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Client-Centred Rehabilitation

The pathways to meet rehabilitation expectations
by

Dennis Radman

on 4 July 2013

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Transcript of Client-Centred Rehabilitation

Brain Injury Rehabilitation
Restore Function
Compensatory Measures
Constraint-Based
Research / Evidence
Physical
Walking
Talking
Swallowing
Fine / Gross Motor
Types of research
Intervention protocols
Techniques / Methodologies
Strategies
Optimization of
Residual Function
Substitution
of Intact Function
International Classification
of Functioning
Theory
Skill
Attitude
Pathology
Underlying disease or diagnosis
Impairment
Immediate physiological
consequences and signs
Disability
Handicap
Functional consequences
& abilities lost
Social consequences,
freedoms lost
Brain
Client-Centred Rehabilitation:
A Comprehensive Pedagogy of Theory, Skill and Attitude towards Clinical Competence

Learning Theory
Teaching Theory
Rehabilitation
Physiological
Psychological
Physical
Social
Skills
Physical - wheelchair
Memory - PDA
Emotional - Script
Reading - computer
Vision - prism glasses
Client
Environment
Functioning
Cognitive
Behavioural
Psycho-Social
Physical
Emotional
Spiritual
Goals
Short-term vs. Long-term
SMART Goals & GAS
Objective vs. Subjective
Baseline Assessment
Duration, Intensity, Frequency
Likert scale vs. Dichotomous
Physiology
Psychology
Sociology
Ethics
Legal
Medicine
Administrative
Political
Physiatry
Speech-Language Patholgy
Occupational Therapy
Social Work
Nutrition
Recreation / Leisure
Case Management
Co-morbidity
Depression
Chronic Pain
Sleep Disturbances
Spinal Cord Injury
Mental Health
Drug / Alcohol Abuse
Seizures
Frontal Lobe
Parietal Lobe
Occipetal Lobe
Temporal Lobe
Cerrebelum
Brainstem
* Inability to attend to more than one object at a time.
* Inability to name an object (Anomia).
* Inability to locate the words for writing (Agraphia).
* Problems with reading (Alexia).
* Difficulty with drawing objects.
* Difficulty in distinguishing left from right.
* Difficulty with doing mathematics (Dyscalculia).
* Lack of awareness of certain body parts and/or surrounding space (Apraxia)
* Inability to focus visual attention.
* Difficulties with eye and hand coordination.
* Loss of simple movement of various body parts (Paralysis).
* Inability to plan a sequence of complex movements
* Difficulty completing multi-stepped tasks, such as making coffee (Sequencing).
* Loss of spontaneity in interacting with others.
* Loss of flexibility in thinking.
* Persistence of a single thought (Perseveration).
* Inability to focus on task (Attending).
* Mood changes (Emotionally Labile).
* Changes in social behavior.
* Changes in personality.
* Difficulty with problem solving.
* Inability to express language (Broca's Aphasia).
* Defects in vision (Visual Field Cuts).
* Difficulty with locating objects in environment.
* Difficulty with identifying colors (Color Agnosia).
* Production of hallucinations.
* Visual illusions - inaccurately seeing objects.
* Word blindness - inability to recognize words.
* Difficulty in recognizing drawn objects.
* Inability to recognize the movement of object (Movement Agnosia).
* Difficulties with reading and writing.
* Difficulty in recognizing faces (Prosopagnosia).
* Difficulty in understanding spoken words (Wernicke's Aphasia).
* Disturbance with selective attention to what we see and hear.
* Difficulty with identification of, and verbalization about objects.
* Short term memory loss.
* Interference with long term memory.
* Increased and decreased interest in sexual behavior.
* Inability to catagorize objects (Categorization).
* Right lobe damage can cause persistent talking.
* Increased aggressive behavior.
* Loss of ability to coordinate fine movements.
* Loss of ability to walk.
* Inability to reach out and grab objects.
* Tremors.
* Dizziness (Vertigo).
* Slurred Speech (Scanning Speech).
* Inability to make rapid movements.
* Decreased vital capacity in breathing, important for speech.
* Swallowing food and water (Dysphagia).
* Difficulty with organization/perception of the environment.
* Problems with balance and movement.
* Dizziness and nausea (Vertigo).
* Sleeping difficulties (Insomnia, sleep apnea).
Relationships
Work & Education
Health & Leisure
Activities of Daily Living
Social
Family
Friends
Home
Relationships
School
Work
Community
Thinking: memory and reasoning
Sensation: touch, taste, and smell
Language: communication, expression, understanding
Behaviour: aggression, acting out, and social inappropriateness
Emotion: depression, anxiety, personality changes
Multi-dimensional model of TBI Problems
1. Social competence
2. Intimacy
3. Behavioural
4. Maturity / Independence
5. Neurophysiological
6. Mood
7. Executive Functioning
8. Non-executive Funtioning
Passive Teaching
Lecture
Reading
Audio-visual
Demonstration
Participatory Teaching
Discussion
Practice
Teaching Others
Learning
Ownership
Engagement
Social
Contextual
Active
requires
encourages
is
is
is
Multiple
Intelligences
Bodily / Kinesthetic
Musical / Rhythmic
Verbal / Linguistic
Logical / Mathmetical
Naturalist
Visual / Spatial
Existential
Interpersonal
Intrapersonal
Anchoring – tendency to rely too heavily, or "anchor," on one trait or piece of information when making decisions.
Bandwagon – the tendency to do (or believe) things because many other people do (or believe) the same.
Confirmation bias – the tendency to search for or interpret information in a way that confirms one's preconceptions.
Focusing effect – the tendency to place too much importance on one aspect of an event; causes error in accurately predicting the utility of a future outcome.
Psychological / Behavioural Difficulties
Anger, aggression, frustration
Depression, suicide
Anxiety, stress, PTSD
Awareness, emotional lability
Inappropriate language
Disinhibition, impulsivity, perseveration
Psychological Treatments / Strategies
Cognitive Behaviour Therapy
Systematic Desensitization
Problem Solving Skills (STOP-CALM-THINK)
Destructive Self-talk Awareness and Refusal Method (DISARM)
Role-play, positive reinforcement, modeling, shaping, chaining
ABC's (antecedents, behaviours, consequences)
I want to drive
I want to go to work
I want my girlfriend back
Assessment
Intervention
Evaluation
Modality
Audio
Visual
Kinesthetic
ABC's
Modeling, thinning
Shaping, generalization
Chaining, prompting, fading
Incidental teaching
Positive reinfocement
Redirection, feedback
Reality testing, instruction
Instruction, analogy
Demonstration, explanation
Participation, completion
PEARL
Positive: upbeat, enthusiastic ...
Early: proactive, intervening early ...
All: Acts these ways all the time ...
Reinforce: Consistently recognizing ...
Look: Looking for opportunities ...
Mutual Reinforcement and Reciprocity
Goal-Focused Rehabilitation

