Lezioni di Medicina Fisica e Riabilitativa

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1 Seconda Università degli Studi di Napoli Facoltà di Medicina e Chirurgia Corso di Laurea in Medicina e Chirurgia CI di Malattie dell Apparato Locomotore e Medicina Fisica e Riabilitativa Lezioni di Medicina Fisica e Riabilitativa Francesca Gimigliano

2 Programma International Classification of Functioning Disability and Health Progetto e Programma Riabilitativo Le terapie fisiche L esercizio terapeutico Il trattamento riabilitativo del paziente geriatrico Il trattamento riabilitativo del bambino Il trattamento riabilitativo del paziente affetto da patologia ortopedica Il trattamento riabilitativo del paziente affetto da patologia neurologica

3 ICF International Classification of Functioning Disability and Health

4 interferenza con l organismo etiologia esaurimento del processo patologico guarigione con restitutio comparsa di alterazioni in tessuti, organi e sistemi patogenesi quadro anatomopatologico quadro clinico presenza di segni e sintomi di malattia cronicizzazione guarigione con esiti danni (impairments, menomazioni)

5 Riabilitazione - definizioni Il ritorno della funzione dopo una malattia o un trauma, spesso mediante l assistenza di personale medico specializzato Processo di soluzione dei problemi e di educazione nel corso del quale si porta una persona a raggiungere il miglior livello di vita possibile sul piano fisico, funzionale, sociale ed emozionale, con la minor restrizione possibile delle sue scelte operative Linee guida della riabilitazione

6 Riabilitazione - definizioni 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 WHO

7 Medicina Fisica e Riabilitativa 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, treatments and rehabilitation management of people with disabling medical conditions and co-morbidity across all ages Union Européenne des Médecins Spécialistes (UEMS) Scaricato Section da SunHope of PRM

8 Il FISIATRA have a holistic approach to people with acute and chronic conditions, examples of which are musculoskeletal and neurological disorders, amputations, pelvic organ dysfunction, cardio-respiratory insufficiency and the disability due to chronic pain and cancer work in various facilities from acute care units to community settings use specific diagnostic assessment tools and carry out treatments including pharmacological, physical, technical, educational and vocational interventions because of their comprehensive training, they are best placed to be responsible for the activities of multi-professional teams in order to achieve optimal outcomes

9 Tipologie degli interventi riabilitativi interventi riabilitativi prevalentemente di tipo sanitario interventi riabilitativi prevalentemente di tipo sociale

10 Attività Sanitarie di Riabilitazione interventi valutativi, diagnostici terapeutici e le altre procedure finalizzate a portare il soggetto, affetto da menomazioni, a contenere o minimizzare la sua disabilità, ed il soggetto disabile a muoversi, camminare, parlare, vestirsi, mangiare, comunicare e relazionarsi efficacemente nel proprio ambiente familiare lavorativo, scolastico e sociale

11 Interventi riabilitativi di tipo sociale legge quadro per l'assistenza, l'integrazione sociale e i diritti della persone handicappate (L. 104/92) e successive modifiche ed integrazioni, nonché la vigente normativa regionale, definiscono in modo chiaro ed articolato gli interventi a sostegno dell'inserimento e dell'integrazione sociale (attività di riabilitazione sociale) le azioni e gli interventi finalizzati a garantire al disabile la massima partecipazione possibile alla vita sociale con la minor restrizione possibile delle sue scelte operative, indipendentemente dalla gravità delle menomazioni e delle disabilità irreversibili al fine di contenere la condizione di disabilità

12 OMS Salute: stato di completo benessere fisico, mentale e sociale e non soltanto assenza di malattia o infermità Malattia: condizione fisica o mentale percepita come deviazione dallo stato di salute normale; può essere descritta in termini di sintomi e segni e dar luogo a guarigione con restitutio ad integrum, guarigione con esiti, cronicizzazione

13 ICD: una risorsa pubblica internazionale 150 anni di storia Standard internazionali Data Base Mortalità: 85 Paesi Tabelle di conversione ICD 8, 9, 10 Connessioni Internet Istruzioni On-line

14 International Classification of Impairments, Disabilities and Handicaps (ICIDH), 1980 Menomazione o danno (impairment): perdita o anormalità di una struttura o di una funzione Disabilità: limitazione o perdita (conseguente a menomazione) della capacità di effettuare un attività nel modo e nei limiti considerati normali per un essere umano Handicap: situazione di svantaggio sociale, conseguente a menomazione e/o disabilità, che limita o impedisce l adempimento di un ruolo normale per un dato individuo in funzione di età, sesso, fattori culturali e sociali impairment disabilità handicap

15 Enabling-disabling Process

16 Enabling-disabling Process Enabling-disabling as basis of rehabilitation

17 Disability

18 Disability is a function of the interaction between the person and the environment

19 The biopsychosocial model of functioning and disability of the World Health Organization Health condition (disease, trauma) Functioning Environmental factors Personal factors Contextual factors

20 Body functions & structures Activity & Participation

21 Activity is the execution of a task or action by an individual. It represents the individual perspective of functioning.

