Thomas McNalley, MD
Chronic Care: Introduction to
Rehabilitation Medicine, Functional
Assessment & Disability
2014-15
Objectives
• Take a functional history
• Appreciate the scope and foci of
rehabilitation medicine (PM&R)
• Review functional scales
• Reflect on the definitions of disability and
impairment, and the impact of medicalization
on social roles.
Function
What have you done today?
• Mobility
• Activities of Daily Living
(Basic/Instrumental)
• Cognition/communication
• Vocational/avocational
• Transportation and community
mobility
Rehabilitation Physician
• PM&R
• physiATrist or phySIatrist?
• 4 yr residency
• Diagnosis and mgmt of neurologic and
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musculoskeletal impairment
Emphasis on function and QOL
Electrodiagnosis
Pain mgmt – both interventional and noninterventional
TEAM based intervention
Inpatient Rehabilitation Team
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Rehab Nursing
Rehab psychology
Social Work
Nutrition
Rehab/vocational counseling
Education/school
Therapists
• Physical
• Occupational
• Speech pathologists
• Recreation therapy
Conditions we Treat
• Spinal cord injury
• Traumatic Brain Injury
• Stroke
• Multiple sclerosis
• Low back pain
• Neuromuscular disease including:
• Muscular dystrophies
• ALS
• Neuropathies – hereditary and acquired
• Sports Medicine
• Musculoskeletal medicine
Functional scales
• Functional Independence Measure (“FIM”) or
pediatric version – “WEE FIM”)
• Karnofsky
• East Coast Oncologic Group (ECOG)
• Folstein Mini Mental Status
• Roland-Morris Pain Scale
• Pain Intensity and Interference Scale
Functional Independence Measure (FIM)
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Contains 18 items composed of 13 motor tasks and 5 cognitive tasks (BADLS)
7 point ordinal scale: total assistance (or complete dependence) to complete
independence
Scores 18 (lowest) to 126 (highest) indicating level of function
Scores are generally rated at admission and discharge
Dimensions assessed include:
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Eating
Grooming
Upper body dressing
Lower body dressing
Toileting
Bladder management
Bed to chair transfer
Toilet transfer
Locomotion (ambulatory or wheelchair level)
Cognitive comprehension Expression
Problem solving
Memory
Bathing
Bowel management
Shower transfer
Stairs
Social interaction
Palliative Care: Karnofsky Performance Scale
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* 100% - normal, no complaints, no signs of disease
* 90% - capable of normal activity, few symptoms or signs of disease
* 80% - normal activity with some difficulty, some symptoms or signs
* 70% - caring for self, not capable of normal activity or work
* 60% - requiring some help, can take care of most personal
requirements
* 50% - requires help often, requires frequent medical care
* 40% - disabled, requires special care and help
* 30% - severely disabled, hospital admission indicated but no risk of
death
* 20% - very ill, urgently requiring admission, requires supportive
measures or treatment
* 10% - moribund, rapidly progressive fatal disease processes
* 0% - death.
Palliative care: ECOG/WHO/Zubrod Scale
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0 - Asymptomatic
1 - Symptomatic but completely ambulant
2 - Symptomatic, <50% in bed during the
day
• 3 - Symptomatic, >50% in bed, but not
bedbound
• 4 - Bedbound
• 5 - Death
Geriatrics: Katz Independence Measure (ADLS)
ACTIVITIES
Points (1 or 0)
DEPENDENCE:
(1 POINT)
(0 POINTS)
NO supervision, direction or personal
WITH supervision, direction, personal
assistance
assistance or total care
Points: ________
(1 POINT) Bathes self completely or
needs help in bathing only a single part of
the body such as the back, genital area or
disabled extremity.
(0 POINTS) Needs help with bathing more
than one part of the body, getting in or out
of the tub or shower. Requires total
bathing.
Points: ________
(1 POINT) Gets clothes from closets and
drawers and puts on clothes and outer
garments complete with fasteners. May
have help tying shoes.
(0 POINTS) Needs help with dressing self
or needs to be completely dressed.
Points: ________
(1 POINT) Goes to toilet, gets on and off,
arranges clothes, cleans genital area
without help.
(0 POINTS) Needs help transferring to the
toilet, cleaning self or uses bedpan or
commode.
Points: ________
(1 POINT) Moves in and out of bed or
chair unassisted. Mechanical transferring
aides are acceptable.
