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1990-2017

Prof. Ivet Koleva, DM, PhD, DMSc


European Definition of the
Medical Act (Munich, 2005):
The medical act encompasses all the professional actions,
e.g. scientific, teaching, training and educational,
organizational, clinical and medico-technical steps,
performed to promote health and functioning, prevent
diseases, provide diagnostic or therapeutic and rehabilitative
care to patients, individuals groups or communities in the
framework of the respect of ethical and deontological values.
It is the responsibility of, and must always be performed by a
registered medical doctor / physician or under his or her
direct supervision and / or prescription.
Definition of UEMS PRM Section
According the definition of the European Union of
Medical Specialists PRM Section: PRM is an
independent medical specialty, oriented to the
promotion of physical and cognitive functioning,
activities (including environment), participation
(including quality of life) and changes in personal
factors and environment.
The specialty PRM is responsible for the
management of the prevention, diagnostics,
treatment and rehabilitation of patients with health-
related disability and co-morbidity of all ages.
White Book on PRM
According the White Book on PRM the basic
objective of PRM is the optimization of social
participation and the amelioration of the quality
of life of patients.
Tasks of PRM are: treatment of existing
pathology; reduction of disability; prevention
and therapy of complications; amelioration of
functioning and activity; stimulation of patients
participation in different activities.
World Disability Report
The World Report on Disability of the World Health
Organization and World Bank defines the goals of
rehabilitation: prevention and slowing the rate of loss
of function; improvement, restoration or
compensation of lost function; maintenance of current
function.
Modern rehabilitation has an integrative and holistic
approach to the patient, based on the International
Classification, disability and Health (ICF) and on
clinical principles.
Prof. Ivet Koleva, DM, PhD, DMSc
From the group of NATURAL PHYSICAL MODALITIES: :
water (incl. mineral waters), air (incl. ions & aerosols),
temperature (heat or cold); movement (active & passive); with
the respective parts of PRM: HYDRO / BALNEO / therapy,
ERO / IONO / therapy, THERMO / CRYO / therapy, KINESI
(PHYSIO) therapy, ERGO (occupational) therapy.

From the group of PREFORMED PHYSICAL MODALITIES:


electric currents, magnetic field, light (including laser),
ultrasond; with the respective parts of PRM: LECTRO- &
MAGNETO-therapy, LIGHT therapy, LASER-therapy,
ULTRASOUND-therapy.

Prof. Ivet Koleva, DM, PhD, DMSc


REFLECTORY CONNECTIONS
During last years the development of the physical
medicine proved the existence of some reflectory
connections in the human body, based on the theory for
the metameric structure of the embryo in the intra-uterine
development.
In PRM we apply the following groups of reflectory
connections: cutaneous-visceral (zones of Head),
subcutaneous-connective tissue-visceral (zones of Leube
Dicke), proprio-visceral (zones of Mackenzie), periostal-
visceral (zones of Vogler - Krauss), and motor-visceral
(zones of Mackenzie).

Prof. Ivet Koleva, DM, PhD, DMSc


GROUPS OF REFLECTORY CONNECTIONS
PROPRIO-VISCERAL
CUTANEOUS-VISCERAL (zones of Mackenzie)
(zones of Head)
MOTOR-VISCERAL
(zones of Mackenzie)

PERIOSTAL-VISCERAL
(zones of Vogler-Krauss)

REFLECTORY
CONNECTIONS SUBCUTANEOUS-CONNECTIVE
TISSUE- VISCERAL
(zones of Leube-Dicke)

Prof. Ivet Koleva, DM, PhD, DMSc


REHABILITATION

IN

BULGARIA

Prof. Ivet Koleva, DM, PhD, DMSc


The Bg PRM school uses
modern methods for
PHYSICAL ASSESSMENT
&
PHYSICAL THERAPY

Prof. Ivet Koleva, DM, PhD, DMSc


Functional evaluation of the patient in Bg PRM is based on
INTERNATIONAL CLASSIFICATION OF FUNCTIONNING,
DISABILITY AND HEALTH
(ICF, WHO, 2001)
HEALTH CONDITION
(disease)

ICF
Body functions Activities Participation
() (Limitations) (Disability)

Environmental factors Personal factors

Prof. Ivet Koleva, DM, PhD, DMSc


In clinical practice we apply the
COMPLEX REHABILITATION PRINCIPLE

Physiotherapy, electrotherapy,
massages, ergotherapy
In different groups ofdiseases
Or
Synergic combination of different
physical modalities and
techniques:
Complex rehabilitation programme
for every health condition

Thessaloniki, 2012
Prof. Ivet Koleva, DM, PhD, DMSc
In therapy we apply the
PHYSICAL-THERAPEUTIC AND
REHABILITATION PUZZLE

KINESI PREFORMED
(physio) MODALITIES
(electro/magneto/light/th)
therapy

HYDRO/
ERGO
BALNEO/
(occupational)
PELOIDO/ therapy
CLIMATO-th

The found is always adapted diet and strict medication of the basic disease
Devices for electro-therapy
(low and middle frequency)
ELECTRODES
for electrotherapy with
low frequency and middle frequency currents

,
Low frequency pulsed
magnetic field
LASER
THERAPY, PUNCTURE, ACUPUNCTURE

Physiolaser in any configuration


between 635 to 904 nm:
from 50 mW/ 785 nm up to terrific 500
mW/810 nm or 90 W/904 nm.
New: 200 mW/685 nm (red).
Laser puncture
Passive MECHANOTHERAPY
Passive MECHANOTHERAPY
Active mechanotherapy
Extension therapy
Cervical tractions
Extension vertebrotherapy
Lumbar tractions
OCCUPATIONAL THERAPY

Adapting the environment for ADL

--- Assos.prof.Yvette KOLEVA, M.D., Ph.D.

Activities of daily living

EATING

--- Assos.prof.Yvette KOLEVA, M.D., Ph.D.

ADL

---

ADL

---

ADL

---

ADL

--- Assos.prof.Yvette KOLEVA, M.D., Ph.D.

