Key Concept Process of education of the disabled person + Ultimate aim of assisting that individual to cope with family, friends, work, and leisure as independently as possible + Involves the disabled person in making plans and setting goals that are important and relevant to their own particular circumstances Not done to the disabled person but done by the disabled person themselves, with the guidance, support, and help of a wide range of professionals Goes beyond narrow confines of physical disease; deals with the psychological consequences of disability and the social environment wherein he has to function Requires an active partnership with other of health and social service professionals © scanned with OKEN Scannerions of the WHO's International on of Impairments, Disobilities ond Handicaps Any loss o search ope poh o¢ anatomical suture or function Any restriction or lack of aciviy resubing from on oe ‘o perform on octvty in fhe manner or in es or ai ne resulfing from meet ot ee fat liIMPAIRMENT, DISABILITY AND t HANDICAP (wuo 1980) Pe ected ice elsvpeicror roel Physiological or anatomical structure or function Any restriction or lack of activity resulting from an impairment to perform an activity in the manner or in the range considered normal for people of the same age, sex, and culture Handicap A disadvantage for a given individual resulting from impairment or disability that limits or prevents the fulfilment of a role that would iar otherwise be normal for that individualImpairment zDy Nel sti ' + Functional consequence of impairment + Neurological rehabilitation goes beyond the impairment and looks at the functional consequence and fries to minimize the impact of the disability on the individual + Neurological rehabilitation mainly deals with fe [elelliingHandicap + social context of the disability Will have implications for the goals of the rehabilitation process €.g. right hemiparesis - mild weakness — not qualified to join armed forces Neurological rehabilitation needs to take into account not only the disability but also the handicap for the individual, while bearing in mind that some of the social and physical barriers depend on societal attitudes and the physical environment and may be outside the control of the rehabilitation team_— + Impairment — oe eaaiiiins) + Handicap - ern, iTable 2 New classifications of the Intemational Clas fion of Functioning and Disability: ICIDH Il Impairment The loss or oe boty are ofa ; : Son Fie hatte ond eet of Reckinieg Gs eal et the person, Acivities may be limited in nature, duration, and quality 3 s Induce the Features, ospects and attributes of eed hae (08 provision, and ies i sod, and atfitudingl eeaaeey in Nh ale live and conduct their lives. Contextual fadors “ey both environmental factors and personal wore |||) : © scanned with OKEN ScannerTHE REHABILITATION PROCESS - basic tasks ccurate Information and advice he nature of the disabllity, natural a to the needs and perceptions of the id person and thelr family vith other professional colleagues in lsciplinary fashion ia Wiis as necessary with key carers and + To assist with the establishment of realistic rehabilitation goals, which are both appropriate to that person's disability and thelr family, social, and employment needs © scanned with OKEN ScannerBASIC APPROACHES IN NEUROLOGICAL REHABILITATION + Active and dynamic process through which a disabled person is helped to acquire knowledge and skills in order to maximize their Physical, psychological, and social functioning + Three key areas: » Approaches to reduce disability « Approaches to acquire new skills and strategies, which will maximize activity » Approaches to alter the environment, both physical and social, so that a given disability caries with it minimal consequent handicap © scanned with KEN ScannerThe Goals aThe Goals a t wy + Must be precise . al CaN a ‘ 3 pail ie iss UIce 0) =) . W i acenlt=ncele)| =} + Relevant OT nae M aah =22The Goals + Both the disabled person and the rehabilitation team need to know when the goals have been achieved. Paseo Noro Multiineni-ehve Kou el- ele Met cou Man cre nec} PUN ee aids tone ree: oll ulna selene net rererttcecy (simple and quick) + E.G. Improvementin mobility - timed walking over 10 metres + Also remember that while objective measurement is important, subjective opinion of the disabled person with regard to progress towards the goals UY rele a cette + Goal setting process should never be rigid and will often need adjustment and re-evaluation as the individual progresses through rehabilitationWHO IS IT FOR? + Five categories of people with disabilities + Those who will make a spontaneous full improvement over a short period of time — with mild stroke + Those who steadily and may or may not return to pre-morbid function— moderate stroke or traumatic brain injury Those who will not improve greatly and who can expect a residual level of disability, but in whom some progress is possible— severe stroke or traumatic brain injury + Those who will deteriorate slowly over time— multiple sclerosis or porkinson's disease Those who will unfortunately progress steadily and rapidly—motor neuron disease or malignant gliomaTHE REHABILITATION TEAM + Key principle of neurological rehabilitation is the close working together of all relevant health professionals + May also need to involve other professionals outside the context of the health service (e.g. social service, employment sector). + Essence of rehabilitation is that individuals go beyond