1. Rehabilitation Dr J Hobart

2. 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.

3. Rehabilitation is… For people with achievable goals

4. Rehabilitation is about changing one or more of… The person The way they do things The environment

5. Rehabilitation is not…. Respite Suitable for all disabled people

6. Neuro-rehabilitation Assessment Measurement Planning Treatment Evaluation Reassessment

7. Assessment Multidisciplinary team Identification of the problem Measurement of the problem

8. Assessment frameworks ICIDH World Health Organisation International Classification of Impairment, Disability and Handicap PILS Prevention, Independence, Lifestyle, Social resources

9. WHO ICIDH (1980) Pathology Impairment Disability Handicap

10. WHO ICF (2001) Pathology Impairment Activity limitations Participation restrictions

11. 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

12. Impairment the direct neurophysiological consequences of the underlying pathology sometimes pathology is silent signs used to deduce underlying pathology

13. 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

14. 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

15. History Taking Pathology Diagnosis Impairment Examination Disability ReviewFunction based Handicap ReviewDaily routine

16. PILS Prevention What future adverse events can be prevented Accidents, Broken Skin, Contractures, Diet..... Independenc e How is it reduced? How could it be increased? Lifestyle Goals, Roles and Soul Social resources Who can help?

17. Rehabilitation Assessment Planning Treatment Care Evaluation

18. Planning Multidisciplinary problem analysis Identify areas of potential functional improvement Setting goals

19. Goal Setting Terminology Short term goalsAims for patient Long term goalsObjectives for patient Action plansTeam tasks A goal should be specific, time limited, easily measured and patient centred

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

21. Evaluation Checking on the effectiveness of any intervention Define criteria Measure success/failure against criteria

22. Evaluation Process Goal achievement Integrated care pathways Outcome Impairment Disability Handicap Quality of life

23. 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

24. Helpful (?) advice for primary care Try to identify goal/s Think: person, strategy, environment Don’t underestimate cognitive problems Try to understand why rehab may not be suitable

25. Spasticity

26. 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

27. 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

28. Spasticity management Drugs Therapists Continence advisors Social services

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

30. Continence advice Impact of UMN syndrome on sphincters Impact of sphincter probs on spasticity Bladder management Strategies, drugs, catheters Bowel regimens Diet, drugs

31. Social services Impact of environment on spasticity Optimise aids Optimise care package

32. Anti-spasticity drugs Baclofen Tizanidine Dantrolene Diazepam Cannabis Botox Intrathecal baclofen Intrathecal phenol

33. 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