ADL

--- Assos.prof.Yvette KOLEVA, M.D., Ph.D.

SPA
Sanus Per Aquam
or
health by water
In clinical rehabilitation practice we apply the
CHOLISTIC APPROACH
to the patient
from the analysis to the synthesis

Prof. Ivet Koleva, DM, PhD, DMSc


In clinical practice we use the
PATIENT CENTERED
APPROACH

PRM doctor

PATIENT
Physiotherapist

Ergo therapist

Prof. Ivet Koleva, DM, PhD, DMSc


We apply the
TEAM REHABILITATION PRINCIPLE

MULTI-DISCIPLINARY REHABILITATION TEAM

Prof. Ivet Koleva, DM, PhD, DMSc


Rehabilitation team
Different models of organization of the teamwork of the staff are
applied: interdisciplinary (complex care of the patient from
different scientific and professional disciplines); multi-disciplinary
or multi-professional (role of every professional is completely
independent from the others); transdisciplinary (everyone helps
the work of the others; role and functions are distributed).
In Bulgarian rehabilitation practice traditionally a lot of specialists
are included: medical doctors specialists in Physical and
Rehabilitation Medicine; professional bachelors in Rehabilitation,
bachelors and masters in Medical Rehabilitation and Ergotherapy,
in Kinesiotherapy and in Ergotherapy; masters in Medical
Rehabilitation and Balneology.
EVOLUTION OF
CONCEPTS:

from the definition of health (WHO, 1946)


to ICF (WHO, 2001)
Health is the level of functional or metabolic efficiency of a living
being.
The World Health Organization (WHO) defined health in its broader
sense in 1946 as "a state of complete physical, mental, and social
well-being and not merely the absence of disease or infirmity.
Although this definition has been subject to controversy, in particular
as having a lack of operational value and the problem created by
use of the word "complete", it remains the most enduring.
Classification systems such as the WHO Family of International
Classifications, incl. ICF & ICD, are commonly used to define and
measure the components of health.
The maintenance and promotion of health is achieved through
different combination of physical, mental and social well-being,
together sometimes referred to as the health triangle.
DEFINITION of HEALTH
World Health Organization WHO, 1946

HEALTH

Physical Psychical Social


Prosperity prosperity Prosperity

2012 43
STAR OF LIFE

Represents the Rod of Asclepius, with a snake around it,


on a 6-branch star shaped as the cross of 3 thick 3:1 rectangles.
DETERMINANTS OF HEALTH
The individual health status and quality of life depend of a lot of factors:
advancement and application of health science, lifestyle; etc.

According to the WHO concepts, the main determinants of health


include the social and economic environment, the physical
environment, and the person's individual characteristics and
behaviors.

More specifically, key factors that have been found to influence whether
people are healthy or unhealthy include: social status, education literacy,
employment (work), social and physical environment; health care services,
culture, etc.
The PEO model

PERSON ENVIRONMENT
OCCUPATION MODEL OF
PERFORMANCE
PEO MODEL
First described by Law et al 1996
Doesnt prescribe specific assessments or methods of intervention
GUIDES CLINICAL REASONING ABOUT WHAT WE CHOOSE & WHY

PERSON
SKILLS & ABILITIES - MUSCLE STRENGTH, VISUAL-PERCEPTION,
COGNITIVE ABILITIES
INTRINSIC MOTIVATION, VALUES & GOALS
Each person is unique; Person could also apply to a group of people e.g. students with a disability in a school

ENVIRONMENT
PHYSICAL; SENSORY; SOCIAL; CULTURAL; INSTITUTIONAL

OCCUPATION
GROUPS OF ACTIVITIES THAT HELP A PERSON BE for example: A student, A player,
A brother, A friend
Includes: Writing an essay, riding a skateboard, playing football, making a snack
Multiple avenues for intervention:
PERSONcomponent skills e.g. strength, balance, coordination, social
skills
ENVIRONMENTraising awareness, physical adaptations, visual
timetables
OCCUPATIONhandwriting programmes, visual prompts for dressing,
teach to ride a bike

Occupational performance is the result of the dynamic relationship between


the person, their environment and their activities.
Relationships vary across the lifespan.

The PEO model provides multiple options for assessment,


intervention and outcome evaluation.
The Ankh sign.
Temple of Karnak, Luxor
International Classification of
Functioning, Disability and Health
(ICF)

Classification internationale du fonctionnement, du


handicap et de la sante
CIF
ICF
The ICF is WHO's framework for measuring health
and disability at both individual and population
levels.
The ICF was officially endorsed by 191 WHO
Member States in the Fifty-fourth World Health
Assembly on 22 May 2001 (resolution WHA 54.21).
Unlike its predecessor, which was endorsed for use
in Member States as the international standard to
describe and measure health and disability.
ICF
The ICF puts the notions of 'health' and 'disability' in a new
light. It acknowledges that every human being can experience
a decrement in health and thereby experience some degree of
disability. Disability is not something that only happens to a
minority of humanity. The ICF thus 'mainstreams' the
experience of disability and recognizes it as a universal human
experience.
By shifting the focus from cause to impact it places all health
conditions on an equal footing allowing them to be compared
using a common metric - the ruler of health and disability.
Furthermore ICF takes into account the social aspects of
disability and does not see disability only as 'medical' or
'biological' dysfunction.
By including Contextual Factors, in which environmental
factors are listed, ICF allows to record the impact of the
environment on the person's functioning.
ICF or ICD-X - Many decisions have to be made
Body FUNCTIONS ENVIRONMENTAL
and Structures FACTORS

