Rehabilitation Slides

1. Rehabilitation
Impairment, Disability & Handicap
Assistant Professor
H/Dr.Nazar Deen PT
BSPT.MSAPT.DdPT.DHMS
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2. Contents
• Background
• Rehabilitation
• Types of Rehabilitation
• Rehabilitation Types Based on Treatment
• Principles of Rehabilitation
• Definitions & Concept
• Pathophysiology of the Disease Causing Physical Disability
• Epidemiology
• Conditions, Prevalence and Limitation
. Rehabilitation Journey of An Amputation-
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3. Background
❖ It is restoration of ability to function.
❖ It is to support the patient with an injury or disability illness to
achieve maximum function and independence
❖ Rehabilitation is a goal-oriented treatment process intended to
maximize independence in individuals with compromised
function that results from primary pathological processes and
resultant impairments.
❖ Rehabilitation generally addresses the sequelae of pathology
rather than the pathology itself.
❖ Physical rehabilitation focuses particularly on sequelae that
impact physical functioning and activity and uses interventions
that are noninvasive and physical in nature to promote progress
toward functional goals.
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4. Rehabilitation
❖ W.H.O define rehabilitation as “the combines and
coordinated use of medical, social, educational and
vocational measures for training the individual to the highest
level of functional ability”
❖ Rehabilitation is a treatment designed to facilitate the process
of recovery from injury, illness, or disease to as normal a
condition as possible.
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5. Types of Rehabilitation
❖ Medical Rehabilitation: Help a person better in all his daily
physical and mental activities. Related to increasing the
potential capabilities and correction of deformities, restoration
of functions.
❖ Social Rehabilitation: Implies social life; restoration of
family, social interactions or relationship
❖ Psychological Rehabilitation: Includes psychological
restoration of personal dignity and confidence of the disabled.
❖ Vocational Rehabilitation: Help those patient who find it
difficulty to get employment
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6. Based on the treatment types
❖ Cardiopulmonary Rehabilitation.
❖ Physical Rehabilitation
❖ Speech Rehabilitation.
❖ Occupational Rehabilitation.
❖ Psychological Rehabilitation.
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7. Types Based on Treatment
CARDIC REHABILITATION:
Cardiac Rehabilitation Program is committed to providing comprehensive risk
factor management to our patients with cardiovascular disease.
PHYSICAL REHABILITATION:
Physical rehabilitation helps the patient restore the use of muscles, bones and
the nervous system through exercise and other technique.
OCCPATIONAL REHABILITATION:
Occupational rehabilitation helps the patient regain the ability to do normal
everyday tasks. This may be achieved by resting old skills, or teaching the
patient new skills to adjust to disabilities through adaptive equipment, orthotics
and modification of the patient’s home. The therapist will visit the patient’s
home and analyze what the patient can and cannot do
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8. Types Based on Treatment conti…
SPEECH REHABILITATION:
Speech therapy helps the patient correct speech disorders or restores speech. It
involves regular meetings with the therapist in an individual or group setting
and home exercises.
e.g. To strengthen muscles, the patient might be asked to say words, smile,
close his mouth. Or stick out his tongue. Picture cards may be used to help the
patient remember everyday objects and increase his vocabulary.
PSYCHIATRIC REHABILITATION:
Psychiatric rehabilitation involves helping people with mental illness, gain or
improves skills while obtaining the necessary resources and support in reach
their goals.
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9. Principles of Rehabilitation
❖ Rehabilitation should begin during the initial contact with
the patient
❖ The emphasis of rehabilitation is to restore the patient in
independence or pre-illness or pre-injuries level of function
in as short a time as possible
❖ He must be an active participant.
❖ Motivates the patient and help him to attain social
independence
❖ Focus is on needs of group of people with specific condition
❖ Every patient has right to the rehabilitation services
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10. Principles of Rehabilitation
❖ The activities of daily living are facilitated.
❖ The individual with a disability is encouraged to wear his
clothing enhances self-esteem and dignity.
❖ Motivates the patient and helps him to attain social
independence.
❖ Focus is on the needs of groups of people with specific
condition
❖ Every patient has a right to the rehabilitation services
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11. Health
WHO’s definition:
❖ Health is a state of complete Physical, mental, and social
well-being and not merely the absence of disease or infirmity.