It is not enough to simply provide treatment and assume that the services are helpful. Treatment must be planned and provided within the framework of a systematic process. Results must be evaluated on the basis of specific outcome criteria. These outcome criteria are expressed in the form of therapeutic or life goals. They relate directly to functional improvements in the individual. Identifying outcome criteria is a critical step.
Domains of functioning
Mobility, Cognition, Communication
Health Issues, Self-help skills
Household management
Community & Leaisure skills
Vocational skills
Behaviour

ABCs
Rate/Frequency, Duration
Latency / Intensity / %
Routines / Habits
Practice
Repetition
Routine / Habit
Sequencial
Task Analysis
Errorless learning
Cuing hierachy
Emphasize strategies which focus on teaching the individual to self-manage unwanted behaviors, to develop independence with completion of task(s), to self-monitor instead of reliance on others to intervene. This insures maximum inclusion and control by the individual and has the greatest likelihood of maintaining and generalizing to other settings and persons.
Carry out treatment for goals in all therapeutic contexts.
Assistive devices
Day planner, PDA, calendar
White Board, checklists, to-do lists
Watch, Data-Link watch, pager
Dossette, binders, journals
Timers, alarms
Recipes, cue-cards, post-its
Strategies
STOP-CALM-THINK
Problem-solving
Metacognitive
PQRST, TOWER
Scripts
5 W's
Chunking
Conversational Maxims
Humor
Don't take things personally
Stay calm
Don't talk down to people
Treat everyone with dignity and respect
Positive
Flexibility
Consistency
Supportive
Client-centred
Inclusive
The therapist's openness and genuineness—the willingness to relate to clients without hiding behind a professional facade.
Unconditional positive regard means that the therapist accepts the client totally for who he or she is without evaluating or censoring, and without disapproving of particular feelings, actions, or characteristics. The therapist communicates this attitude to the client by a willingness to listen without interrupting, judging, or giving advice.
The therapist tries to appreciate the client's situation from the client's point of view, showing an emotional understanding of and sensitivity to the client's feelings throughout the therapy session.
Accountability
Confidentiality
(a) relational connection,
(b) autonomy,
(c) beneficence,
(d) nonmaleficence,
(e) competence,
(f) humility,
(g) professional growth,
(h) openness to complexity and ambiguity,
(i) self-awareness
Nine ethical values of
master therapists
Pain Management
McGill Pain Questionnaire
Pain Catastrophizing Scale
Pain Disability Index
Tampa Scale for Kinesiophobia
Quality of Life Scale
Cognitive-Behavioural
Agitated Behavior Scale (ABS)
The Family Needs Questionnaire (FNQ)
Functional Assessment Measure (FAM)
Functional Independence Measure (FIM)(TM)
Glasgow Outcome Scale (GOS)
Functional Behaviour Analysis (FBA)
Strengths and Difficulties Questionnaire (SDQ)
Community Integration Skills Assessment
Galveston Orientation and Amnesia Test (GOAT)
Satisfaction With Life Scale
Beck Depression Inventory
Sleep Assessments
Athens Insomnia Scale
Epworth Questionnaire
Pittsburgh Sleep Quality Index
Stanford Sleepiness Scale
Insomnia Severity Index
Evaluation Matrix
Behaviour Log
Task Analysis
Rating Scale / Likert Scale
Dichotomous Rating
Frequency – How often it happens
Duration – How long does the behavior last?
Interval – Is it occurring at a certain interval?
Latency – How much time elapses before the behavior is exhibited?
Intensity – How much effort (hi/med/low) effort is put into behaviour
Observable & Measurable
• Easily observed
• Countable
• Beginning/end
• Repeatable
Humble
Assessment in Domains of functioning
Strengths & Weaknesses as it relates to discharge
Standard tools according to discipline
Timing
Rapport
Congruence
Unconditional Positive Regard
Empathy
Evaluation / Data collection

* Using available information (reports)
* Observations
* Interviewing (face-to-face)
* Administering written questionnaires
* Projective techniques, mapping, scaling
Shrine
Shoes
Garbage pail
Development of new routine
Repetition
Guidance, support
External Internal
Full transcript