ACTIVITIES

PERSONAL
FACTORS
PARTICIPATION
BODY FUNCTIONS
ICF CHECKLIST - Version 2.1a, Clinician Form
Demographical data ; Diagnosis ICD-X revision
First Qualifier: Extent of impairments
0 No impairment means the person has no problem
1 Mild impairment means a problem that is present less than 25% of the time, with an intensity a
person can tolerate and which happens rarely over the last 30 days.
2 Moderate impairment means that a problem that is present less than 50% of the time, with an
intensity, which is interfering in the persons day to day life and which happens occasionally over the
last 30 days.
3 Severe impairment means that a problem that is present more than 50% of the time, with an
intensity, which is partially disrupting the persons day to day life and which happens frequently over
the last 30 days.
4 Complete impairment means that a problem that is present more than 95% of the time, with an
intensity, which is totally disrupting the persons day to day life and which happens every day over
the last 30 days.
8 Not specified means there is insufficient information to specify the severity of the impairment.
9 Not applicable means it is inappropriate to apply a particular code (e.g. b650 Menstruation
functions for woman in pre-menarche or post-menopause age).
BODY FUNCTIONS

CHAPTER 1
MENTAL FUNCTIONS
This chapter is about the functions of the brain: both
global mental functions, such as consciousness,
energy and drive, and specific mental functions, such
as memory, language and calculation mental
functions.
b1. MENTAL FUNCTIONS
b110 Consciousness
b114 Orientation (time, place, person)
b117 Intellectual ( incl. Retardation, dementia)
b130 Energy and drive functions
b134 Sleep
b140 Attention
b144 Memory
b152 Emotional functions
b156 Perceptual functions
b164 Higher level cognitive functions
b167 Language
BODY FUNCTIONS
CHAPTER 2
SENSORY FUNCTIONS AND PAIN
This chapter is about the functions of the senses, seeing,
hearing, tasting and so on, as well as the sensation of pain.

Seeing and related functions (b210-b229)


b215 Functions of structures adjoining the eye
Functions of structures in and around the eye that facilitate
seeing functions.
Inclusions: functions of internal muscles of the eye, eyelid,
external muscles of the eye, including voluntary and tracking
movements and fixation of the eye, lachrymal glands,
accommodation, pupillary reflex; impairments such as in
nystagmus, xerophthalmia and ptosis
Exclusions: seeing functions (b210); Chapter 7
Neuromusculoskeletal and Movement-related Functions
b229 Seeing and related functions, other specified and
unspecified
b2. SENSORY FUNCTIONS AND PAIN
b210 Seeing
b230 Hearing
b235 Vestibular (incl. Balance functions)
b280 Pain
BODY FUNCTIONS

CHAPTER 3
VOICE AND SPEECH FUNCTIONS

This chapter is about the functions of producing


sounds and speech.
b3. VOICE AND SPEECH FUNCTIONS
b310 Voice
BODY FUNCTIONS
CHAPTER 4
FUNCTIONS OF THE CARDIOVASCULAR,
HAEMATOLOGICAL, IMMUNOLOGICAL AND
RESPIRATORY SYSTEMS

This chapter is about the functions involved in the


cardiovascular system (functions of the heart and
blood vessels), the haematological and immunological
systems (functions of blood production and immunity),
and the respiratory system (functions of respiration and
exercise tolerance).
b4. FUNCTIONS OF THE CARDIOVASCULAR,
HAEMATOLOGICAL, IMMUNOLOGICAL AND
RESPIRATORY SYSTEMS

b410 Heart
b420 Blood pressure
b430 Haematological (blood)
b435 Immunological (allergies, hypersensitivity)
b440 Respiration (breathing)
BODY FUNCTIONS
CHAPTER 5
FUNCTIONS OF THE DIGESTIVE,
METABOLIC AND ENDOCRINE SYSTEMS

This chapter is about the functions of ingestion, digestion and


elimination, as well as functions involved in metabolism and
the endocrine glands
b5. FUNCTIONS OF THE DIGESTIVE,
METABOLIC AND ENDOCRINE SYSTEMS

b515 Digestive
b525 Defecation
b530 Weight maintenance
b555 Endocrine glands (hormonal changes)
BODY FUNCTIONS

CHAPTER 6
GENITO-URINARY AND
REPRODUCTIVE FUNCTIONS

b6. GENITOURINARY AND REPRODUCTIVE FUNCTIONS


b620 Urination functions
ICF Checklist World Health Organization, September 2003.
Page 3
b640 Sexual functions
b7. NEUROMUSCULOS
BODY FUNCTIONS
CHAPTER 7
NEUROMUSCULOSKELETAL AND
MOVEMENT-RELATED FUNCTIONS

This chapter is about the functions of movement


and mobility, including functions of joints, bones,
reflexes and muscles.
Movement functions (b750-b789)
b7. NEUROMUSCULOSKELETAL
AND
MOVEMENT RELATED FUNCTIONS

b710 Mobility of joint


b730 Muscle power
b735 Muscle tone
b765 Involuntary movements
BODY FUNCTIONS
CHAPTER 8
FUNCTIONS OF THE SKIN AND RELATED STRUCTURES
This chapter is about the functions of skin, nails and hair.