22 Activity is the execution of a task or action by an individual. It represents the individual perspective of functioning. Participation is involvement in a life situation. It represents the societal perspective of functioning.

23 Impaired body functions & structures Limitation in activity Restriction in participation

24 The biopsychosocial model of functioning and disability Health condition (disease, trauma) Body function and body structure Activity Participation Environmental factors Personal factors Contextual factors

25 Disability Health condition (disease, trauma) Impairment of body function & structure Limitation in activities Restriction in participation Environmental Personal factors factors Contextual factors

26 Disability

27 Functioning Health condition (disease, trauma) Body function & structure Activity Participation Environmental Personal factors factors Contextual factors

28 Functioning

29 The biopsychosocial model of functioning and disability Health condition (disease, trauma) Body function and body structure Activity Participation Environmental factors Personal factors Contextual factors ICF provides an international common language for describing functioning, disability and health

30 Fondamenti dell ICF Funzionamento Umano - non la sola disabilità Modello Universale Modello Integrato Modello Interattivo Equivalenza Inclusivo del contesto Applicabilità Culturale Operazionale - non modello per minoranze - non solo medico o sociale - non progressivo-lineare - non causalità eziologica - non la sola persona - non concezione occidentale - non solo teorico Per tutte le classi di età - non centrato sull adulto

31 Funzionamento Umano vs mera disabilità Funzioni Corporee vs menomazioni Strutture Corporee Attività vs limitazioni dell attività 1980 disabilità Partecipazione vs handicap

32 Partecipazione o Handicap? Linguaggio neutrale politically correct uso corretto intervento opportunità aspetti positivi

33 Modello vs. Modello di Universale Minoranze Ognuno può avere disabilità Continuum Multi-dimensionale Gruppi con specifiche menomazioni Categoriale Uni-dimensionale

34 Modello versus Modello medico sociale Problema PERSONALE vs Problema SOCIALE cura medica vs integrazione sociale trattamento individuale vs azione sociale aiuto professionale vs responsabilità individuale & collettiva intervento sulla persona vs modificazione ambientale comportamento vs atteggiamenti prendersi cura vs diritti umani politica sanitaria vs politiche adattamento individuale vs cambiamento sociale

35 Equità / Equivalenza Perdita di un arto mine = diabete = talidomide Giorni persi per attività abituali influenza = depressione = mal di schiena = angina Stigma lebbra = schizofrenia = epilessia = HIV

36 Fattori Contestuali Persona genere età altre condizioni di salute capacità di adattamento background sociale educazione professione esperienze passate Stile del carattere Ambiente Prodotti Ambiente prossimo Istituzioni Norme sociali Ambiente culturale Ambiente costruito Fattori politici Ambiente naturale

37 Applicabilità Culturale Equivalenza concettuale e funzionale della Classificazione Traducibilità Utilizzabilità Comparabilità Internazionale

38 World Health Assembly Use the ICF in Member States in: research surveillance reporting surveys clinical settings Joint use with ICD

39 The biopsychosocial model of functioning and disability Health condition (disease, trauma) Body function and body structure Activity Participation Environmental factors Personal factors Contextual factors

40 Struttura ICF Classificazione Parte 1: Funzionamento e disabilità Parte 2: Fattori Contestuali Parti Funzioni e Strutture Corporee Attività e Partecipazione Fattori Ambientali Fattori Personali Componenti Cambiam.Fu nz.ioni Corporee Cambiam.Str utture Corporee Capacità Performance Facilitatore/ Barriera Costrutti/ qualificatori livello item: livello Item: livello Item: Iivello item: livello Item: Union Domini e categorie ai diversi livelli

41 Health condition (disease, trauma) 493 Body functions and body structure Activities & Participations Environmental factors Personal factors Contextual factors

42 Health condition (disease, trauma) 493 Body functions and 310 structures Activities & Participations Environmental factors Personal factors Contextual factors

43 Health condition (disease, trauma) 493 Body functions and 310 structures 384 Activities & Participations Environmental factors Personal factors Contextual factors

44 Health condition (disease, trauma) 493 Body functions and 310 structures 384 Activities & Participations 253 Environmental factors Personal factors Contextual factors

45 Health condition (disease, trauma) 493 Body functions and 310 structures 384 Activities & Participations 253 Environmental factors Personal factors Contextual factors

46 ICF Categories Health condition (disease, trauma) 493 Body functions and 310 structures 384 Activities & Participations 253 Environmental factors Personal factors Contextual factors

47 - Body functions Body structures Activity and participation Environmental factors

48 "A clinician cannot easily take the main volume of the ICF and consistently apply it to his or her patients. In daily practice, clinicians will only need a fraction of the categories found in the ICF" Üstün B et.al. Common yet specific tools to measure clinical outcomes: ICF Comprehensive Sets and ICF Core Sets. J Rehab Med 2004; (44 suppl):7-8.