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12. Impairment
❖ Impairment is any loss or abnormality of psychological,
physiological or anatomical structure or function as the result of
some underlying pathology.
❖ Impairment includes clinical features or manifestations of the
disease or condition. Examples: weakness, limited ROM,
confusion etc. In this definition function is the function of a
body part, not the whole-person function.
❖ An impairment is a measure at the organ or organ system level
and is equivalent to a sign or an objective measure. For example,
decreased cervical flexibility, diminished deep tendon reflexes,
reduced force production or endurance, and absent sensation
are all impairments.
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13. Disability
❖ Disability is any restriction or lack (resulting from an impairment)
of ability to perform an activity in the manner or within the
range considered normal for a human being.
❖ “The inability to perform or a limitation in the performance of
actions, tasks, and activities usually expected in specific social
roles that are customary for the individual or expected for the
person’s status or role in a specific sociocultural context and
physical environment.”
❖ Disability is the consequence of an impairment that may be
physical, cognitive, mental, sensory, emotional, developmental,
or some combination of these. A disability may be present from
birth, or occur during a person's lifetime.
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14. Handicap
❖A disadvantage for a given individual resulting from an
impairment or a disability that limits or prevents the fulfillment of
a role that is normal (depending on the age, gender, social and
cultural factors) for that individual.
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❖ Cerebral palsy is handicapping to
the extent that it prevents him
from fulfilling a normal role at
home, in preschool, and in the
community.

15. Functional Limitation
❖ “The restriction of the ability to perform,at the level of the
whole person, a physical action, task, or activity in an efficient,
typically expected, or competent manner”
❖ Examples of functional limitations are an inability to lift more
than 20 lb or a limitation in sitting tolerance.
❖ Although functional limitations and impairments are related, it
is not uncommon that an impairment does not, at least initially,
result in any functional limitation. It is 3 types
❖ Mental: decisions, ,office rules
❖ Physical : Hearing ,vision etc
❖ Environmental : Avoid extreme heat or cold, Limit exposure to
excessive dust or noise
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16. Pathophysiology of the Disease Causing
Physical Disability
CEREBRAL PALSY
❖Depending on the etiology, it varies.
❖The major signs that collectively lead to a CP are abnormal postural control, persistence of
primitive reflexes, delayed motor activity, and also lesions in brain that result from
prenatal, perinatal, and postnatal events. The premature neonatal brain is susceptible to
two main pathologies that increase the risk of CP. These are INTRAVENTRICULAR
HEMORRHAGE (IVH) and PERIVENTRICULAR LEUKOMALACIA (PVL).
❖PVL has a separate pathological process including IVH as a risk factor. PVL pathogenesis
arises from two factors:
✔Ischemia/hypoxia:
✔Infection and inflammation
❖CP is more common in males (30%) than in females and is more likely caused by acquired
injuries like infections, toxins, and environmental effects than genetic (Johnston and
Hagberg
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17. Pathophysiology of the Disease Causing
Physical Disability
PARKINSON’S DISEASE
❖ Depending on the etiology, it varies.
❖ It also involves several molecular mechanisms that lead to neuronal cell
death including protein processing pathways, oxidative stress, mitochondrial dysfunction,
microglial activation, and inflammation. These mechanisms are the result
of reduced GSH levels (Glutathione (GSH) body master antioxidant), α-Syn (α-Synuclein
aggregation ) aggregation, proteasome impairment, and autophagy dysfunction,
❖ In PD, selective degeneration of monoamine-containing cell occurs in the brainstem and
basal ganglia, particularly DAergic neurons of the SN (diffusely release dopamine (DA))
❖The study of MPTP, a potent neurotoxin, provides an important clue about the PD
pathogenesis.
❖ Insecticide AND herbicide which inhibits mitochondrial complex
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18. Pathophysiology of the Disease Causing
Physical Disability
MULTIPLE SCLEROSIS
❖ The mechanism including Demyelination, inflammation, and defect
in synaptic transmission and circulating blocking factors play an important role in MS
Pathophysiology
❖ Axonal conductance blocked due to the axonal injury is the key feature of the
disability in MS, which occur due to the Demyelination
❖ Local inflammation, rise in the temperature of the body, and large number of impulse
conductance also block the axonal conductance.