b8. FUNCTIONS OF THE SKIN AND RELATED


STRUCTURES
Part 1 b:
IMPAIRMENTS of BODY STRUCTURES

Body structures are anatomical parts of the


body such as organs, limbs and their
components.
Impairments are problems in structure as a
significant deviation or loss.
First Qualifier: Extent of impairment
0 No impairment means the person has no problem
1 Mild impairment means a problem that is present less than 25% of the time, with an intensity
a person can tolerate and which happens rarely over the last 30 days.
2 Moderate impairment means that a problem that is present less than 50% of the time, with
an intensity, which is interfering in the persons day to day life and which happens occasionally
over the last 30 days.
3 Severe impairment means that a problem that is present more than 50% of the time, with an
intensity, which is partially disrupting the persons day to day life and which happens frequently
over the last 30 days.
4 Complete impairment means that a problem that is present more than 95% of the time, with
an intensity, which is totally disrupting the persons day to day life and which happens every day
over the last 30 days.
8 Not specified means there is insufficient information to specify the severity of the impairment.
9 Not applicable means it is inappropriate to apply a particular code (e.g. b650 Menstruation
functions for woman in pre-menarche or post-menopause age).
Second Qualifier: Nature of the change
0 No change in structure
1 Total absence
2 Partial absence
3 Additional part
4 Aberrant dimensions
5 Discontinuity
6 Deviating position
7 Qualitative changes in structure, including accumulation of fluid
8 Not specified
9 Not applicable
Short List of Body Structures
s1. STRUCTURE OF THE NERVOUS SYSTEM
s110 Brain
s120 Spinal cord and peripheral nerves
s2. THE EYE, EAR AND RELATED STRUCTURES
s3. STRUCTURES INVOLVED IN VOICE AND SPEECH
s4. STRUCTURE OF THE CARDIOVASCULAR, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS
s410 Cardiovascular system
s430 Respiratory system
s5. STRUCTURES RELATED TO THE DIGESTIVE, METABOLISM AND ENDOCRINE SYSTEMS
s6. STRUCTURE RELATED TO GENITOURINARY AND REPRODUCTIVE SYSTEM
s610 Urinary system
s630 Reproductive system
s7. STRUCTURE RELATED TO MOVEMENT
s710 Head and neck region
s720 Shoulder region
s730 Upper extremity (arm, hand)
s740 Pelvis
s750 Lower extremity (leg, foot)
s760 Trunk
s8. SKIN AND RELATED STRUCTURES
ACTIVITIES AND PARTICIPATION
PART 2: ACTIVITY LIMITATIONS & PARTICIPATION RESTRICTION
Activity is the execution of a task or action by an individual.. Participation is involvement in
a life situation.
Activity limitations are difficulties an individual may have in executing activities.
Participation restrictions are problems an individual may have in involvement in life
situations.

The Performance qualifier indicates the extent of Participation restriction by describing


the persons actual performance of a task or action in his or her current environment.
Because the current environment brings in the societal context, performance can also be
understood as "involvement in a life situation" or "the lived experience"
of people in the actual context in which they live. This context includes the environmental
factors all aspects of the physical, social and attitudinal world that can be coded using the
Environmental. The Performance qualifier
measures the difficulty the respondent experiences in doing things, assuming that they
want to do them.
ACTIVITIES AND PARTICIPATION

The Capacity qualifier indicates the extent of Activity limitation by


describing the person ability to execute a task or an action. The Capacity
qualifier focuses on limitations that are inherent or intrinsic features of the
person themselves. These limitations should be direct manifestations of the
respondent's health state, without the assistance. By assistance we mean
the help of another person, or assistance provided by an adapted or specially
designed tool or vehicle, or any form of environmental modification to a room,
home, workplace etc.. The level of capacity should be judged relative to that
normally expected of the person, or the person's capacity before they acquired
their health condition.
First Qualifier: Performance
Extent of Participation Restriction

Second Qualifier: Capacity (without


assistance)
Extent of Activity limitation
0 No difficulty means the person has no problem
1 Mild difficulty means a problem that is present less than 25% of the time,
with an intensity a person can tolerate and which happens rarely over the last
30 days.
2 Moderate difficulty means that a problem that is present less than 50% of
the time, with an intensity, which is interfering in the persons day to day life and
which happens occasionally over the last 30 days.
3 Severe difficulty means that a problem that is present more than 50% of the
time, with an intensity, which is partially disrupting the persons day to day life
and which happens frequently over the last 30 days.
4 Complete difficulty means that a problem that is present more than 95% of
the time, with an intensity, which is totally disrupting the persons day to day life
and which happens every day over the last 30 days.
8 Not specified means there is insufficient information to specify the severity of
the difficulty.
9 Not applicable means it is inappropriate to apply a particular code (e.g. b650
Menstruation functions for woman in pre-menarche or post-menopause age).
Short List of A&P domains

d1. LEARNING AND APPLYING KNOWLEDGE


d110 Watching
d115 Listening
d140 Learning to read
d145 Learning to write
d150 Learning to calculate (arithmetic)
d175 Solving problems
d2. GENERAL TASKS AND DEMANDS
d210 Undertaking a single task
d220 Undertaking multiple tasks
d3. COMMUNICATION
d310 Communicating with -- receiving -- spoken messages
d315 Communicating with -- receiving -- non-verbal messages
d330 Speaking
d335 Producing non-verbal messages
d350 Conversation
Short List of A&P domains - 2

d4. MOBILITY
d430 Lifting and carrying objects
d440 Fine hand use (picking up, grasping)
d450 Walking
d465 Moving around using equipment (wheelchair, skates, etc.)
d470 Using transportation (car, bus, train, plane, etc.)
d475 Driving (riding bicycle and motorbike, driving car, etc.)
d5. SELF CARE
d510 Washing oneself (bathing, drying, washing hands, etc)
d520 Caring for body parts (brushing teeth, shaving, grooming, etc.)
d530 Toileting
d540 Dressing
d550 Eating
d560 Drinking
d570 Looking after one`s health
Short List of A&P domains - 3
d6. DOMESTIC LIFE
d620 Acquisition of goods and services (shopping, etc.)
d630 Preparation of meals (cooking etc.)
d640 Doing housework (cleaning house, washing dishes laundry, ironing,
etc.)
d660 Assisting others
d7. INTERPERSONAL INTERACTIONS AND
RELATIONSHIPS
d710 Basic interpersonal interactions
d720 Complex interpersonal interactions
d730 Relating with strangers
d740 Formal relationships
d750 Informal social relationships
d760 Family relationships
d770 Intimate relationships
d8. MAJOR LIFE AREAS
Short List of A&P domains - 4

d8. MAJOR LIFE AREAS


d810 Informal education
d820 School education
d830 Higher education
d850 Remunerative employment
d860 Basic economic transactions
d870 Economic self-sufficiency
d9. COMMUNITY, SOCIAL AND CIVIC LIFE
d910 Community Life
d920 Recreation and leisure
d930 Religion and spirituality
d940 Human rights
d950 Political life and citizenship
ANY OTHER ACTIVITY AND PARTICIPATION
GENERAL QUESTIONS FOR
PARTICIPATION & ACTIVITIES - 1
I. MOBILITY
(Capacity)
(1) In your present state of health, how much difficulty do you have walking long
distances (such as a kilometer or more) without assistance?
(2) How does this compare with someone, just like yourself only without your health
condition?
(Or: "than you had before you developed your health problem or had the accident?)

