Quality and Outcomes for
Medical Rehabilitation
WHO-QOL BREF
RHEUMATOLOGIC REHABILITATION
Cifu, David (2016). Chapter 31: Rheumatologic
Rehabilitation
CASES
(DISCLAIMER: SOME DOESN’T HAVE ANSWERS, SO USE AT
YOUR OWN RISK)
CASE 1
Twenty-eight year old female with recurring neck and back
pain over the past three months. She has been working as a
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call center agent for five years. The pain is localized to the nape
and both upper trapezius and supraspinatus areas. The pain is
worst after work. The end ranges of neck extension, rotation
and lateral flexion is painful, but active range of motion (ROM)
are complete. There is no numbness of the hand or radiating
pain. The referring diagnosis of the orthopedic surgeon is
Cervical Strain Syndrome.
A. Using the WHO-ICF Checklist, list the impairment/s of the
above client?
B. Give at least two possible activity limitations caused by the
impairments.
C. Outline your rehabilitation plan for the above client. Use the
table below to guide you.
D. In the third column, prioritize your plan of action by ranking
them from 1 to 4. Label as #1 the intervention that is most
effective in giving a long term, if not a permanent relief, to the
disorder of the client. Be ready to justify your answer when we
meet on Feb. 3.
wheelchair-borne during consult because the pain is worse
when he walks. He was supposed to return to his ship and
resume work on the day he had the acute gouty attack. He is
very frustrated because he needs help to go to the bathroom
and don his lower garments. He was also unable to play with
his children and go out with the family
A. Using the WHO-ICF, what is/are the impairment/s, activity
limitations and participation restrictions of the above client.
B. Outline your rehabilitation plan for the client using the table
below.
C. In the third column, prioritize your plan of action by ranking
them from 1 to 4. Be ready to justify your answer when we
meet on Feb. 3.
Area of Concern Specific Action Priority Level
Therapeutic
Rehabilitative
Preventive
Promotive

Area of Concern Specific Action Priority Level

D. Design a functional outcome measure for the client with
Therapeutic gouty arthritis. You can use the table below as a guide. You can
also choose not to use the table, and instead create a system
Rehabilitative
of your own. Please be ready to explain your work when we
Preventive meet on Feb. 3.
Promotive

E. Write a referral to two members of the Medical Desired Condition/Parameters to be Score/Grade

Rehabilitation team. Please indicate in your referral Outcomes evaluated
a. What you want the team member to do.
b. What changes you hope to see in the client after 1. a.
the team member manages her.
b.
F. The client followed-up with you after two weeks of
undergoing rehabilitation therapy. You expected an 80-100% c.
relief of the neck pain, instead, the client said there was only a
20-30% relief of pain. She complied with the suggested six
2. a.
sessions of therapy. You are very confident this is a simple
cervical strain problem. What do you think caused the poor
response to rehabilitation therapy? b.

CASE 2 c.
A 43 year old seaman with a diagnosis of Hyperuricemia was
referred to you for rehabilitation by an internist. For a week 3. Etc. a.
now he has been confined to his home because of severe pain
in the right knee and left first MTP joint and difficulty in
walking. On examination both joints were acutely inflamed b.
with hyperthermia and swelling. He was already prescribed an
NSAID and uric-lowering drugs by the internist. He was