❖ In chronic active lesions, Demyelination is associated with the immunoglobulin deposition
and association of myelin to macrophages converted into droplets which undergo
phagocytosis
❖ There are several factors associated with inflammation that disrupt the synaptic
transmission in normal tissues. These factors are interleukin-1 (IL-1), interleukin-2 (IL-2),
interferons (IFN), and nitric oxide.
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19. Pathophysiology of the Disease Causing
Physical Disability
HUNTINGTON’S DISEASE
❖ In HD, the corpus striatum (caudate nucleus, putamen, and globus pallidus) is
abnormal.
❖ The most striking features occur in neostriatum (caudate nucleus and
putamen), which undergoes diffuse atrophy accompanied by selective loss of
neurons with astrogliosis
❖ Other regions, including the globus pallidus, subthalamic regions, substantia nigra,
medulla oblongata, spinal cord, amygdala, and cerebellum, show varying degrees of
atrophy depending on the pathologic grade (Vonsattel et al. 1985).
❖Marked neuronal loss in the deep layers of the cerebral cortex
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20. Epidemiology
❖ Epidemiology is the study (scientific, systematic, and
data-driven) of the distribution (frequency, pattern) and
determinants (causes, risk factors) of health-related states and
events (not just diseases) in specified populations
(neighborhood, school, city, state, country, global).
❖ In Rehabilitation the macrolevel view of current prevalence and
distribution of disability in a population as organized within four
domains drawns from ICF.
✔ Body function and structure
✔ Activities and participation
✔ Personal factors
✔ Environment
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21. Explanation
❖ The conceptualization of disability is complex and has evolved over time.
Initially, disability was viewed as a purely medical phenomenon determined by
an individual having an impairment in body functioning or structure (e.g. the
presence of mobility or visual impairments) Later, the Social Model framed
disability as resulting from external restrictions placed by society on people with
impairments , for instance, through inaccessible buildings reducing the options
for people with physical impairments to work.
❖ The prevailing framework is the International Classification of Functioning
,Disability and Health (ICF), developed by The World Health Organization (WHO)
in 2001. The ICF is considered a bio-psycho- social model of disability, which
refers to dysfunctioning in one of three interlinked levels– impairments in body
function or structure, activity limitations, or participation restrictions– and is the
result of an interaction between a health condition and contextual factors.
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22. Example
For example, the disease poliomyelitis (health condition)may affect
leg muscle weakness (body function and structure) limiting the
individual’s ability to walk (activities) and thus attend school
(participation restrictions). This “dysfunctioning” can be mediated
by environmental factors (e.g. assistive devices) and personal
factors (e.g. family support).
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23. Conditions, Prevalence and Limitation
1. Back Pain
❖ Prevalence:
✔ 59.1 millions adults (age > 18 years) have had back pain within
last 3 months, among those 28.9% have LBP and 15.5 % have
Neck pain in past last 3 months
❖ Incidence:
✔ 139/ 100,000 persons
❖ Activity / Participation and other Limitation
✔ 24.7 % population have functional limitation
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24. Conditions, Prevalence and Limitation
2. Osteoarthritis
❖ Prevalence:
✔ 49.9 millions adults (age > 17 years) in 2009
✔ 26.9 million adults (age > 25 years) in 2005
❖ Incidence:
✔ Hip: 81/ 100,000 persons year
✔ Knee: 240/100,000 person year
✔ Hand: 100/100,000 person year
❖ Activity / Participation and other Limitation
✔ 42 % population have arthritis attributable to activity limitation
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25. Conditions, Prevalence and Limitation
3.Rheumatoid Arthritis
❖ Prevalence:
✔ 0.5%- 1.0% of the general population
✔ 1.2 million adults (age > 18 years) in 2005
✔ 2% adults in North America
❖ Incidence:
✔ 41/100,000 person year
❖ Activity / Participation and other Limitation
✔ 30 % more likely need help with personal care. People with RA
are twice as likely to health related activity limitation
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26. Conditions, Prevalence and Limitation
4. Stroke:
❖ Prevalence:
✔ 6.8 million adults age >20 years
✔ 28% of adult population
✔ 2% adults in North America
❖ Incidence:
✔ 795,000/ year
✔ 610,000/year for first stroke
❖ Activity / Participation and other Limitation
✔ Among stroke survivors age > 65year , 26% were dependent on
activities of daily living,50% had hemiparesis,30% were unable
to walk without any assistance,19% had aphasia,26% were in
Nursing home 6 months post stroke
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27. Conditions, Prevalence and Limitation
5. Traumatic Brain Injury:
❖ Prevalence:
✔ 3.32 % with long term disability
✔ 1.1% of total population
❖ Incidence:
✔ 5382 cases /100,000 persons year
✔ 1565000 cases in 2003
❖ Activity / Participation and other Limitation
✔ 43% of patient discharged after acute TBI hospitalization
developed long term disability
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28. Conditions, Prevalence and Limitation
6. Amputation:
❖ Prevalence:
✔ 1.6 million in 2005
❖ Incidence:
✔ 30,000 – 50,000 lower limb amputation/year
✔ 330/100,000 in people with diabetes
❖ Activity / Participation and other Limitation
✔ 31% patient unable to live independently at 24 months
✔ 49% lost ambulation
✔ 43 % - 74 % 5 year mortality after lower limb amputation
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29. Conditions, Prevalence and Limitation
7. Multiple Sclerosis:
❖ Prevalence:
✔ 53 – 95 /100,000 individual
❖ Incidence:
✔ 10,400 cases / year
✔ 36/100,000/year cases (women)
✔ 20/100,000/year cases (men)
❖ Activity / Participation and other Limitation
✔ Average time from disease onset to difficulty walking is 8 year.