(Performance)
(1) In your present surroundings, how much of a problem do you actually have in
walking long distances (such as a kilometer or more)?
(2) Is this problem walking made worse, or better, by your actual surroundings?
(3) Is your capacity to walk long distances without assistance more or less than what
you actually do in your present surroundings?
GENERAL QUESTIONS FOR
PARTICIPATION & ACTIVITIES - 2
II. SELF CARE
(Capacity)
(1) In your present state of health, how much difficulty do you have washing yourself,
without assistance?
(2) How does this compare with someone, just like yourself only without your health
condition?
(Or: "than you had before you developed your health problem or had the accident?)
(Performance)
(1) In your own home, how much of a problem do you actually have washing
yourself?
(2) Is this problem made worse, or better, by the way your home is set up or the
specially adapted tools you use?
(3) Is your capacity to wash yourself without assistance more or less than what you
actually do in your present surroundings?
GENERAL QUESTIONS FOR
PARTICIPATION & ACTIVITIES - 3
III. DOMESTIC LIFE
(Capacity)
(1) In your present state of health, how much difficulty do you have cleaning the floor
of your where you live, without assistance?
(2) How does this compare with someone, just like yourself only without your health
condition?
(Or: "than you had before you developed your health problem or had the accident?)
(Performance)
(1) In your own home, how much of a problem do you actually have cleaning the
floor?
(2) Is this problem made worse, or better, by the way your home is set up or the
specially adapted tools you use?
(3) Is your capacity to clean your floor without assistance more or less than what you
actually do in your present surroundings?
GENERAL QUESTIONS FOR
PARTICIPATION & ACTIVITIES - 4
IV. INTERPERSONAL INTERACTIONS
(Capacity)
(1) In your present state of health, how much difficulty do you have making new
friends , without assistance?
(2) How does this compare with someone, just like yourself only without your health
condition?
(Or: "than you had before you developed your health problem or had the accident?)

(Performance)
(1) In your present situation, how much of a problem do you actually have making
friends?
(2) Is this problem making friends made worse, or better, by anything (or anyone) in
your surroundings?
(3) Is your capacity to make friends, without assistance, more or less than what you
actually do in your present surroundings?
GENERAL QUESTIONS FOR
PARTICIPATION & ACTIVITIES - 5
V. MAJOR LIFE AREAS
(Capacity)
(1) In your present state of health, how much difficulty do you have getting done all
the work you need to do for your job, without assistance?
(2) How does this compare with someone, just like yourself only without your health
condition?
(Or: "than you had before you developed your health problem or had the accident?)
(Performance)
(1) In your present surroundings, how much of a problem do you actually have getting
done all the work you need to do for your job?
(2) Is this problem fulfilling your job requirements made worse, or better, by the way
the work environment is set up or the specially adapted tools you use?
(3) Is your capacity to do your job, without assistance, more or less than what you
actually do in your present surroundings?
GENERAL QUESTIONS FOR
PARTICIPATION & ACTIVITIES - 6
VI. MAJOR LIFE AREAS
(Capacity)
(1) In your present state of health, how much difficulty do you have participating in
community gatherings, festivals or other local events, without assistance?
(2) How does this compare with someone, just like yourself only without your health
condition?
(Or: "than you had before you developed your health problem or had the accident?)
(Performance)
(1) In your community, how much of a problem do you actually have participating in
community gatherings, festivals or other local events?
(2) Is this problem made worse, or better, by the way your community is arranged or
the specially adapted tools, vehicles or whatever you use?
(3) Is your capacity to participate in community events, without assistance, more or
less than what you actually do in your present surroundings?
PART 3: ENVIRONMENTAL FACTORS
Environmental factors make up the physical, social and attitudinal environment in
which people live and conduct their lives.

Qualifier in environment:
0 No barriers 0 No facilitator

Barriers or facilitator

1 Mild barriers +1 Mild facilitator


2 Moderate barriers +2 Moderate facilitator
3 Severe barriers +3 Substantial facilitator
4 Complete barriers +4 Complete facilitator
Short List of Environment - 1
e1. PRODUCTS AND TECHNOLOGY
e110 For personal consumption (food, medicines)
e115 For personal use in daily living
e120 For personal indoor and outdoor mobility and transportation
e125 Products for communication
e150 Design, construction and building products and technology of buildings
for public use
e155 Design, construction and building products and technology of buildings
for private use
e2. NATURAL ENVIRONMENT AND HUMAN MADE
CHANGES TO ENVIRONMENT
e225 Climate
e240 Light
e250 Sound
Short List of Environment - 2
e3. SUPPORT AND RELATIONSHIPS
e310 Immediate family
e320 Friends
e325 Acquaintances, peers, colleagues, neighbours and community
members
e330 People in position of authority
e340 Personal care providers and personal assistants
e355 Health professionals
e360 Health related professionals
e4. ATTITUDES
e410 Individual attitudes of immediate family members
e420 Individual attitudes of friends
e440 Individual attitudes of personal care providers and personal assistants
e450 Individual attitudes of health professionals
e455 Individual attitudes of health related professionals
e460 Societal attitudes
e465 Social norms, practices and ideologies
Short List of Environment - 3
E5. SERVICES, SYSTEMS AND POLICIES
e525 Housing services, systems and policies
e535 Communication services, systems and policies
e540 Transportation services, systems and policies
e550 Legal services, systems and policies
e570 Social security, services, systems and policies
e575 General social support services, systems and policies
e580 Health services, systems and policies
e585 Education and training services, systems and policies
e590 Labour and employment services, systems and policies