(0 POINTS) Needs help in moving from
bed to chair or requires a complete
transfer.
(1 POINT) Exercises complete self control
over urination and defecation.
0 POINTS) Is partially or totally incontinent
of bowel or bladder.
(1 POINT) Gets food from plate into mouth
without help. Preparation of food may be
done by another person.
(0 POINTS) Needs partial or total help with
feeding or requires parenteral feeding.
BATHING
DRESSING
TOILETING
TRANSFERRING
CONTINENCE
Points: ________
FEEDING
Points: ________
TOTAL POINTS = ______
6 = High (patient independent)
dependent)
INDEPENDENCE:
0 = Low (patient very
Pain: The Roland-Morris Low Back Pain and Disability
Questionnaire
Please read instructions: When your back hurts, you may find it
difficult to do some of the things you normally do. Mark only the
sentences that describe you today.
 I stay at home most of the time because of my back.
 I change position frequently to try to get my back comfortable.
 I walk more slowly than usual because of my back.
 Because of my back, I am not doing any jobs that I usually do
around the house.
 Because of my back, I use a handrail to get upstairs.
 Because of my back, I lie down to rest more often.
 Because of my back, I have to hold on to something to get out
of an easy chair.
 Because of my back, I try to get other people to do things for
me.
 I get dressed more slowly than usual because of my back.
 I only stand up for short periods of time because of my back.
 Because of my back, I try not to bend or kneel down.
 I find it difficult to get out of a chair because of my back.
 My back is painful almost all of the time.
 I find it difficult to turn over in bed because of my
back.
 My appetite is not very good because of my back.
 I have trouble putting on my sock (or stockings)
because of the pain in my back.
 I can only walk short distances because of my back
pain.
 I sleep less well because of my back.
 Because of my back pain, I get dressed with the
help of someone else.
 I sit down for most of the day because of my back.
 I avoid heavy jobs around the house because of my
back.
 Because of back pain, I am more irritable and bad
tempered with people than usual.
 Because of my back, I go upstairs more slowly than
usual.
 I stay in bed most of the time because of my back.
Pain intensity and interference: 2-item scale
• “Over the last month, on average, how would
you rate your pain?” 1-10 scale
• “Over the last month, on average, how much
has pain interfered with your daily activities?”
1-10 scale, with 1 “no interference,” and 10
“unable to carry on daily activities.”
Impairment, disability and society:
International Classification of Function (ICF)
ICF: Back pain as example
Impairment and disability
• Impairment: an injury, illness, or congenital
condition that causes or is likely to cause a
loss or difference of physiological or
psychological function.
• Disability: a social construct -- the loss or
limitation of opportunities to take part in
society on an equal level with others due to
social and environmental barriers.
Examples of impairment and disability
Impairment (cause)
• Abnormal gait (spastic
diplegia)
• Executive dysfunction
(TBI)
• Fecal incontinence
(neurogenic bowel)
• Wheelchair use
(paraplegia)
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Disability
• Can’t join soccer team
• Reduced educational
performance
• Limited social interaction
• Reduced access to
buildings  fewer
employment opportunities
Models of disability
• Medical
• Identify
impairments and
classify them
• Reductionist?
• Brings resources
to bear
• “problem to be
fixed”
Models of disability (cont)
• Moral/Charity model
• Punishment/God’s will
• Inspiration porn
• Social Model
• Cultural construction of disability
• Social change can mitigate (eliminate?) disability
• Bio-psycho-social model
• See ICF
Implications of disability for healthcare
• 28% of insured persons with disabilities report not
getting needed tx, equipment, medications (vs. 7% of
non-disabled)
• 19% of those with disabilities did not get medical
care when they needed it (vs. 6% of nondisabled)
• Why?
• Lack of insurance coverage
• High costs
• Difficulties/disagreements w/ doctors
• Access to clinics
• Communication disorders
Resources
• UW Disability Studies (Upper campus)
• Disability Non-clinical selective
• Implicit Associations Test
https://implicit.harvard.edu/implicit/
• Dept of Rehabilitation Medicine
• Center for Human Development and
Disability
6 Whispers of the (palliative) care team
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Be a healing presence
Be a humble servant
Trust your team
Words are important; silence is profound.
Do your dance and retreat in peace.
Don’t be afraid to reach out and ask for help.
Thanks!