The Functional Continuum: How to Drive Skill Acquisition in Our Patients Rusty Moore, DO Lindsay Pugmire, MSPT Steven Wallenfels, OTR/L

Transcription

1 The Functional Continuum: How to Drive Skill Acquisition in Our Patients Rusty Moore, DO Lindsay Pugmire, MSPT Steven Wallenfels, OTR/L FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

2 If We Are Measuring Function, Then Why Not Treat Function?

3 Objectives Describe the top-down model and its application in the interdisciplinary approach. Understand the differences between the medical model and the top-down model and how these two models work together. Identify how functional dependency is endemic in the medical model. Describe the functional movement continuum. Understand the difference between unskilled and skilled movement within function and how that relates to or determines sustainability.

4 Objectives -- cont d Identify the detrimental effects caused by the repetition of poor body mechanics. Describe the benefits of coordinated and efficient body mechanics. Describe the benefits of the interdisciplinary approach. Understand the importance of all disciplines taking responsibility for the patient s quality of practice in functional tasks. Identify how disciplines can support each other and spearhead the functions that are closest to their respective areas of practice and expertise.

5 Top-Down Model of Neurologic Rehabilitation, Gordon, 2005 Disablement Disability Relation to Society Enablement Roles Functional Limitations Whole Person Skills Impairments Organ or System Level Resources Pathology Cellular or Tissue Level Recovery

6 Implications of the topdown model Patient-centered focus for planning intervention. The diagnosis and intervention plan do not derive from diagnosis of pathology. Dual emphasis We need to view the patient from both perspectives. Implications for evidence-based practice Need for evidence to be linked to movement skills rather than merely disease categories and/ or impairments. * Slide taken from presentation Motor Behavior Group Seminar 3/31/2006. Modes of Disability ; Sue Leach, PT, and Noelle Moreau, PT.

7 Implications of the topdown model The outcome of therapy is the development of skill With the traditional ADL approach, independence is the ceiling The skill-based approach provides a richer framework for planning and measuring outcomes. Was the goal achieved consistently, with efficiency, effectiveness and flexibility? * Slide taken from presentation Motor Behavior Group Seminar 3/31/2006. Modes of Disability ; Sue Leach, PT, and Noelle Moreau, PT.

8 Dual Emphasis Medical Model Pathology: Mitral valve stenosis Impairment: SOB with exertion Functional Limitation: Decreased walking distance, Decreased ability to tolerate activities each day. Disability: Decreased community activities, must park close to store, maybe use power cart in store. Intervention: Open Heart surgery to replace heart valve. Top-Down Model Roles: Husband, Father, Grandfather, Breadwinner, gardener, etc. Skills: Mobility skills, balance skills, gait skills, floor recovery, problem solving, self-care skills, etc. Resources: Family support, equipment when necessary, support groups, outpatient therapy, education Recovery: True recovery is healing, new pathways using neuroplasticity, getting back to life. Intervention: Interdisciplinary focus practicing skilled function and regaining health.

9 Which Model Should We Use During Rehabilitation? Medical Model Pathology: Right MCA CVA Impairment: Left LE/UE weakness, Decreased ROM, decreased sensation. Functional Limitation: Impaired self care, balance, mobility, gait Disability: Limits to previous lifestyle, decreased involvement in life roles Intervention: ROM, strength training, adaptive techniques for self care. Each discipline provides silo d treatment that is impairment driven. Top-Down Model Roles: Autonomous Being, Husband, Father, Grandfather, Breadwinner, gardener, etc. Skills: Mobility skills, balance skills, gait skills, floor recovery, problem solving, self-care skills, self directing skills, etc. Resources: Family support, equipment when necessary, support groups, outpatient therapy, education Recovery: True motor recovery, skill acquisition, new pathways using neuroplasticity, getting back to roles in life. Intervention: Interdisciplinary focus practicing skilled function, motor relearning, controlling risk factors

10 Which Model Should We Use During Rehabilitation? Medical Model Top-Down Model Others control your outcome Control and responsibility is given back to the patient. Or better yet. The Patient takes control of their outcome.

11 Movement Therapy. Neuroplasticity is the proven concept that gives the potential for normal, integrated movement to be achieved. It is widely accepted in the research community that the CNS comprises inherently plastic neural networks that are amenable to reorganization Wolpaw JR, Carp JS. Plasticity from muscle to brain. Prog. Neurobiol. 2006;78(3-5): [PMID: ]

12 Functional Continuum Cognitive Skills Psycho-Social Skills Perceptual Skills Spiritual Skills Physiological Health CATEGORY 1

13 Movement skill continuum Optimal Function Mobility Optimal Function Ambulation Debility Dressing Optimal Function Toileting Optimal Function

14 Movement Therapy Optimal function is efficient, effective, and coordinated. Optimal function requires skill acquisition. Optimal Function Ambulation Compensation Debility Compensation

15 Contaminated Functional Practice Would we do this with medications? Patient with High Blood Pressure: A.M. meds: Lisinopril P.M. meds: Midodrine..Or hold Lisinopril? NO! Yet we do this often with movement and functional training. We need to be careful that we are not doing negative training with our patients or creating functional dependency.

16 Movement Therapy Optimal function is efficient, effective, and coordinated. Optimal function requires skill acquisition. Optimal Function Ambulation Compensation Debility Compensation

17 Movement skill continuum Optimal Function Mobility Optimal Function Ambulation Debility Dressing Optimal Function Toileting Optimal Function

18 Functional Continuum Cognitive Skills Psycho-Social Skills Perceptual Skills Spiritual Skills Physiological Health CATEGORY 1

19 Movement Therapy Concepts The outcome of therapy will depend on the approach and skill sets of the therapist teaching the movements. In the case of the neurological patient, we cannot expect they will gravitate towards the best motor patterns possible based on their perception. Movement disruption comes not only from the neuromotor insult but also the alteration in their processing and interpreting of visual, vestibular and somatosensory information. To optimize function these systems must be treated concurrently with the motor component.

20 Benefits of Coordinated and Efficient Movement Decreased wear and tear on the musculoskeletal system (Collateral Damage). Decreased energy demand sustain function longer during the day. Decreased stress on the cardio-pulmonary system. Preserves capacity to learn more advanced skills and continue improvement. Increased ability to adapt to multiple environments.

21 Benefits of Coordinated and Efficient Movement Increased confidence and sense of autonomy, including within the social context. Skill is number ONE when it comes to reducing fear of falling and falls. Decreased caretaker burden. Eliminates over-recruitment which we believe minimizes spasticity development.

22 Benefits of an Interdisciplinary Approach Removes individual from the dependent environment All disciplines on the same page with same goal All disciplines feel engaged and invested in the process of skill acquisition All disciplines looking at the whole person

23 Benefits of an Interdisciplinary Approach Skilled functional practice over 24 hour period (Functional Dosage) Increased Functional Outcomes More sustainable function that will correlate to decreased readmissions

24 Overall FIM Gain * CMG-adjusted YTD NSR - Dixie National Average

25 Interdisciplinary Synergy. How? Co-Treating within function in real time. Finding shared work space Space is patient centered. Shadowing Patient handling pass-offs/training.

26 Interdisciplinary Synergy. How? Team Conference open sharing and interdisciplinary problem solving. Ground Rules and teamwork/communication training. Commitment to philosophy from leadership.

27 Contact Information Rusty Moore, DO Lindsay Pugmire, MSPT Steve Wallenfels, OTR/L