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Community Reintegration: Life After Stroke

Community Reintegration: Life After Stroke. Dr Kenneth Lam Stroke Physiatrist. How I got invited to give this talk. Four “unrelated” Topics. Post Stroke Depression Driving After Stroke Sexuality Botox management of upper extremity spasticity to improve hand function.

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Community Reintegration: Life After Stroke

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  1. Community Reintegration: Life After Stroke • Dr Kenneth Lam • Stroke Physiatrist

  2. How I got invited to give this talk

  3. Four “unrelated” Topics • Post Stroke Depression • Driving After Stroke • Sexuality • Botox management of upper extremity spasticity to improve hand function

  4. Important topics regarding community reintegration!!! • Post Stroke Depression • Driving After Stroke • Sexuality • Botox management of upper extremity spasticity to improve hand function

  5. Objectives • Why discuss community reintegration • Terms, concepts and models • Determinants of Participation • Enhancing Participation • Measuring instruments (research vs simple clinical tools)‏ • Two simple tools

  6. Why this talk • Community reintegration is the final stage of rehabilitation with real world outcome • We don't talk about it enough • We don't ask our patient and caregiver about it enough • We don't measure it enough • We don't use it as an outcome for our therapeutic approaches

  7. Why this talk • Great proportion of stroke patients have restrictions in participation/community reintegration • Pang, Eng & Miller 2007 • Major area of restrictions: • Vocation • Leisure • Mobility • Education • Family • Financial • Social participation • Cardol et. al. 2002

  8. Concepts and models of functioning in society • Terms • Community reintegration • Participation • Occupational Performance/ Occupation • Instrumental ADL • Life habits • Models • ICD • ICF • Disability Creation Process Model

  9. Concentrate on 2 terms • Community Reintegration • Participation

  10. The term community reintegration is used to refer to returning to the mainstream of family and community life, engaging in normal roles and responsibilities, actively contributing to ones social groups and of society as a whole (Dijkers 1998). Community Reintegration

  11. Community Reintegration • Return to Roles Inside and Outside the home • Vocation • Avocation • Taking care of oneself

  12. Participation(WHO)‏ • Involvement in a life situation

  13. The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) – Older WHO concept • Impairment: Loss of structure, or abnormality of function at the organ level • Disability: Restriction of activities at the person level • Handicap: set of disadvantages within the individual's particular social context • Highlight the comparison with the able body in the social context. • ICF is more client centered, put into consideration of personal and environmental factors

  14. Newer WHO Concept-International Classification of Functioning, Disability and Health (ICF)(The ICF was officially endorsed by all 191 WHO Member States in the Fifty-fourth World Health Assembly on 22 May 2001)‏ • Body Function • Body Structure • Activities • Participation

  15. ICF components of Stroke

  16. Concepts and models of functioning in society • Terms have very similar meaning • Models used depends on discipline and which part of the country • There are differences in construct and limitation with each model especially if you're into reaserch • Concept of Particiaption and Community Reintegation almost completely overlap(Dijkers 1988)‏

  17. A unified view • Community reintegration is the final stage of Stroke Rehabilitation • “Real World” outcome of Community Reintegration are Quality of Life and Participation • Few RCT uses participation as outcome • Few trials have measures pertaining to participation

  18. Community Reintegration/Activities & Participation

  19. Post Discharge Period-Transition from Acute Rehabilitation to Community Reintegration • Discharge from Acute Care • Discharge from Inpatient Rehabilitation • Discharge from Outpatient Rehabilitation • Time of Change • Loss of social, emotional and practical support offered by professionals • Difficult time for patient and family • If Managed Well Can be Most Rewarding

  20. Life after “ rehab” • Ongoing therapy base rehabilitation beyond sixth month can improve ADL and fitness and BUT does NOT necessary address participation • This may require “planned withdrawal” of medical and rehabilitation services and substituting them with leisure and social activity to encourage independence and reintegration to normal life

  21. Life starts after formal therapy • This is when the real work start • From “Stroke Survivors” to “Stroke Thrivers”

  22. Predictors of Participation after Stroke (Desrosiers 2002)‏ • Assessment of Life Habits (LIFE-H)- DCP model • Daily activities • Nutrition • Fitness • Personal Care • Communication • Housing • Mobility • Social roles • Responsibilities • Interpersonal relationships • Community Life • Education • Employment • Leisure