✔ 15 year for cane use
✔ 30 year for wheel chair use
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30. Conditions, Prevalence and Limitation
8.Spinal Cord Injury:
❖ Prevalence:
✔ 2,36000 – 3,27000 individual in 2012
❖ Incidence:
✔ 43-77 / million
✔ 12,000 – 20,000 / year
❖ Activity / Participation and other Limitation
✔ Functional recovery after SCI depends on severity and spinal
level
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31. Phases of Amputation Care
Amputation rehabilitation journey
The continuum of Amputation Care is divided into 5 Phases
1. Pre-operative Phase
2. Post-operative Phase
3. Pre-Prosthetic Phase
4. Prosthetic Training Phase
5.Long Term Follow-up Phase
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32. Journey Continue…
1.Pre operative phase
1. Decision
2. Amputation level
3. Access functional status
4. Pre operative education
5. Emotional Support
6. Physical therapy (CVS,
Flexibility,strength,balance,
coordination,mobility)
7. Nutritional support
8. Pain management
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33. Journey Continue…
2. Post Operative phase
1. Time in hospital after
amputation surgery, lasting
5-14 days.
2. Hemodynamic stability,
wound healing,
3. prevention of complications
4. Care of residual limb, patient
education,
5. Physical therapy, occupational
therapy,
6. Behavioral health
7. PT’s-Baseline fxn
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34. Journey Continue…
2. Post Operative phase
8. Dressing
9. Residual Limb Management –
encourage patient participation to
reduce edema, shaping limb with
compression, pain
control,contracture prevention
10. Continued patient and family
education
11. Continued coping with loss of a
limb
12. Mirror therapy
13. Discharge planning from Acute Care
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35. Journey Continue…
3. Pre - Prosthetic Phase
1. Begins with d/c from acute care up to 6 - 12
weeks after surgery
2. Shift to rehabilitation focus - maximizing
physical function, social function concerning
daily activities, and re-integration to home and
community
3. Goals for independence at w/c level without
prosthesis
4. Independence with residual limb management,
transfers, mobility, ADL, w/c and DME, Home
Exercise Program, ROM, Strength, CV training
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36. Journey Continue…
4. Prosthetic Training Phase
1. Predicting prosthetic use
2. Good cognitive abilities, younger age, distal
amputation level, and preoperative good
functional status predict physical mobility with a
prosthesis.
3. Simple clinical assessments completed prior to
prosthetic provision can be used to predict
mobility outcome and Predicting Walking Ability
by following criteria (Sansam, et al 2012)
I. ROM to detect contractures of hip/knee
II. Single leg standing test
III. Age
IV. Gender
V. Level of amputation
VI. Cognition
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37. Journey Continue…
Prosthetic Prescription special
consideration
1. Bilateral
2. Level
3. Comorbidities
4. Cardiac Stress test clearance
5. Is a Prosthesis Appropriate to
Improve Functional Status and
Meet Realistic Patient Goals?
