samenvatting klinisch redeneren bij neurologische aandoeningen
inclusief: theorie en praktijk, parkinson, CVA, dwarslaesie, KNO
nog te bekijken: extra oefeningen praktijk
Theorie Neurogeriatrie
Clinical reasoning framework
1) ASSESSMENT
movement analysis (waarom beweegt mijn patiënt zo?)
Subjective: interview patients AND family (zijn de impairment tgv stroke?, P soms moeilijkheden met
communicatie)
objective: identify impairments on all ICF levels
indeling in body function and structure OF activities (zie dia 5)
participatieproblemen = wat patiënt aangeeft (huishouden, werkgerelateerd, hobbies, sport)
!! use standardised outcome measures !!
2) INTERPRETATION
hypothesis: why does my patient move in this way?
vb. strength, core, spasticity, stability shoulder
in verschillende contexten bekijken: positie en/of taak aanpassen lukt dit beter?
3) GOAL SETTING
patient centered
achievable!! breakdown in subgoals
adapted to the stage of the recovery process
influences the mindset of patient and therapist
influenced by the beliefs/ expectations of your patient and the therapist (jij moet ook geloven dat het
haalbaar is!)
!! set goals that keep your patients motivated !!
communication and education ( professionals and patients) about goals niet altijd makkelijk tgv
communicatieprobleem
4) TREATMENT PLAN
principles of neurorehabilitation:
- specific and task oriented
- problem solving (laat P zelf de juiste manier zoeken)
- motor learning
- feedback (performance and result)
- intensity and dose
- variation (repetition without repetition)
- motivational and meaningful
task specific :
- focus on meaningful tasks
- challenging more motivation
- enough variation generalization
- achievable more self efficacy
self-efficacy= the patient’s believe in his/her own capabilities
more motivation to act
more adherence to therapy
normal movement = not always possible
optimal movement = efficient movements motivate the patient to keep on performing his
activities ( E-level, goal )
,recovery = true neurologic recovery (not always complete)
adaptation (compensation) = alternative strategies to perform functional movements ->
optimize movements, detrimental for optimal movements
teamwork: work towards the same goal (focus on different aspects)
self management: responsibility of P om de oef. te doen, P = active problem solver
- patient engagement
- integrated care
- personalized treatment plan
- patient experiences
- care coordination
5) EVALUATE AND REASSESS
achieved? new goals
not achieved? why? (compliance, intensity,…)
Neuroplasticity
= enduring changes in structure and function of the central nerve system
acute: spontaneous recovery after brain damage
after a few days: result of experience and therapy (exercises at right level and frequently enough)
- use dependent and specific
- influenced by motivation, feedback, attention and patients characteristics
- repetition
- intensity
- time sensitive
Fugl-meyer Assessment
5 domains: motor, sensory, balance, ROM, joint pain
stroke specific, performance based test on impairment level
determines severity of stroke and quantifies recovery
lower scores are correlated with a lower functional ability and a lower corticospinal tract integrity
and prognosis
Main focus: test the ability of patients to isolate and control individual joints outside a flexion or
extension synergy
= selectivity (motor control)
= not strength
Hierarchical structure:
1) reflexes 2) movements in synergies 3) movements out of synergies 4) coordination and speed
increasing functionality (4= moeilijker)
UL score = related to dexterity:
- <31: poor-hand capacity
- > =31 – 52: limited to notable arm-hand capacity
- >52: likely to show full capacity
, UL score can be used to determine therapy goals
< 19: severe impairment
- prevention secondary complications
- self-management
19-47: moderate impairment
- dissociated movements
- reaching and grasping
- functional arm training
>47: mild impairment
- fine motor training
- high level functional training
Mbv FM kan je bepalen welke therapie in welke positie
UL score can be used to determine task difficulty
‘’the first 5 consecutive items on which 3 of these received the next lowest rating” identify
exercises ( zie dia 39-41)
LL assessment:
- not used as prediction for walking (independence of walking) strength and trunk control is not
assessed
- can be used to identify impairments that can be trained to optimize walking pattern (quality!) and
functional locomotion
CB&M scale
= complex interaction of dynamic sensorimotor processes
- designed to evaluate balance and mobility in ambulatory (walk independently!) patients with
balance impairments that reduce their full engagement in community living
- less ceiling effect
- better able to capture change in higher functioning groups
- score is compared to age and gender specific normative data
Opstelling zie dia 46
Berg balance scale
ceiling effect: score verandert niet altijd wanneer evenwicht wel vooruitgang boekt
mogelijk dat P een hoge score heeft maar toch problemen heeft met evenwicht die niet kunnen
worden gedetecteerd
Case stroke patient
Possible functional activities to observe:
getting dressed/washing, taking stairs,
grasping objects, household activities, eating,
neglect task, double tasks, walking in
different environments, more functional
transfers
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