神经疾病的作业治疗

1. 神经疾病的作业治疗 李国辉 香港作业治疗师协会 香港理工大学 昆明医学院外聘教师

2. Rehabilitation • Definition • WHO in 1986 • Rehabilitation implies the restoration of patients to the highest level of physical, psychological and social adaptation attainable. It includes all measures aimed at reducing the impact of disabling and handicapping conditions and a enabling disables people to achieve optimum social integration

3. Physical Rehabilitation • Aim • restore the patients function by all measures and to reduce the impact of physical diseases

4. What guide the physical treatment? • How to provide treatments in physical rehabilitation? • Anything guided the treatment provided to patient? • Model & Frame of reference

5. Model • is characterizes by a description of the profession’s philosophical assumptions, ethical code, theoretical foundation, domain of concern, legitimate tools, and the nature of and principles for sequencing the various aspects of practice (Mosey, 1981)

6. Frame of reference • principles behind practice with specified patient or client populations. It includes a description of the population to be served, guidelines for determining adequate function or dysfunction, and principle of remediation (Bruce & Borg, 1993)

7. A profession model e.g. Medical model, Model of Occupational Performance, etc Frame of Reference e.g. Behavior frame of reference, Cognitive-behavioral frame of reference, Biomechanical frame of reference, etc. Approaches e.g. Biomechanical approach, Rood approach, NDT approach, etc. Model, Frame of reference and Approaches

8. Model of Occupational Performance Work Performance Component Sensori-motor Community independent, fulfill roles in community Cognitive Self- Care Leisure Psychosocial Environment

9. Treatment Process • Treatment provided to patients depends on: • What problems did the patients suffer? • What assets did patient have? To obtain the answers, we need to conduct assessments

10. Treatment Process Assessment Problem Identification Goals Setting Evaluation Treatment Intervention

11. Treatment Continuum ADL Work Leisure activities Sensorimotor Cognitive function Psychosocial component Occupational Performance Purposeful Activities Enabling Activities Adjunctive methods

12. Assessments • Mental State, • Alertness, Orientation, follow instruction,etc. • Motor • AROM, PROM, MMT, Muscle tone, coordination,etc. • Vestibular • Sitting / Standing balance (Static / Dynamic) • Sensory • Sensation, proprioception, kinesthesia, stereognosis • ADL function

13. Treatment Approaches • Biomechanical approach • Sensory-motor approach • Rehabilitative approach

14. Biomechanical Approach • Basic assumption • CNS intact • Based on the mechanical principle • Dealing with the force and movement acting on body • Knowledge of Anatomy • Bone structure • Muscle groups’ function, e.g. origin and exertion • Applied for most orthopedic cases

15. Sensory – Motor Approach • Basic assumption • CNS deficit • Based on the theory of motor recovery and neurophysiology • Various approaches developed • Rood approach • Brunnstom movement therapy • Proprioceptive neuromuscular facilitation (PNF) • Bobath (neurodevelopmental technique, NDT)

16. Rood Approach – Principle of treatment (Rood, 1956) • Tone normalization • Tonic neck and labyrinthine reflex

17. Rood Approach – Principle of treatment • Ontogenetic motor pattern • Supine withdrawal (Supine Flexion) • Rollover (Side lying) • Pivot Prone (Prone extension) • Neck co-contraction (Co-innervations) • On elbow (Prone on elbow) • All Fours (Prone on 4 limbs) • Static Standing

18. Rood Approach – Special Techniques used in treatment • Light moving touch • Important for normal growth • Send input to limbic structure and increase the corticosteroid, which increase resistance against disease, tissue repair and fluid and electrolyte balance

19. Rood Approach – Special Techniques used in treatment • Fast Brushing • Stimulate C fibers, send collaterals to the reticular activating system • Increase fusimotor activities • Applied over dermatomes • Effect last for 30 minutes • Contraindication – do not applied outer ring of trigeminal nerve (C2 dermatomes begin) • Not applied for cervical spinal cord and brain stem injuries, as autonomic dysreflexia and possible induce deep state of unconsciousness

20. Rood Approach – Special Techniques used in treatment • Icing • A icing (Fast Icing) – stimulate A fibers causing reflex withdraw response in superficial muscle. • C icing – Stimulate non specific C fibers that maintain postural response • Applied according to dermatomes • Contraindications – Avoided for patient with hx of cardiovascular problems. • Do not applied over the neck, otherwise will cause sudden low BP

21. Brunnstom movement therapy • By Signe Brunnstrom in 1970 • Described stages of motor recovery • Flaccidity • Begin develop of spasticity • Spasticity increase, synergy pattern • Spasticity decrease, movement deviated from synergy pattern • Synergy no longer dominant • Spasticity absent except rapid movement, isolated joint movement

22. Proprioceptive neuromuscular facilitation (PNF) • All Human beings have potentials that are not fully developed • Normal motor development proceeds in a cervico-caudal and proximal –distal direction • Early motor behavior is dominated by reflex activity. Mature motor behavior is reinforced or supported by postural reflex • The growth of motor behavior has cyclic trends as evidenced by shifts between flexor and extensor

23. Proprioceptive neuromuscular facilitation (PNF) • Goal-directed activity is made up of reversing movement • Normal movement and postural depend on synergism and a balance interaction of antagonists • Develop motor behavior is expressed in orderly sequence of total pattern of movement and postural • Normal of motor development has an orderly sequence but lacks a step by step quality

24. Proprioceptive neuromuscular facilitation (PNF) • Improvement of motor ability depends on motor learning • Frequency of stimulation and repetition of activity are used for promotion and retention of motor learning and for development of strength and endurance • Goal-directed activities, coupled with facilitation are used to hasten learning of total pattern of walking and self-care

25. Proprioceptive neuromuscular facilitation (PNF)

26. Proprioceptive neuromuscular facilitation (PNF)

27. Bobath (neurodevelopmental technique, NDT) • Developed by Bobath in 1940 • Encourage normal movement and proper position • Treatments techniques included: • Weight-bearing • Trunk rotation • Scapular protraction • Pelvis forward

28. Rehabilitative Approach • Also know as compensation approach • Fully use of patient’s assets • By providing of aids to enhance function • Adaptation of environments

29. Treatment skills • Remedial and Functional activities • Physical agent • Splinting and pressure garment • Aids and Environment adaptation

30. Remedial Activities • Exercise – repetition of an action • Remedial Activity – Goal directed activities • Functional Activity – Activities that is goal directed and the goal is purposeful and meaningful to the patient

31. Remedial activities

32. Leisure Activities

33. FunctionalActivities

34. Physical Agent • Thermo – therapy • Cryotherapy • Hydrotherapy • Ultrasound • Electrotherapy • LASER therapy

35. Splinting

36. Splint

37. EnvironmentModification

38. Environment Modification

39. Aids

40. Aids

41. ~END~ Thank You