49 Acceptance relies on truly practical and useful tools!

50 ICF Core Set List of ICF categories with the typical spectrum of problems in functioning and environmental factors in patients with a specific condition

51 b1 b130 b134 b152 b180 b1801 s299 s710 s720 s730 s73001 s73011 d170 d230 d360 d410 d415 d430 e110 e115 e120 e125 e135 e ICF Core Set

52 Health Conditions Chronic widespread pain Low back pain Osteoarthritis Osteoporosis Rheumatoid arthritis Chonic ischemic heart disease Diabetes Obesity Obstructive pulmonary diseases Depression Breast cancer Stroke

53 ICF Core Sets Comprehensive ICF Core Set to guide multidisciplinary assessments in patients with that condition Brief ICF Core Set to be used in clinical studies

54 OA - Body Functions b280 Sensation of pain b710 Mobility of joint functions Brief ICF Core Set b730 Muscle power functions b770 Gait pattern functions b715 Stability of joint functions Comprehensive b740 Muscle endurance functions ICF Core Set b780 Sensations related to muscles and movement functions b760 Control of voluntary movement functions b134 Sleep functions b735 Muscle tone functions

55 OA - Body Structures s750 Structure of lower extremity s730 Structure of upper extremity s770 Additional musculoskeletal structures related to movement s740 Structure of pelvic region s720 Structure of shoulder region

56 OA - Activity & Participation d450 Walking d540 Dressing d445 Hand and arm use d510 Washing oneself d470 Using transportation d530 Toileting d430 Lifting and carrying objects d640 Doing housework d910 Community Life d440 Fine hand use d410 Changing basic body position

57 OA - Environmental Factors e115 Products and technology for personal use in daily living e310 Immediate family e580 Health services, systems and policies e150 Design, construction and building products and technology of buildings for public use e355 Health professionals e540 Transportation services, systems and policies e120 Products and technology for personal indoor and outdoor mobility and transportation e135 Products and technology for employment e155 Design, construction and building products and technology of buildings for private use e340 Personal care providers and personal assistants

58 Problem-solving approach

59 ICF Sheet Patient perspective Diagnose ICD-10 Goals of Rehabilitation M51.1 Lumbar and other short-term: intervertebral disc disorders with radiculopathy long-term : back pain I can not walk for long periods > 5 minutes I am in sick leave weakness in both legs I can not sleep through I can not sit for long periods driving I can not carry my chlid Body-Structures/Functions Activities/Participation Rehabilitation team perspective herniated vertebral disk nerve root compression limited ROM spinal column muscular atrophy muscle weakness of lower extremities and trunk muscles muscle tension walking for more than 5 minutes standing for more than 15 minutes carrying objects (3 kilos) in the arms sitting for more than 5 minutes Posture Personal factors His wife is PT +, pain-related coping strategies - Environmental factors lives in a 3 rd floor Scaricato flat without da SunHope lift- pain killers but not time contingent -

60 ICF Sheet Patient perspective Diagnose ICD-10 Goals of Rehabilitation M51.1 Lumbar and other short-term: Reduce pain, muscle endurance and walking and sitting for longer intervertebral disc disorders periods of time with radiculopathy long-term : return to work and improvement of coping strategies back pain I can not walk for long periods > 5 minutes I am in sick leave weakness in both legs I can not sit for long periods I can not carry my chlid I can not sleep through driving Body-Structures/Functions Activities/Participation Rehabilitation team perspective herniated vertebral disk nerve root compression limited ROM spinal column muscular atrophy muscle weakness of lower extremities and trunk muscles muscle tension walking for more than 5 minutes standing for more than 15 minutes carrying objects (3 kilos) in the arms sitting for more than 5 minutes Posture Personal factors His wife is PT +, pain-related coping strategies - Environmental factors lives in a 3 rd floor Scaricato flat without da SunHope lift- pain killers but not time contingent -

61 ICF Sheet Patient perspective Diagnose ICD-10 Goals of Rehabilitation M51.1 Lumbar and other short-term: Reduce pain, muscle endurance and walking and sitting for longer intervertebral disc disorders periods of time with radiculopathy long-term : return to work and improvement of coping strategies back pain I can not walk for long periods > 5 minutes I am in sick leave weakness in both legs I can not sit for long periods I can not carry my chlid I can not sleep through driving Body-Structures/Functions Activities/Participation Rehabilitation team perspective herniated vertebral disk nerve root compression limited ROM spinal column muscular atrophy muscle weakness of lower extremities and trunk muscles muscle tension walking for more than 5 minutes standing for more than 15 minutes carrying objects (3 kilos) in the arms sitting for more than 5 minutes Posture Personal factors His wife is PT +, pain-related coping strategies - Environmental factors lives in a 3 rd floor Scaricato flat without da SunHope lift- pain killers but not time contingent -

62 Rehabilitation Rehabilitation is dedicated to optimizing patients functioning and health and to prevent or minimize disability Concepts, models, classifications and measurements of functioning, disability and health are thus at the core of rehabilitation clinical practice, research, and teaching Stucki G et.al. Disabil Rehabil 2002; 24(17):932ff Walsh N, Arch Phys Med Rehabil; 85:1395ff

63 Rehabilitation = Management of functioning and health