6. Transfers vs Ambulation
Training
1. Up to 6 months after healing
2. Begins with temporary
prosthesis
3. Rapid changes in residual limb
volume
4. Return to vocational and
5. recreational activities
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38. Journey Continue…
5. Long Term Follow up
Phase
1. Life-long prosthetic,
functional, medical
assessment and emotional
support
2. The consultant and/or prosthetist
may ask for physiotherapy input. For
example, if the patient is having a
change of prescription, their goals
have changed, their mobility has
decreased/increased. The
physiotherapist may be required to
re-commence a gait rehabilitation
programme with the patient or
advice only may be required.
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39. Rehabilitation Journey of An
Amputation-
INTRODUCTION
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❖ Patient is a 71 year old male s/p L BKA who presented to OP PT five months after his
amputation.
❖ PMH includes osteoarthritis, L BKA: 10/03/10, L TKR: 15/01/09.
❖ Please note that this patient did not have any pain complaints throughout his OP PT
sessions, although he did have one episode of L knee catching sensation and often
commented about fatigue and/or a heaviness in his L LE during ambulation.

40. Rehabilitation Journey of An
Amputation-
GOALS
Patient had ROM goals established at the
time of his initial evaluation (8/9/10):
❖Increase L knee extension flexibility to -63
degrees supine to optimize LE
alignment for improved fit of prosthesis.
❖ Increase L hip extension flexibility to - 20
degrees side lying to optimize LE
alignment for improved fit of prosthesis.
❖ Pt able to perform LE stretching there
frequently throughout the day with assist
of family members as needed
❖Progressed to the functional goals below
when prosthesis was ready (10/26/10):
❖ Patient will perform sit to stand from 18”
chair without arm support with modified
independence with LBQC with equal foot
position (L/R)
❖ Patient will ambulate for 6 minutes for
total of 500 feet with LBQC with
supervision on level surfaces with L LE
prosthesis.
❖ Patient will perform Four Square Step Test
with LBQC in 1 minute.
❖ Patient will perform timed up and go with
LBQC in 20 seconds
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41. FUNCTIONAL OUTCOME
MEASURES
❖Timed Up and Go Test
❖6 Minute Walk Test
❖Amputee mobility predictor
❖Four Square Step Test
❖Patient-Specific Functional Scale
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Rehabilitation Journey of An Amputation-

42. HISTORY
Patient was initially seen in OP PT for approximately two times per week for eight
weeks with emphasis on increasing PROM/AROM of L hip extension and L knee
extension to decrease contractures, improve fit of prosthesis, and increase
performance and independence with functional mobility at an ambulatory level.
The patient’s OP PT was transitioned to more functional mobility once patient’s L
LE below knee prosthesis was ready at seven months post-op. Patient initiated
ambulation with AlterG the following weeks and was intended to continue AlterG
two times per week for four weeks with the goals of increased gait speed,
improved endurance/tolerance for ambulation, and better gait mechanics on
level surfaces. Due to weather and a scheduling error, patient completed eight
sessions on AlterG within six weeks and was extended for four additional
sessions on AlterG within three weeks for a total of 12 sessions on AlterG. See
table below for details re: AlterG parameters utilized during OP PT sessions.
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Rehabilitation Journey of An Amputation-

43. AlterG Anti-Gravity Treadmill
The Anti-Gravity Treadmill, or AlterG, helps
patients regain mobility, develop strength
and fitness, and increase their range of
motion and natural movement — all while
minimizing stress on injuries. The Alter-G
uses differential air pressure technology to
provide an environment of weightlessness
for mobility and ambulation training.
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44. Rehabilitation Journey of An
Amputation-
HISTORY CONTINUE…
The patient was seen for a total of 11 physical therapy sessions for the above
described treatment, 1-on-1 with the physical therapist. In addition, he attended
7 sessions for exercise and Alter G walking. He achieved post-operative knee
ROM of 0/125. He had a good gait pattern and good strength of his R LE after
physical therapy. He was able to climb stairs with proper gait mechanics. He was
able to work without increased in pain or swelling. Pain level at initial evaluation
was 4/10 and decreased to 0/10 upon discharge. He felt ready to begin his return
to the golf course at 8 weeks post-op. The rehabilitation program
incorporating the Alter G enabled this patient to return to golf and pain-free
function faster than similar patients on a traditional rehabilitation program.
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45. “Hard things are put in our way, not to stop us, but to call
out our courage and strength.”
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