Rehabilitation Approach for a Person Experiencing Disability - Case Study Example

REHABILITATION PROCESS: WITHIN A COMMUNITY REHABILITATION APPROACH FOR A PERSON EXPERIENCING DISABILITY The community rehabilitation process would be undertaken keeping in consideration the following case study: I am an elderly widowed woman 70 years of age living alone, have advanced chronic Rheumatoid Arthritis (RA) and reside in Cunnamulla, Queensland, Australia. My home is a high set dwelling with 10 steps leading up to the front entrance door and internal steps leading to the bottom section of house where the laundry is located As climbing up and down the steps is extremely painful and dangerous for me to accomplish, I am unable to complete simple activities such as doing the laundry or watering the garden. To have an in-depth study of the case ‘Gordon’s Functional Health patterns’ would be analyzed on the grounds of three main areas biological, psychological and social. From the biological perspective the ‘activity exercise pattern’, from the psychological perspective ‘self –perception and self concept’ and ‘role-relationship pattern’ from social standpoint are selected for further scrutinization of the case. OBJECTIVES DETERMINED BASED ON THE ‘GORDON’S FUNCTIONAL HEALTH PATTERNS’: Biological: to determine the extent of the physical exercise as an effective treatment for RA, helping the patient in improving his mobility and confidence. Psychological: analyzing and interpreting the self perception attributes of the patient especially related to feelings of anger, frustration, fear etc which the patient often goes through. Social: To examine the strength and stability of the relationships between disease-related factors. Plan for goal 1 in accordance with the ICF Impairment of body structures and function barrier and facilitator: Rheumatoid Arthritis caused functional impairments in the form of long term joint damage, joint stiffness and swelling. The inflammatory substance generated by the cells caused damage to the cartilage which further leads to bone degeneration and functional impairment. Physiotherapy helps in the prevention of physical impairment and restores functional ability through proper use of exercise, education, and physical modalities. Moderate- to high-intensity aerobic and strengthening exercises help in stabilizing rheumatoid arthritis (Westby D M, Linda Li, 2006). Poor balance and the risk of falls can also be lessened through the use of specific therapeutic exercises as in the related case. Activity Barrier & Facilitator: The client suffers extreme pain and stiffness while sitting and standing and avoids long distance walks and also pertains to the risk of falling. The mobility is also restricted. Difficulty in keeping self care and domestic cores, commuting and use of time were the major barriers. Regular exercise and physical activity is vital for minimizing disability, preventing secondary chronic health problems related to sedentary lifestyles, and dawdling age-related musculoskeletal changes in the clients body functions. Participation Barrier & Facilitator: The client due to the mobility barriers is not able to participate in the family functions ceremonies, social activities, such as visiting friends or acquaintances. Therapeutic exercise facilitate the client to participate in the recreational activities Environmental Barrier & Facilitator: Barriers such as physical environments, lack of transport and basic services, such as electricity, and attitudes of others lead to social exclusion, loss of a sense of self and independence. Environmental facilitators such as assistive devices and health care services can improve functioning of the client. Personal Barrier& facilitator: the pain is the greatest personal barrier which prevents the client from exercising (Newman S; Mulligan K. 2000). Pain management is an important focus for intervention. Identification of potential strategy: The client could have access to physiotherapy and occupational therapy services for exercises and provision of assistive or adapted devices. Collaborative program planning: Specifically related to Arthritis, appropriate exercise programs were selected through some provincial divisions of The Arthritis Society (Joint Works and Water Works), local fitness facilities, and senior centres. Plan for goal 2: Step1: Identification of facilitators and barriers Impairment of body structures & Functions: self perception of the client is inclined towards feeling of sacredness, anger and frustration with her disability, which has been affecting her life despondently. Support from various community, state and national organisations helps in generating coping skills. Activity & Participation barrier: The feelings of empathy and dependence restrict the activities and participation of the patient. The bodily restriction of the patient’s in terms of elbows, eyes, wrists, fingers, ankles, toes etc makes her feel low and dejected . The Cunnamulla Primary Health Centre (2008) and Blue Care (2008) are two community organisations which extends necessary health care and domiciliary support services, helping the patient to regain the confidence and self esteem. Environmental barrier & facilitator: The attitude of others, both within the family and outside, plays a significant role in determining participants' self perceptions. Within their close family, the client felt accepted, understood and supported and expressed this as an important facilitator. Personal Barriers & Facilitator: The client’s personal barriers related to negative feelings of fear, anger, lost confidence poses another problem, hindering the recovery process. Identification of potential strategies: Illness and self perceptions do have important