Neurorehabilitation Flashcards
What is meant by the term ‘neurorehabilitation’?
‘Rehabilitation is the process of helping a person to reach the fullest physical, psychological, social, vocational and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations and desires and life plans.’
DeLisa and Currie (1998)
What are the two main principles of rehabilitation medicine?
- Rehabilitation
- Disability management
Rehab medicine is a small + relatively new specialty, first established in 1994. Rehabilitation is the primary treatment strategy and is often problem rather than diagnosis focused e.g. the patient may have a visual field defect secondary to stroke but the problem might be that they continually walk into furniture. Rehabilitation focuses on assisting the patient address their problems in a goal directed setting.
What is the ICF framework and its application to neurorehabilitation?
- international classification of functioning, disability + health (ICF)
- World Health Organisation, 2001
- impairment → activity limitation → participation limitation
- (formerly impairment, disability + handicap)
What are examples of other guidelines and frameworks for neurorehabilitation?
Don’t need to know them all but be aware / familiar of them
In regards to models of working in rehabilitation, what is the medical model?
- medic leads + co-ordinates patient care
- idenitifies a need for and refers to specialist therapy + med staff
- therapy staff feedback to lead medic (and not necessarily each other)
What is the multidisciplinary model?
- medic leads links w/ relevant professionals
- discipline specific assessment + decision-making
- discipline specific goals set
- information shared between team members
- outcomes fed back to medic lead
What is the interdisciplinary teamworking model?
- group responsibility for patient care
- collaborative communication between team members
- patient + family viewed as part of the team
- aim for optimal treatment plan via joint goal setting
Interdisciplinary working involves a partnership between a team of health professionals + a client in a participatory, collaborative + coordinated approach to shared-decision making around health issues
What is the difference between inter-disciplinary and multi-disciplinary working?
- inter-disciplinary underpins rehab medicine
- several healthcare providers work simultaneous + co-operatively in delivery of pt care
- combining their input in a common + SHARED decision-making process
- contrasts w/ multi-disciplinary working, where each discipline provides vital information towards decision making about the patient’s care
- but only one person, such as the doctor, makes the final treatment decision
IDT working in practice case study
Jane (62), L MCA infarct 2/12, prior to event fully independent + active, lived alone in a 6th floor flat, 2 daughters + supportive brother, regularly looked after grandchildren, PMHx - NSTEMI w/ no symptoms but ischaemica on ECG + rise in troponin, length of stay at rehab = 18 wks.
Give examples of goals for this patient
- to wash + dress w/ assistance of 1
- to self-medicate
- to have a communication support folder
- to be continent at night
- to sequence wheel chair set up
- to transfer w/ quad stick + assistance of 1
- to mobilise short distances w/ support
- to use 10 key words within a conversation
What are the key roles and skills of the doctor in rehab medicine?
- diagnosis + prognosis → ICE, when to intervene, IDT
- risk assessment → falls, pressure areas, footcare, spasticity
- medical management → symptom mx/control, triggers, psych complications, 2o prevention
- leadership → accountability, sharing goals + facilitating team
- advocacy → capacity, dealing w/ conflict + ineffective services/treatments
- enablement → motivational interviewing + dealing w/ pt loss of autonomy
- counselling → understanding + supporting, family working + pt dynamics, continuity of care
- public health → community management, bringing up disability-related issues
Often roles of therapists can be divided and targeted to the different components of the ICF.
What is the role of Speech and Language Therapy (SALT)?
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IMPAIRMENT:
- computer based therapy → target aphasia + apraxia of speech, helps to improve linguistic function
- apraxia of speech treatment → singing, modelling of mouth movements, repetition/imitation of words
- oro-motor exercises → target facial weakness, joint w/ physio
-
ACTIVITY:
- observe patient carrying out activities
- develop a communication tool (folder) + guidelines
- total communication - sessions w/ family + staff
-
PARTICIPATION:
- joint sessions w/ social work
- assessment of capacity to make decision around discharge destination etc
- communication resource folder to support convos + decision making in the family
- exploring identity - facilitating personal choice making
What is the role of the occupational therapist?
-
IMPAIRMENT:
- apraxia → use of strategy training, errorless learning
- upper limb-hand over hand facilitation; joint w/ physio on tone management; splinting
- neglect-use of scanning; visual/verbal/auditory cues; limb activation
-
ACTIVITY:
- functional practice in familiar context (eg. personal care in bathroom or cooking in kitchen)
- home visit assessment + risk assessments to explore environmental/equipment/care needs on discharge
- joint work w/ physio → mobility + transfers
-
PARTICIPATION:
- joint sessions w/ social work + SALT
- assessment of capacity to make decision around discharge destination - info from home visit
- joint sessions w/ family eg. childcare role w/ grandchildren
What is the role of physiotherapy?
-
IMPAIRMENT:
- spasticity management → positioning, splinting, orthotics
- sensory re-education + orientation
- specific muscle strengthening through functional tasks
- exploring use of adjuncts (orthotics, NMES)
- task breakdown, repetition, transference of skills
-
ACTIVITY:
- transfers progressions → recommendations to staff/fam/carers
- mobility → hands on facilitation, orthotics + walking aids
- risk assessment re: safety - consider environment
- sequencing tasks
-
PARTICIPATION:
- joint working w/ family members, OT, SLT + SW
- risk assessments + recommendations
- exploring options available given the complex care + needs
What is the role of the social worker?
- discharge planning
- assessment of community care needs (health needs + risk)
- welfare + benefits advice for family
- liaison w/ other agents - funding providers
- acting as an advocate
- identifying discharge location options + facilitating pt and family involvement in choosing discharge location
What is the role of the neurorehabilitation nurse?
- continence management overnight
- support during mealtimes
- increasing consistency + independence in transfers and ADLs
- teaching self-management → understanding + administrating meds
- liaison w/ medical team around reviews of meds
- liaison w/ GP prior to discharge
Hands-on techniques include two main types: restorative and compensatory. Restorative assumes that the impairment is reversible whereas compensatory assumes impairment is irreversible.
What is the role of the neuropsychologist?
- cognitive assessment + observation of behaviours/abilities within tasks
- interventions → compensation focused rather than restitution - eg through manipulating the environment
- review of mood → based on observations + liaison w/ team
- liaison w/ neuropsychiatry → trial of anti-depressant meds
Outcome measures must be published, standardised, valid, reliable, sensitive to change, clinically useful and feasible.
What are examples of outcome measurement tools used in neurorehabilitation?
What is Goal Attainment Scaling (GAS)?
- developed by Kiresuk and Sherman (1968)
- system that measures the extent to which goals are achieved
- goal scaling frameworks have shown to be a reliable outcome measurement system
- GAS now used for all inpatients + many outpatients at Wolfson
- goals scaled in terms of level of support**, **frequency** or **duration of a particular observable behaviour + are scored regularly at goal planning meetings
