1. Principles and Practice of Medical Rehabilitation Nachum Soroker, M.D. Loewenstein Rehabilitation Hospital Raanana, and Sackler Faculty of Medicine, Tel-Aviv University, Israel

2. Medical Rehabilitation - Basic Definitions WHO rehab definition: “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. UEMS PRM definition: “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 co-morbidity across all ages”

3. Functional Consequences of Disease and Trauma Former WHO (ICIDH) definitions: –Impairment. –Disability. –Handicap. Adverse psychological reactions, reduced QoL. Rehabilitation role in tertiary prevention* (i.e., prevention of activity limitation and restriction of participation) and prevention of disease recurrence. * primary prevention – of disease/injury. secondary prevention – of direct effects and complications.

4. WHO International Classification of Functioning, Disability and Health (ICF, 2001) Aetiologically neutral. Functioning defined both at individual and population levels. Useful framework for managing the rehab programs of all disabling conditions. Points to different aspects of underlying pathophysiology. Sets clear goals and points to necessary assessment and intervention measures. Considers the ability to participate in society which depends not only on personal functioning but also on contextual factors affecting the individual’s life and environment.

5. Basic ICF Definitions Health condition: - disease, disorder, injury, trauma. - ageing, genetic predisposition, stress - coding: ICD-10 Body functions and structures: - physiological functions of body systems; psychological functions - body structures – e.g., internal organs, limbs, and their components - deviation from normality – impairment

6. Basic ICF Definitions (cont.) Activity: - execution of task / action by an individual. - represents the individual perspective of functioning. - adverse effect of health condition – activity limitation. Participation: - involvement in a life situation. - represents the social perspective of functioning. - adverse effect of health condition – participation restriction. Contextual factors: - Personal: e.g., gender, age, education, race, fitness, lifestyle, habits, social background, cognitive and emotional style - Environmental: physical, social, attitudinal, legal environment in which people live, work, study, etc. Environmental factors can act as facilitator or barrier factors.

7. Basic ICF Definitions (cont.) Functioning: - Body functions + activity + participation. Disability in ICF model: - Impairment + activity limitation + participation restriction. - The negative aspect of functioning. Rehabilitation principal role: - To improve all aspects of functioning by way of inter-disciplinary patient-oriented management, in consideration of health condition as well as personal and environmental factors, using longitudinally standardized assessment measures of functioning at different levels and attempting to optimize the effects of contextual factors.

8. Overview of ICF Model Health Condition (Disease / Trauma) ActivitiesParticipation Body Functions & Structures Environmental Factors Personal Factors

9. Relevance of Medical Rehabilitation Overall prevalence of disability – 10%. Constant increase with population ageing. Increased burden and cost of medical and social care. Rehabilitation has proven benefits in terms of functional improvement and prevention of additional complications.

10. The Case of Stroke Rehabilitation Epidemiological considerations in stroke rehabilitation. Principles of medical care and rehabilitation in stroke. Rehabilitation oriented assessment of structural impairment in different cortical regions following

11. Stroke statistics Incidence: ~ 2000/10 6 per year First event / Recurrent events = 5/1 –~ 30 % die within the first 3 weeks Stroke – 3 rd leading cause of death behind heart diseases and cancer 7.6 % of ischemic strokes and 37 % of hemorrhagic strokes result in death within 30 days Stroke death rate fell ~ 15% from 1988 to 1998 –~ 30 % recover completely –~ 40 % left with disability : ~ 90 % initially unable to walk ~ 75 % initially have upper limb plegia / paresis ~ 50 % have some language / speech problems

12. Stroke statistics (cont.) Prevalence: ~ 6000/10 6 (60% - 3600 - disabled) Recurrence rate following 1 st stroke or TIA: 14 % within 1y % survival in 1 and 4 years following ischemic stroke, in different age groups: –<65y : 81, 70 | 65-74y : 81, 59 | 75-84y : 67, 42 Stroke survivors - 24 % of all severely disabled people living in the community. ~ 28 % of strokes occur in people under the age of 65. ~ 50-70 % of stroke survivors regain functional independence, but 15-30 % are permanently disabled ; ~ 20 % require institutional care at 3 months after onset.