implications for adaptation to illness and they balance the impact of medical disease status on depression, physical function and pain. Strategies such as PSPP and PIP were identified as coping strategies (Macsween A, Brydson G, Fox KR, 2004). Collaborative program planning: Client agreed for the Benson Relaxation technique (Bagheri-Nesami M, Mohseni-Bandpei MA, Shayesteh-Azar M, 2006).along with the assessment of the PSPP and PIP (Macsween A, Brydson G, Fox KR. 2004) to improve her mental strength Plan for goal 3: Impairment of body structures and functions restrict the client to gain social acceptance, however the understanding of the family and supportive external environment works as a facilitator. Reduced activity & participation has also reduced the social circle of the client, however families assistance and local government’s services helps to be a part of the social activities as well. As per the environmental factors, the client described difficulties in moving around, interacting socially and taking part in community activities, fulfilling social roles and earning a living. The community based intervention helps in focusing on wellness, increased socialization, and peer support. Personal factor affected the client such as reluctance to go out and socialize because of difficulty in mobility and use of transport. Identification of potential strategies The social strategies may include taking assistance from the relatives, friends, and voluntary organizations for the fulfillment of daily chores. Make use of equipments such as wheel chair in order to become independent. Restructuring of institutions and provision of financial assistance is another potential strategy. Collaborative program planning Social support is linked to level of social activity. The greater variety in community based exercise facilities, classes, and equipment may enhance motivation and ongoing adherence (Westby D M, Linda Li, 2006). The client adheres to using support of the Australian Government Human Services Organisation known as Centrelink (2008) who could incorporate community care services into the work for the dole scheme for assistance provision to disabled community members like her. PITFALLS IN SETTING GOALS In setting up of goal related to physical exercise, the major drawback was lack of equipments. Physicians and health professionals should be equipped with strategies to overcome barriers and facilitate treatment adherence when prescribing exercise (Westby D M, Linda Li, 2006). Maintaining physical well-being is itself a challenge for people living with arthritis. Moreover, the physiological aspects of aging combined with the physical inactivity aggravate arthritis-related causes making it difficult for the clinician to identify and treat the interrelated signs and symptoms. Past studies clearly reveal that a stipulated coaching program for healthy physical activity have certainly resulted in improved perceived health status and muscle strength, but the mechanisms are still vague , as self-reported physical activity at healthy level had no remarkable changes as such (Brodin N, Eurenius E, Jensen I, Nisell R, Opava CH, 2008). Moreover, educating patients with RA may increase compliance for potential strategies but these effects are limited and short-term (Mayoux-Benhamou A, Giraudet-Le Quintrec JS, Ravaud P, Champion K, Dernis E;Zerkak D, Roy C, Kahan A, Revel M, Dougados M, 2008). Taking into consideration patient’s perception of health can be different with equal disease activity (Kievit W; Welsing PM; Adang EM; Eijsbouts AM; Krabbe PF; van Riel PL.2006). To establish a relationship between disease severity, disablement and psychological well-being is a complex exercise. Lack of time, motivation, and enjoyment are psychological constraints and it is likely that the patient believes that she is physically unable to exercise and unskilled in exercise. Primary social barriers to exercise including lack of support from friends and family and lack of specific recommendations from healthcare providers are another major pitfall. Environmental barriers including weather, such as cold and rain, along with the cost of programs could be another hindrance. On the whole the selection of three criteria is itself insufficient as other parameters crucial for the case study are ignored. INTERVENTIONS FOR EACH GOAL Good communication between community-based providers and health care professionals facilitates positive, successful exercise experiences are observed to be an effective intervention for attainment of the goal. Physicians and health professionals should be equipped with strategies to overcome barriers and facilitate treatment adherence when prescribing exercise. Potential strategies may include increasing exercise participation along with incorporating pain management strategies and coping skills into exercise interventions and ensuring that health care providers provide specific exercise advice to the patient with Rheumatoid Arthritis. . In accordance with the cartilage problem of the client, it is also stated that moderate weight-bearing and strengthening exercises increase glycosaminoglycan (GAG) content in the medial femoral cartilage (Westby D M, Linda Li. 2006). Physicians and other health professionals should consider all possible to enhance treatment adherence when prescribing exercises. The individual's stage of readiness to change exercise behaviour is also very important in defining education and prescription strategies, and increasing the possibility of continuous exercise. Physical activity must be encouraged for people with disabilities due to increase in endurance and strength that may improve functional capability as well and also because people with disabilities who participate