ANY OTHER ENVIRONMENTAL FACTORS


ICF Options
balancing expectations and risks in neurological conditions

A wide range of ICF options


with an increasing need for activities and participations

PERSONAL
BODY
FACTORS ACTI
FUNCTIONS
Technical Age, sex, VITIES
assistance Polymorbidity, Operating Management PARTICI
PAIN
Health culture contact contact PATION
Verticalization
Range Family
ENVIRONMENT
of Motion Mobility
Home Leisure
Transport
MUSCLE Employment Locomotion Social life
WEAKNESS Health (rates
(performance
based) Transport Political
(time Services related) activities
COORDI
based) Assurance
NATION Grasp
Family
Friends ADL

and a need for adaptation to individual circumstances


Prof. Ivet Koleva, DM, PhD, DMSc
METHODS
FOR INVESTIGATION and EVALUATION
OF the PHYSICAL DEVELOPMENT
and FUNCTIONAL STATUS
of the MOTOR SYSTEM

SOMATOSCOPY
AND
ANTROPOMETRY
SOMATOSCOPY
INSPECTION
for determinate qualities of the patients body:
BODY MASS
DEVELOPMENT OF MUSCULAR SYSTEM
SQUELETON (thorax, vertebral spine, lower extremities, foot)
POSITION of the body
LOCOMOTION
DEGREES OF QUALITATIVE EVALUATION :
GOOD
FAIR
POOR
PHOTOSOMATOSCOPY
SOMATOSCOPY

INSPECTION from the front, at the back, sidelong


FORM of the THORAX conic, cylindrical, excavate, flat chest,
pectus carinatus; pathological (emphysematic, rachitic, paralytic thorax);
FORM OF VERTEBRAL SPINE physiological curves (neck
line), pathological turns (scoliosis);
BACK FORM normal, round, oval, excavate;
FORM OF LOWER EXTREMITIES normal, like O, like X;
FOOT FORM regular arch, flat foot - pes planus;
BODY POSITION excellent, good, bad.
ANTROPOMETRY
BJECTIVE QUANTITATIVE EVALUATION

STATURE HEIGHT in standing position men 170 +/- 6 m; women 156 +/- 5 m;
HEIGHT in sitting position on a chair 40 cm, from the vertex to the floor;
LONGITUDINAL MEASUREMENT OF THE BODY measurement from the
suprasternal point (incisura) to the symphysis;
LONGITUDINAL MEASURES OF EXTREMITIES standard measures of upper
and lower extremities
MEASUREMENT OF DIAMETERS
(BIACROMIAL; Sagital diameter of the thorax , pelvic diameter; distantia cristarum, distantia
spinarum, distantia trochanterica) circul measurement
MEASUREMENT OF BODY MASS kg;
BODY WEIGHT body-mass index;
CENTIMETRY (THORACAL DIAMETER, chest measurement, waist measurement, haunch measurement, abdominal
measurement) in centimeters;
EVALUATION OF THE PULMONAR VITAL CAPACITY SPIROMETRY
EVALUATION OF MUSCLE FORCE DINAMOMETRY
NUAL MUSCLE TESTING
ANTROPOMETRY
VALUATION OF THE SPINE (VERTEBRAL) MOBILITY
CERVICAL REGION flexion, extension, lateroflexion, rotation;
HORACAL REGION flexion (distance fingers-floor, tests Ott, Forestier
valuation in centimeters;
LUMBO-SACRAL SPINE (Schober test) cm

VALUATION OF VERTEBRAL CURVATURES :


KYPHOSIS, LORDOSIS, HYPER-.., HYPO-..;
SCOLIOSIS

PLANTOGRAPHY pes planus


GONIOMETRY
Objective method for QUANTITATIVE EVALUATION of the JOINT RANGE
OF MOTION
method SFTR acronyms of the planes in which the movement is
realized:
S SAGITAL PLANE
F FRONTAL PLANE
T RANSVERSAL PLANE
R ROTATION

During a movement the quantity of movement the distance between


the initial and the final position of the body segment - arc of the
movement; assessment in positive or negative angular degrees;

UNIVERSAL GONIOMETER evaluation from the anatomic standard position from 0 to


180 degrees;
GRAVITATION GONIOMETER scale 360 degrees (total round);
COMBI-GONIOMETER scale of 360 degrees.
ICF Options
balancing expectations and risks in neurological conditions

A wide range of ICF options


with an increasing need for activities and participations

PERSONAL
BODY
FACTORS ACTI
FUNCTIONS
Technical Age, sex, VITIES
assistance Polymorbidity, Operating Management PARTICI
PAIN
Health culture contact contact PATION
Verticalization
Range Family
ENVIRONMENT
of Motion Mobility
Home Leisure
Transport
MUSCLE Employment Locomotion Social life
WEAKNESS Health (rates
(performance
based) Transport Political
(time Services related) activities
COORDI
based) Assurance
NATION Grasp
Family
Friends ADL

and a need for adaptation to individual circumstances


FUNCTIONAL EVALUATION OF PATIENTS WITH NEUROLOGICAL
CONDITIONS OR DISEASES OF THE LOCOMOTOR SYSTEM, BASED ON ICF
The holistic approach to the patient must be obligatory the complex evaluation must
include:
COGNITIVE CAPACITIES (orientation, memory, attention, compliance during
rehabilitation, conscience of necessity of preventive measures due to the principal
disease);
PAIN (localization, type, intensity /verbal or visual analogue scale/; activities increasing
pain);
RANGE OF MOTION (active and passive);
MUSCLE FORCE OR MUSCLE WEAKNESS, motor deficiency;
COORDINATION (static, locomotor or dynamic ataxia);
MOBILITY (necessity of technical aids, gadgets; instruments, etc.);
ENDURANCE (capacity to support extreme changes, necessity of pauses during
investigations and functional activity);
INDEPENDENCE IN ACTIVITIES OF DAILY LIVING (bathing, dressing, eating,
hygiene, necessity of assistance in the self-care).
EVALUATION OF SOME PROBLEMS OF THE PATIENT:
Reduced endurance and supportability to , fatigue;
Motor weakness;
Coordination problems (posture, locomotion, grasping);
Pain ;
Necessity of preventive measures;
Necessity of technical aids;
Necessity of assistance;
Difficulties in activities of daily living;
Reduced performance and
Reduced functional mobility.
The final complex evaluation, based on ICF, have to include :

BODY FUNCTIONS (pain, range of motion, motor weakness,


dyscoordination syndromes - ataxia);
ACTIVITIES (verticalization, mobility, standing up, walking,
transport, grasping, ADL);
PARTICIPATION (family life, leisure, social life, participation in
political activities);
ENVIRONMENTAL FACTORS (environment at home & at work,
family & friends, health insurance, health assurance, social
contacts);
PERSONAL FACTORS (health culture, polimorbidity, age, sex).
***
FUNCTIONAL EVALUATION of patients with neurological ,
rhumatological and orthopedic conditions, with sensory, motor,
autonomic dysfunctions and deficiencies must be effectuated
before and after every rehabilitation course.