simply working together but blur their own roles and work together in an interdisciflinary fashion « Goals are set not discipline by discipline but according to the needs and requirements of the personHOSPITAL OR COMMUNITY 2 > Traditionally based in hospitals and largely serve the needs of the Post acute disabled banana Taian lime Neg traumatic brain injury I LN AAU dale Lo) oa hospital into the community Moye cece ed Clee ovat tA. tet) nevertheless such studies that do exis! show a clear trend for community based teams to be at least as effective as hospital based teams, as well Qs being cheaper and preferred by the disabled customers. Neurological rehabilitation practitioners should now be prepored to spend at least some of their tine working within the community for the longer term support of people with neurological disabilities. °Case scenario 7 + Amiddle aged man has multiple sclerosis. + He has been working quite successfully in his post in a large factory. He is married with two children and has an active social life. However, he has recently developed increasing problems with walking secondary to a developing paraparesis, complicated by spasticity. In addition he has recently developed problems of urinary frequency and urgency.Case Scenario + Aneurological rehabilitation programme, using the three basic approaches, could be as follows: + Attempts to reduce his disability by appropriate treatment of his spasticity and medication to help control bladder symptoms. + He could leam new skills— e.g. walking with external support such as a stick, or perhaps using a wheelchair for longer distances (from office car park to his place of work)Case Scenario + Approaches to alter his inmediate work environment » May need to approach employer to change or reduce his hours if prolonged periods of standing lead to increased fatigue, At home, may need to provide grab- fails in the toilet or other adaptations to the bathroom or Lola + His wife and family will need to be involved in this process in order to understand his condition and adjust their family lifestyle to cope with his new problems (wife, may share riving task if problems with spasticity begin to interfere with ability to control the car)Case Scenario + Neurological rehabilitation is not complicated + Practical and common sense application of basic principles applied within the framework of a detailed knowledge and Understanding of the natural history of a given condition and associated symptoms © scanned with KEN Scanner» An educational process >» Central involvement of the disabled person in programme planning » Key involvement of family, friends, and colleagues » A process that requires clear goals to be set and measured » An interdisciplinary SS » Aprocess based on peek of disability (activity) and * ene (pain © scanned with KEN Scanner1. quality versus quantity of life - focuses on continually improving quality of person’s life and not merely maintaining life itself 2. care versus cure - focus of care is related to adaptation and acceptance of an altered life rather than to resolving an irreversible illness 3. high cost of interdisciplinary care versus long-term care - rehabilitation is expensive, success is sometimes seen as a return to productive employment or if the individual becomes sufficiently independent that no caregiver is required © scanned with OKEN ScannerNeurological Rehabilitation - majority of neurological recovery occurs in 1st 3 months with 5% who continously show recovery for up to 1 year - recovery in function w/ adaptation & training w/ or w/o natural neurologic recovery is very much dependent on quality, intensity of therapy anaieiaaron © scanned with OKEN ScannerNeurological Rehabilitation gauged by improvement in independence in areas of self care and mobility recovery is modifiable by interventions phases of neurological recovery 1. early recovery - due to local processes (ie - edema resolution, reperfusion, resorption of local toxins, recovery of partially damaged ischemic neurons) © scanned with OKEN ScannerNeurological Rehabilitation - phases of neurological recovery 2. late recovery - due to neuroplasticity that allows changes in neuronal organization (ie - collateral sprouting of new synaptic connections, unmasking of previously latent functional pathways, reversibility from diaschisis) © scanned with OKEN ScannerNeurological Rehabilitation - phases of neurological recovery 2. late recovery - diaschisis refers to a sudden change of function in a portion of the brain connected to a distant (but damaged) brain area, site of originally damaged area and of the diaschisis are connected to each other by neurons (new synapses) © scanned with OKEN ScannerNeurological Rehabilitation Neuroplasticity / brain plasticity: - capability of the brain (CNS) to structurally and functionally reorganize and remodel by forming new neural connections throughout life - allows neurons to compensate for injury and disease & to adjust their activities in response to new situations or to changes in environment © scanned with OKEN ScannerRe The 2 Types of Brain Plasticity {hat is Neuroplasticity Type 1: Structural Plasticity Type 2: Functional Plasticit ‘aka Brain Plasticity)? — —— ¢. wes Brain's ability to Experiences or memories Brain functions move fror change and adapt change a brain's physical damaged area to structure undamaaed area © Scanned with OKEN Scanner29@@® MCCUTO CLTTTeiCh EET Ce Looe aT) Potala RN zt (Cy = n ks f 4 | A a Learning Paying Attention ts Exercise New