  23. Predictors of Participation after Stroke (Desrosiers 2002)‏ • Best predictors • Depressive Affect • Lower extremity coordination • Balance • Age • Comorbidity

  24. Predictors of Participation after Stroke (Desrosiers 2002)‏ • Best predictors: Daily activities • Depressive Affect • Lower extremity coordination • Balance • Urinary Incontinence

  25. Predictors of Participation after Stroke (Desrosiers 2002)‏ • Best predictors: Social Activities • Depressive Affect • Lower extremity coordination • Upper extremity Functon • Expression • Walking Endurance

  26. Enhancing ParticipationStroke Survivor to Stroke Thriver • No easy job • Things have to happen at all level • System • Health Care Providers • Caregiver • Stroke Thriver

  27. Stroke Survivor to Stroke ThriverEnhancing Participation • System Level • APSS PILLAR 3 • Ensure adequate funding and resource • Community Program • Self Management Program • Caregiver Support • Education • Accessible Building • Job Accomodation

  28. Stroke Survivor to Stroke ThriverEnhancing Participation • Health Care Provider Level • Awareness Awareness Awareness • APSS • Fostering Community Participation After Stroke • http://www.strokestrategy.ab.ca/mod_fcp.html • Heart and Stroke Foundation • Train the trainer • Stroke Information Card • CME like this talk • Assess, treat or refer

  29. Stroke Survivor to Stroke ThriverEnhancing Participation • Caregiver Level – key to participation • Awareness Awareness Awareness • Support the Caregiver • Direct support • Homecare • Transfer of knowledge from Health Care Provider to caregiver (Stroke Information Card)‏ • Resources • Participation Assessment • Community based program • Living with Stroke • Peer Support • Stroke recovery association • Inform Alberta www.informalberta.ca

  30. Stroke Survivor to Stroke ThriverEnhancing Participation • Stroke Thriver • Awareness Awareness Awareness • Refer back to the system if required for further therapy • Direct support • Homecare • Transfer of knowledge from Health Care Provider to Stroke thriver (Stroke Information Card)‏ • Resources • Participation Assessment • Community based program • Living with Stroke • Living Well • Get on with your Life • Peer Support • Stroke recovery association • Inform Alberta www.informalberta.ca

  31. Stroke Survivor to Stroke ThriverEnhancing Participation • Stroke Thriver Level • Assist Stroke Thriver to Adapt(Alternate participation goals and expectation)‏ • Encourage positive coping skills • Education and problem solving on specific topics • Sexuality • Driving • Depression • Vocation (productivity consultant)‏ • SW consult

  32. Measuring Instruments • Assessment tools • Outcome measures

  33. Assessment of Participation“ NOT ANOTHER F%$^*NG FORM!!!” • Outcome Mesures: • Life Habit(LIFE_H) DCP model • COPM • RNL( retrun to normal livind index)‏ • Stroke Specific Quality of Life Scale • Different models and constructs • Conceptualizing and Measuring Participation • www.torontorehab.com/documents/ParticipationThemeWorkingReport141005.pdf - • Simple Clinical Tools

  34. Domains of Participation • Individual physical functioning • Nutrition • Fitness • Personal Care • Mobility • Mobility Aids • Driving • Transportation • Individual psychological functioning • Mood • Attitude • Leisure • Interaction with other individual • Communication • Interpersonal relationships • Sexuality

  35. Domains of participation • Interaction with the Community • Vocation • Education • Volunteering • Church/ Social group • Barriers – external factors • Accessible housing • Job accommodation • Financial • Support systems • Caregiver • Peer support

  36. Two Clinical Tools • Stroke Information Card • Stroke Recovery Score Card

  37. Stroke Information Card • GTA rehab network • Development of a New Resource for Family Physicians and Other Health Professional

  38. Stroke Recovery Scorecard • Easy for Stroke Thriver and Caregiver to fill out on their own • www.stroke.org/site/DocServer/card.pdf?docID=901

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