The evaluation have to be based on the holistic approach to the


patient, including :
specialized neurological, rhumatological, orthopedical
examination,
and
Functional examination.
SPECIALIZED EXAMINATION SCALES :

STROKE Brunnstrom scale; scale of Michels; Barthell


index; spasticity scale;
PARKINSON URSPD, Scale of Hoehn & Yahr;
MULTIPLE SCLEROSIS - EDSS or Kurtzke scale;
PARAPARESIS the Barthell index;
Diabetic polyneuropathy Dyck scale (modified);
Radiculopathies Drivotinov, Pozniak & Lupian scale;
Metabolic syndrome BMI, Obesity scales.
Bulgarian neurorehabilitation school has a long-time historical
tradition.
Actual state-of-the-art:
We apply a lot of neurological assessment scales and the
bases of the International Classification of Functioning,
disability and health (ICF) in the functional evaluation of
patients with neurological conditions.
We consider that the holistic approach to neurological patient
is very important in every day clinical practice and we use
therapeutic methods of different medical (neurology and PRM)
and non-medical specialties (sociology, psychology,
occupational /ergo/ therapy).
Depending on the results from evaluation of
the rehabilitation potential of a patient, we
apply a tailored selection of physical
modalities, methods, and combinations of all
these.
In every stage of the rehabilitation process it
is necessary to define the goal, tasks and
algorithm of neurorehabilitation.
Our opinion is that the complex
neurorehabilitation plan must include
physical and drug therapy, diet, self control of
the patients.
In our clinical practice we combine
(synergically) ne (maximum two)
lectrotherapeutic and one hydro / balneo /
thermotherapeutic procedure with two (or
three) kinesitherapeutic methods and some
occupational methods.
The individualized PRM-programme must include:
In case of motor weakness kinesitherapy, ergotherapy,
electrostimulations of paretic muscles (in motor points);
In case of spasticity kryokinesitherapy and
electrostimulation of antagonists of spastic muscles;
In case of altered self care autopassive exercises and
ergotherapy both for the healthy and the paretic
extremities;
In depression cases functional and entertaining
ergotherapy;
In all patients education in self-training: exercises,
auto-massages, auto-post-isometric relaxation.
In the neurorehabilitation algorithm in
diseases of the central nervous
system we include
kinesitherapy,
ergotherapy
and
education in activities of daily living.
Neurorehabilitation algorithm in diseases of the central
nervous system:
In post stroke hemiparesis with inportant spasticity we add
kryotherapy or paraffinothreapy.
In case of hemiparetic shoulder with a significant pain
syndrome, we add low frequency low intensity magnetic
field, in humero-scapular periarthritis + ultra-sound therapy
or phonophoresis with non-steroidal anti-inflammatory drug,
in trophic alterations + interferential currents.
In multiple sclerosis patients, we include too kryotherapy
and low frequency low intensity magnetic field; in urinary
incontinence galvanic slips or iontophoresis.
In Parkinsonism, the complex motor programme for every
day self-training is obligatory.
The neurorehabilitation algorithm in diseases of the
peripheral nervous system with peripheral paresis
could include
iontophoresis with Galantamini hydrobromicum
(Bulgarian drug Nivalin),
electrostimulations (in motor points of nerves and
of paretic muscles, according results of
electrodiagnostics),
peloidotherapy (mud applications),
analytic exercises (according results of manual
muscle test), ergotherapy, and therapeutic massage.
In all cases, our objective must be to provide
high-quality rehabilitation care, optimal for the
clinical form of the basic illness, adapted to
the concrete stage, with attention to the other
diseases, adapted to the capacities and
desires of the concrete patient, with the
strategic goal to obtain the best result in view
of quality of life of patients.
The control after a neurorehabilitation
course is obligatory.
At the end of every PRM-programme, we
effectuate a clinical, paraclinical and
instrumental evaluation of the results
obtained through rehabilitation, and
prescribes regular control and courses of
rehabilitation for outpatients of medical
centres and in-patients of specialized
rehabilitation hospitals, resorts, hospices.
In cases when proper synergic combination of
different types of procedures and between
physical and drug therapy was provided, there
were statistically significant favorable effects on
motor weakness, coordination, grip, balance,
gait, independence in activities of daily living,
quality of life of patients.
prf. Ivet Koleva, DM, PhD, DMSc
APPLICATION OF ICF
IN BULGARIAN REHABILITATION PRACTICE:
FROM THE INTRODUCTION OF ICF IN THE EDUCATION
TO THE FUNCTIONAL EVALUATION OF THE PATIENT

Current article presents the concepts of Bulgarian rehabilitation school about the necessity of application of
the principles of the functional evaluation and of the International Classification of Functioning, Disability
and Health (WHO, 2001) in clinical rehabilitation practice and in educational processus.
Functional evaluation of rehabilitation patient is an obligatory part of the rehabilitation algorithms of a lot of
neurological, orthopedical-traumatological and rhumatological conditions. Principal points of the functional
analysis and of the rehabilitation complexes of some socially important diseases are mentioned (stroke,
multiple sclerosis, Parkinsonism, traumatic brain injuries, medullar lesions; poliomyelitis; radiculopathies,
diabetic polyneuropathy; spondyloarthrosis, coxarthrosis, gonarthrosis; metabolic syndrome, etc).
Functional evaluation and ICF are presented in the educational plans of students in Medicine and in the
processus of specialization in Physical and Rehabilitation Medicine (Medical University of Pleven) ,
students in Medical rehabilitation and Ergotherapy (Medical Universities of Pleven and Sofia), students in
Rehabilitation (Medical colleges of Sofia and Stara Zagora). We introduced some specialized disciplines
v.gr. Functional evaluation in Rehabilitation and Functional evaluation and ICF in the educational
programme of students in Medical Rehabilitation and of PRM trainees. For quantitative evaluation of the
level of competence of students and trainees we applied series of electronic tests, especially created for
the rehabilitation practice and adapted to the role of different members of the rehabilitation team: medical
doctors - PRM specialists; PRM trainees; specialists and students in Rehabilitation, Physiotherapy, Medical
rehabilitation and Ergotherapy.

