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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:
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.
- involvement in a life situation.
- represents the social perspective of functioning.
- adverse effect of health condition – participation restriction.
- 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
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: ~ 2000/106 per year
First event / Recurrent events = 5/1
~ 30 % die within the first 3 weeks
Stroke – 3rd 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: ~ 6000/106 (60% - 3600 - disabled)
Recurrence rate following 1st 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 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
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
20. Rehabilitation oriented assessment of structural impairment in damage to the right peri-Sylvian regions
21. Rehabilitation oriented assessment of structural impairment in damage to occipito-temporal & occipito-parietal regions
22. Rehabilitation oriented assessment of structural impairment in damage to structures of the limbic system