Experiences © scanned with KEN ScannerNEUROPLASTICITY Meu ee TRUCE Bala isLaty © scanned with OKEN ScannerNeurological Rehabilitation Neuroplasticity / brain plasticity: - principles necessary for brain remodelling 1. change is mostly limited to those situations in which the brain is in the mood for it 2. the harder you try, the more motivated you are, the more alert you are and the better (or worse) the potential outcome - the bigger the brain changes © scanned with OKEN ScannerNeurological Rehabilitation Neuroplasticity / brain plasticity: - principles necessary for brain remodelling 3. what actually changes in the brain are the strengths of the connections of neurons that are engaged together 4. learning-driven changes in connections increases cell-to-cell cooperation crucial for increasing reliability © scanned with OKEN ScannerNeurological Rehabilitation Neuroplasticity / brain plasticity: - principles necessary for brain remodelling 5. brain strengthens its’ connections between teams of neurons representing separate moments of successive things that reliably occur in serial time 6. initial changes are temporary, make the ghange permanent or not © scanned with OKEN ScannerNeurological Rehabilitation Neuroplasticity / brain plasticity: - principles necessary for brain remodelling 7. the brain is changed by internal mental rehearsal in the same ways and involving precisely the same processes that control changes achieved thru interactions with the external world © scanned with OKEN ScannerNeurological Rehabilitation Neuroplasticity / brain plasticity: - principles necessary for brain remodelling 8. memory guides and controls most learning 9, every movement of learning provides a moment of opportunity for the brain to potentially interfering backgrounds or noise al (e I i © scanned with OKEN ScannerOres Det mur Cy your brain resilient. OC Ua een) recover from stroke, injury, PRUE dus Ce Neuroplasticity means the brain is always learning. But the brain is neutral - De Be between good and bad. SCS ad SU gal Se of being and responding rel | to conflict Pu Cae te Ue ur ae ee Le lb Se) Ou es me at Therefore neuroplasticity may entrench depressive, anxious, Clete ti eT eS Cis eet oSt Mee eau d Pee re Ul Tals sy ° PetsNeurological Rehabilitation What to do first ??? ‘Diagnosis specific’ J ‘Prognosis Oriented’ Evidence based treatment planning © scanned with OKEN ScannerNeurological Rehabilitation Problem list: neurogenic bladder dysphagia constipation skin breakdown seizures) insomnia, deep \ vein thrombosis malnutrition ventilation pain gait dysfunction depression radiculopathy spasticity, contracture © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific: - need for a detailed physiatric history (CC, HPI, PMH, FH, psychosocial hx, ROS) - functional history (ADL, IADL, community / vocational activities) - functional goals - functional exam (MS, neurological exam) -, diagnostics © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific (assess ADL): 1. mobility - bed mobility, wheelchair mobility, transfers, ambulation 2. self care - dressing, self feeding, bathing, grooming 3. communication - writing, typing, computer use, telephone use, special communication devices Al Wi A inl © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific (assess ADL): ADLS. 4 4. environmental hardware e : a - keys, faucets, light 5 Fi switches, use of windows cc =e oh and doors Bosna © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific (IADL): 1. home management - shopping, meal planning / preparation, cleaning, laundry, child care 2. community living skills - money / financial management, use of public transport, driving, shopping, access to recreational activities 3. health management - medication, health risks, making medical appointments © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific (ADL): 4. safety management - fire safety awareness, response to dangerous situations, response to alarms 5. environmental hardware - vacuum cleaner, stove / oven, refrigerator, microwave ovens © scanned with OKEN Scannerges Netrological Rehabilitation Diagnosis specific (muscle strength): 0 - no contractions 1 - palpable contractions noted 2 - full ROM w/ gravity eliminated 3 - full ROM w/ gravity 4 - full ROM wi gravity and slight resistance 5 - full ROM w/ gravity and full resistance Hut © scanned with OKEN ScannerDiagnosis specific: - modified Ashworth scale for spasticity O - no increase in tone 1 - slight increase in muscle tone, manifested by a catch and release or by minimal resistance at end of ROM when affected part is moved in flexion or extension 1+ - slight increase in muscle tone, manifested by a catch followed by minimal resistance thru the remainder (less than half) of ROM 2 - more marked increase in muscle tone thru mest of the ROM but affected parts easily hi ( Moved i m 3 - considerable increase in muscle tone, passive movement difficult 4 - affected parts rigid in flexion or extension © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific: - gait analysis helps show functional weakness using 6 determinants 1. pelvic rotation in horizontal plane 2. pelvic tilt in the frontal plane 3. early knee flexion ii if gg transfer from heel to foot flat Le © scanned with OKEN ScannerNeurological Rehabilitation Diagnosis specific (diagnostics): 1. radiologic studies - radiograms, MRI, CT scans 2. electrodiagnostic studies - in the diagnosis of conditions related to nerves and muscles iP electromyography (EMG) ip. nerve conduction studies (NCS) a “Ne Ce Fi aoe lt i N aii it © scanned with OKEN ScannerDiagnosis of neuromuscul disorders with the use of an electromyograph. © scanned with OKEN ScannerWhat to Expect During an Electromyography Test 1, Needle alectrode 2. Neurologist tells you 3, Needle records muscle inserted into muscle when to contract and activity during rest rest muscle and movementWhat to Expect During a Nerve Conduction Study 1. 