Prof. Ivet Koleva, DM, PhD, DMSc


Prof. Ivet Koleva, DM, PhD, DMSc
INTRODUCTION OF ICF SKILLS
IN THE EDUCATIONAL PROCESSUS OF:
PRM Specialists
PRM Trainees
Students in Medicine
Students in Medical Rehabilitation and Ergotherapy
Students in Rehabilitation

Prof. Ivet Koleva, DM, PhD, DMSc


SPECIALIZED COURSES AND DISCIPLINES
/concerning ICF/

NEUROREHABILITATION
POST-GRADUATE COURSE ICF & FUNCTIONAL EVALUATION IN
MU Pleven

DISCIPLINE FUNCTIONAL EVALUATION & ICF IN REHABILITATION MU


Pleven PRM trainees, students in Medicine, MR&OTh - bachelors and masters
degrees

FUNCTIONAL EVALUATION AND ICF IN KINESITHERAPY MC Stara Zagora,


MC Sofia

ICF IN PHYSICAL THERAPY AND REHABILITATION MU Sofia, bachelors degree

ICF IN NEUROREHABILITATION MU Sofia, masters degree

Prof. Ivet Koleva, DM, PhD, DMSc


Man, through the use of his
hands as energized by mind
and will, can influence the
state of his own health

(Mary Reilly, 1963).


Fields of
competences

PROFESSIONAL
COMPETENCES

BIO-ETHICS;
THEORETICAL PRACTICAL
KNOWLEDGE SKILLS CAPACITIES FOR
TEAM WORK

Minimal level of competence


Physical
Medicine

Rehabilitation Occupational
Medicine Therapy

Body
Activities &
Structures
Participation
& Functions

Personal and
Environmental
Factors

Minimal obligatory level of competence


TPCK - Technological Pedagogical Content Knowledge
PUNYA MISHRA and MATTHEW J. KOEHLER
Michigan State University - 2006

this model has much to offer to


discussions of technology
integration at multiple levels:
theoretical, pedagogical, and
methodological
Model of M. Porter
For the five forces of the market
Mishra
&
Kohler
&
Porter
Model
Buyer concentration to firm The existence of barriers to entry.
concentration ratio Economies of product differences
Degree of dependency upon Brand equity
existing channels of distribution Switching costs or Sunk costs
Bargaining leverage, particularly Capital requirements
in industries with high fixed costs Access to distribution Customer
Buyer volume loyality to established brands
Buyer switching costs relative to Absolute cost*
firm switching costs Industry profitability
Buyer information availability
Availability of existing substitute
products
Buyer price sensitivity
Differential advantage
(uniqueness) of industry products
Recency Frequency Monetary
value Analysis

Supplier switching costs relative


to firm switching costs
Degree of differentiation of inputs
Impact of inputs on cost or
differentiation
Presence of substitute inputs
Strength of distribution channel
Supplier concentration to firm
concentration ratio Buyer propensity to substitute
Employee solidarity
Relative price performance of substitute
Supplier competition - ability to
forward vertically integrate and
Buyer switching costs
cut out the buyer Product differentiation level
Number of substitute products available
in the market
Ease of substitution. Information-based
Innovation products are more prone to
Competitive advantage
Level of advertizing
substitution, as online product can
Competitive strategy easily replace material product.
Vertical integration Substandard product
Visibility Quality depreciation
COMPETENCES OF STUDENTS
Pilot study

40
35
30
25
20 woman

15 man
10
5
0
sex
Physical therapy - theory
Physical therapy practical skills
Ergotherapy - theory
Ergotherapy practical skills
FUNCTIONAL EVALUATION
Kinesitherapy specialized
methods
-

-
-
4.5 Professional competences
Number of students
Theory Practice
4 4 4
3.5 3 3
RESULTS

3
2.5 2
2
2 2
1.5 1
1 1
0.5
0
0 - 25 %
0 25 - 50 % 50 - 75 % 75 - 90 % 90 - 100 %
Theory 0 1 2 4 4
Practice 1 2 3 3 2

Fig. Evaluation of professional competences (theoretical knowledge and practical skills) of


students in Medical rehabilitation and Ergotherapy - masters degree (Module Neurorehabilitation)
percentage of valid answers of tests (questions and resolution of clinical cases)
90
80
88
70
60
YES
50
40 NO
30
13 I DON'T KNOW
20
4
10
0
of answers

STUDENTS OPINION
ABOUT THE INTRODUCTION OF MASTERS THESIS
ILLUSTRATION

IMPORTANCE OF FUNCTIONAL EVALUATION


IN CLINICAL PRACTICE

RESULTS OF FUNCTIONAL EVALUATION


STUDIES IN NEUROLOGICAL PATIENTS
CONCLUSION

IT IS IMPORTANT TO APPLY ICF PRINCIPLES


IN THE FUNCTIONAL EVALUATION
OF THE REHABILITATION PATIENT.
QUALITY OF
REHABILITATION

FUNCTIONAL EVALUATION & NEW ASSESSMENT METHODS

ICF

MODERN THERAPEUTIC METHODS

MODERN DEVICES

QUALIFICATION OF THE STAFF

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