13. Admission of the stroke patient to rehabilitation Pre admission (things to do in the general hospital): –Establish diagnosis – Neuroimaging –Reduce secondary brain damage (Neuroprotection?, TPA, Normoglycemia, Hypothermia?) –Identify and treat risk factors HTN, DM, IHD post MI, AF, Dyslipidemia, Hypercoagulability & Thrombophilia, Smoking, Morbid obesity, Alcoholism, Vasculitis, Carcinomatosis Specific importance: Carotid stenosis, LV mural thrombus In hemorrhagic conditions (SAH, ICH): Consider angiography / MRA / CTA –Prevent complications (Aspiration pneumonia, UTI, Pressure sores, DVT - PE, Upper GIT bleeding, Convulsions) –Select preventive strategy to reduce risk of recurrence –Decide: Rehabilitation needed or not; if yes - where?

14. Verify diagnosis –Special care: ICH - r/o underlying malignancy or focal vascular pathology Complete identification and treatment of risk factors Adjust secondary prevention –antithrombotics/anticoagulants, statines, ace-inhibitors, folate & Vit B Treat coexisting disease conditions –Special care: IHD, peptic disease Medical care in stroke rehabilitation

15. Medical care and physician role in stroke rehabilitation (cont.) Prevent and treat complications –Aspiration pneumonia, UTI, Pressure sores, DVT & PE, Upper GIT bleeding –Post-stroke depression, anxiety, hypoarousal, motivational problems –Post-stroke epilepsy –Post hemorrhage hydrocephalus Organize a coherent list of tasks and objectives to guide follow-up of the patient throughout the rehabilitation period –Disease processes, control of risk factors, secondary prevention –Impairment - Disability - Handicap Lead interdisciplinary team work

17. Rehabilitation oriented assessment of structural impairment in sensory-motor cortex following stroke MCA and ACA supply of the cortical sensory-motor cortex

18. Rehabilitation oriented assessment of structural impairment in damage to the frontal lobes General: Impaired working memory; increased environmental dependency & reflexive behavior (stimulus boundness); impaired goal setting, behavioral planning and control. Dorsolateral prefrontal: Executive behavior deficits: Impaired data retrieval, set shifting, response inhibition, abstraction, creativity. Orbitofrontal: Social behavior deficits: Disinhibited, tactless, impulsive behavior; imitation & utilization behavior. Medial frontal: Motivational behavior deficits: Apathy, reduced interest & initiative.

19. Rehabilitation oriented assessment of structural impairment in damage to the left peri-Sylvian regions General: Aphasic syndromes; acquired dyslexia; ideomotor & ideational apraxia. Posterior-inferior frontal areas: Speech production; phonology; syntax. Posterior-superior temporal areas: Speech comprehension; semantics. Inferior parietal regions: Reading; calculation; praxis; repetition; auditory-verbal short-term memory. Superior temporal regions: Auditory perception & gnosis.

20. Rehabilitation oriented assessment of structural impairment in damage to the right peri-Sylvian regions General: Neglect phenomena; construction and dressing apraxia; impaired pragmatic control of language. Posterior-inferior frontal areas: Expressive prosody; contribution to pragmatics. Posterior-superior temporal areas: Receptive prosody; contribution to pragmatics. Inferior parietal regions: Spatial cognition; spatial motor behavior; spatial attention. Superior temporal regions: Auditory perception; music ?

21. Rehabilitation oriented assessment of structural impairment in damage to occipito-temporal & occipito-parietal regions General: Impaired visual perception, and visually- guided behavior. Occipito-temporal regions: Impaired functioning of the “system of What” (ventral stream); visual agnosia; prosopagnosia. Occipito-parietal regions: Impaired functioning of the “system of Where” (dorsal stream); optic ataxia; neglect phenomena

22. Rehabilitation oriented assessment of structural impairment in damage to structures of the limbic system General: Emotion; memory; motivation. Amygdala: Impaired emotional behavior. Hippocampus: Amnesia. Cingulum: Impaired motivational behavior; impaired attentional selection.