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 c. Therapeutic - Pain management and for 1
swelling
Total Highest possible score and o NSAIDS (Ibuprofen,
Score interpretation Naproxen)
- Transcutaneous Electrical
Lowest possible score and Nerve Stimulation
interpretation - Hot Moist Pack
- Therapeutic Ultrasound
CASE 3 - Continue Patient’s existing
A 60 year old female diagnosed with Rheumatoid Arthritis over treatment for Rheumatoid
the past thirty years returned to consult you because she has Arthritis
marked difficulty walking even within her one-storey home. o DMARDs as first
She has been dependent on a wheelchair to move around her choice of treatment
home and must be assisted in all her transfer activities. She has (Methotrexate)
limitations of motion in all joints of both upper and lower o Given with an Anti-
limbs, and neck. She cannot raise her arms, nor close both TNF Agent such as
hands, and has flexion contractures of both hips and knees. Infliximab with
She stopped doing her home exercises since two years ago Methotrexate therapy
when her husband passed away. She claims she was very close - Anti-depressants for patient’s
to her husband and has been unhappy since he died. She now suicidal ideations
lives alone with a caregiver who helps her with all her self-care Rehabilitative - Address the patient’s 2
activities, including shopping and other official transactions limitation in motion
(paying taxes, going to the bank etc). All her three children live o ROM exercises of
abroad and take turns in visiting her every four months. There both upper and lower
are no signs of an acute inflammation in any of the joints. Bony extremities and neck
swellings and multiple deformities were observed in both on all planes as
hands. X-rays of the joints showed severe erosions and joint tolerated by the
narrowing. Both upper and lower cervical spines showed patient
significant narrowing with atlantoaxial instability. The referral o Stretching of both
from her rheumatologist includes a request for a cervical upper and lower
orthosis. The client appears depressed and verbalized a desire extremities towards all
to die because of the severe discomfort and loneliness. Her motions as tolerated
caregiver reported that the patient just lies in bed most of the by the patient
day and has refused to see and talk to friends. She is even too o Non-weight bearing
lazy to go to the bathroom, thus she prefers to use diapers exercises
even if she still has good bowel and bladder control. o Rest and splinting to
reduce pain
• Make your own diagram or algorithm using the WHO- - Address the patient’s
ICF framework on disability to show all the various decreased strength
factors that has affected the level of functioning of o Isometric exercises
the client with Rheumatoid Arthritis, and how these - Address the patient’s
difficulties in activities of daily
factors interact with one another. Be prepared to
living
explain your diagram to the class on Feb. 3.
o Use of assistive
device
A. Outline your rehabilitation plan for the above client using o Joint projection
the table below. strategies
o Environmental
B. In the third column prioritize your plan of action by ranking education strategies
them from 1 to 4. Be ready to justify your answer when we o Dynamic exercise to
meet on Feb. 3. improve lung function
Area of Specific Action Priority
Concern Level Preventive - Vitamins and Calcium 3
Supplements

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 - Use lowest possible does of the equivalent score. What will be the highest and
glucocorticoids to prevent lowest total scores and what will be the significance
further bone loss of these scores? Be prepared to explain your
- Smoking and drinking alcohol assessment tool on Feb. 3.
is strictly prohibited (major risk
factors) ------ END -------
- Continue home exercises
(Home Instructions and Home
Exercises)
- Regular check up and imaging
to monitor progression of the
patient’s diseases
- Compliance with medications
Promotive - Educate the patient about her 4
condition, possible risks and
outcomes
- Promote practice of a good
and healthy lifestyle by
following medical orders
- Promote a cheerful lifestyle
o Advise patient that
physical therapy can
help her cope with
daily living
o Refer to a
psychologist to REFERENCES
address depression 1. PPT lecture and voiceovers
o Refer to support 2. Lecture notes and recordings
groups 3. Rehab Med handouts
TRANSCRIBERS
1. TRANS GROUP: 4Aeeyyy
Attempt to use the Functional Independence Measure on this
2. SUBTRANSHEAD: ADYP
client.
3. EDITOR: CFCS
• What is your interpretation of the FIM score of this 4. TRANS HEAD: JAMO&JABO
client?
• Review the clinical course and prognosis of
Rheumatoid Arthritis. Recall what you learned about
the factors that can cause disability or affect the level
of functioning of an individual with a disease. What
do you think is the best plan of action in order to
improve the FIM score of this client in the next three
months? Justify your answer.
• Make a list of the three most important things you will
discuss with this client so that she can make an
informed decision regarding her rehabilitation
therapy. Justify or explain your answer.

Review the WHO-QOL questionnaire.

• What do you predict is the likely score (high or low)
and outcome (positive or negative) if your client with
RA answered the WHO-QOL?
• Based on the above, develop a simple, easy to use
outcome measure that will best show the progress of
your client’s quality of life. Remember to clearly state
your desired outcome/s, the parameters or specific
findings that will be evaluated for each outcome and
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APPENDIX

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