3. 5. Stimulating Low-lavel electrical Impulses appear as electrodes placed shock applied through waves on monitor over nerve stimulating electrodes 2 4. Recording electrodes Recording placed over muscle electrodes measures the narve controls speed of impulse stimulating nerve — recording ‘elactrodes elactrodes © Scanned with OKEN ScannerNeurological Rehabilitation What to do first 22? ‘Diagnosis specific’ l Evidence based il treatment plannin ‘Prognosis Oriented’ P 8 © scanned with OKEN ScannerNeurological Rehabilitation Prognosis oriented: - you must always be able to predict what's next and then have the “flexibility to evolve” in your rehabilitation program © scanned with OKEN ScannerNeurological Rehabilitation Solutions: 1. pharmacotherapy - baclofen pump, botox injections 2. physiotherapy - manual therapy 3. heat / cold therapy 4. aquatic therapy © scanned with OKEN ScannerNeurological Rehabilitation Solutions: 5. transcutaneous electrical nerve stimulation (TENS) 6. orthotic (exoskeletons) devices {/prosthesis 8. thickening mixes ra ara ie © scanned with OKEN Scanner® Scanned with OKEN ScannerSample Case : Stroke Rehab Goals: 1. prevent, recognize, manage comorbidities 2. maximize functional independence 3. optimize psychosocial adaptation of patients jand families Hh facilitate resumption of prior life roles and 3 munity reintegration © scanned with OKEN ScannerSample Case : Stroke Rehab Phases : acute care begins as soon as possible after admission after stroke, 70-80% can’t walk independently later only 15-20% can't walk independently most aggressive phase, time for training of new skills, time to prevent deconditioning and contractures, time to prevent medical complications © scanned with OKEN ScannerSample Case : Stroke Rehab Phases : acute care - to prevent medical complications 1. deep breathing & coughing 2. skin inspections for decubitus ulcers 3. swallowing evaluations for dysphagia 4. seating patient in chair 5. perform ADLs without assistance © scanned with OKEN ScannerSample Case : Stroke Rehab Phases : acute care - to prevent medical complications 6. treat sleep disorders 7. start mobilization process ASAP 8. evaluate communications & begin needed training © scanned with OKEN ScannerSample Case : Stroke Rehab Phases : long term acute care (LTAC) - length of stay at least 18 acute care days - utilize team meetings biweekly and all available disciplines Ehases : home rehabilitation 7 NO supervision of Providers, only Caregivers © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 1. constraint induced movement therapy (CIMT) - uses principle of forced use to avoid learned non-use of paretic side as body parts compete for brain representation (neuroplasticity #1) - mainly for training of upper extremity © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 1. constraint induced movement therapy (CIMT) - uses experience-dependent plasticity, there is a need for the brain to use experience to initiate a new synaptic connection between neurons © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 2. mirror therapy (mirror visual feedback) - used to treat phantom pain after amputation, may promote recovery from hemiplegia after stroke - uses movements of the stronger UE & LE to "trick our brain" into thinking that weaker arm is moving, intact hemisphere takes over © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 2. mirror therapy (mirror visual feedback) - MRI studies shows that brain areas involved in sensorimotor learning (mirror neurons) are activated by the visual illusion from mirror therapy © scanned with OKEN ScannerFES taal rMasaaitecl ela lata) ees utulaar sero Lt atte Raat leet tea (ere ce) Caylee muted ta RUM Lt) sd RCL) EM irl mT ume clLanTe] EU ecm ucte at Ty : brain or spinal cord. |Sample Case : Stroke Rehab Interventions that may be used: 4. environmental stimulation 5 verbal and non-verbal stimulation © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 6. reduction of inhibition - remove factors that make the patient less motivated and sleepy - treat post-stroke depression but do not use drugs that induce drowsiness - reduction of inhibition promotes plasticity (neuroplasticity #4) © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: t: virtual rehab - emerged as a new approach in stroke rehabilitation - by simulating real-life activities, patients are able to work on self-care skills in a setting that is usually impossible to create in a hospital environment © scanned with OKEN Scanner© scanned with OKEN Scanner© scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 9. non-invasive brain stimulation (NIBS) - uses application of weak electric or magnetic fields to the brain via the surface of the scalp with the goal of changing or normalizing brain activity - modulates brain excitability and functional plasticity with relative safety © scanned with OKEN ScannerSample Case : Stroke Rehab Interventions that may be used: 9. non-invasive brain stimulation (NIBS) - 2 most common forms are a. transcranial magnetic stimulation (TMS) b. Transcranial direct current stimulation (TDCS) © scanned with OKEN Scanner