in physical activity may further mitigate their risk for developing additional health conditions. To access the validity of self perception, the PSPP (Physical Self-Perception profile) and PIP (Perceived Importance Profile) are valid and sensitive to significant constructs in the mental health of women suffering from Rheumatoid arthritis. Health interventions based on understanding and modifying perceptions of the client related to specific illness may prove useful in facilitating patient well-being (Groarke A, Curtis R, Coughlan R, Gsel A, 2004). The Benson Relaxation technique helps in coping up with clinical symptoms, anxiety, depression, feelings of low well-being and also facilitates in the declining procedure of the disease process (Bagheri-Nesami M; Mohseni-Bandpei MA; Shayesteh-Azar M, 2006). Home based strength training program is a beneficial intervention for transforming a negative self perception into something positive and constructive. A cognitive behavioral intervention can be used in order to facilitate patient adjustment which can also help in management of stress and appraisal. The development of adaptive coping strategies and utilization of social support resources is a beneficial strategy in the current case (Curtis R, Groarke A, Coughlan R, Gsel A. 2005). The management of involves both the physical and social/psychological aspects of disease (Oldfield D, Felson T D, 2008). The main objective of carrying out any intervention is to prevent or control joint damage, minimize pain, maintain physical function and improve HRQL through social and psychological support. CLIENT INFORMATION SHEET (MEDICATION) Rheumatoid Arthritis is a disease in which joints, both of the hands and feet are inflamed resulting in swelling and severe pain. The treatment of the disease may include specific exercises and splinting, drugs and surgery. As far as drugs are concerned, following medications are commonly used to treat Rheumatoid Arthritis: non-steroidal anti-inflammatory drugs (NSAIDs), these drugs may help in reduction of pain but have no effect on the inflammation. The drugs have a high level of side effects. Disease-modifying antirheumatic drugs DMARDs generally slow down the progression of the disease and also show relieve symptoms and are prescribed as soon as the disease is diagnosed. Corticosteroids are high effective drugs for reducing inflammation anywhere in the body but are effective only for a short period of time. Immunosuppressive drugs can slow the progression of disease and decrease the damage to bones adjacent to joints. Leflunomide is a drug with lot of benefits but at the same time may also cause suppression of blood cell production and lung scarring, anakinra (Altman D R, 2008), TNF inhibiting drugs etc (Markenson A J. 2007). Arthritis Factsheet Who and How Many are Affected by Arthritis? Arthritis Cost Estimates Arthritis Risk Factors Affects joints and covers more than 100 conditions and diseases. Joints, tissues, and other connective tissues get affected. Arthritis is a rheumatic condition and includes rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, rheumatic fever, Lyme arthritis, juvenile rheumatoid arthritis, gout, bursitis, carpal tunnel disease and other disorders. Arthritis is characteristic of pain, stiffness and aching in and around the joint. 46 million adults, 18 and above. People older than that report doctor-diagnosed arthritis and 19 million report activities limited by and attributable to arthritis. Children aren’t left unaffected. As many as 75% of people affected by arthritis are younger than 65 years of age. All age groups are affected. The breakup is: 34.3 million white adults, 4.4 million black adults, 2.6 million Hispanic adults, and 1.3 million adults of other races have arthritis. This disease is considered to be a leading cause of disability. Nearly 750,000 hospitalizations and 36 million ambulatory care visits. Women share 63% of this statistics, and those below 65 years of age constitute 63% of these visits. Total estimated cost: $80.8 billion; Total costs (medical care and lost productivity) were $128 billion. Women make up about 60% of arthritis cases. Older Age Obesity Joint Injuries The Effectiveness of Medications for RA In general many disease-modifying agents are effective, both as monotherapy and in combination, for treating rheumatoid arthritis. Through monitoring disease activity and selecting pharmacologic and nonpharmacologic treatment, clinicians can optimize the care of their patients with rheumatoid arthritis (Chou R, 2008). The patient may be benefited by the application of such drugs to a very large extent. Positive Effects of Medications: NSAIDs: reduction of pain, swelling and inflammation, facilitating patients to move more easily and carry out normal activities. DMARDs: Prevents joint and cartilage destruction. Immunosuppressant: restrain the overly active immune system, rapid improvement Corticosteroids: anti inflammatory and immuno-suppressive effects Negative side effects: toxicity is a serious side effect, - Goldskin rash, mouth sores, upset stomach, kidney problems, low blood count, Osteoporosis , Mood changes, Fragile skin, easy bruising, Fluid retention, Weight gain, Muscle weakness, Onset or worsening of diabetes, Cataracts, increased risk of infection, Hypertension (high blood pressure) (Key Note 1). Considering the Use of medications: People who suffer from RA are generally prescribed medications. Studies have revealed that early intervention through medication and the use of drug combinations instead of one medication alone can result in large benefits thereby reducing or preventing joint damage. Once the disease improves or is in remission, the doctor may gradually reduce the dosage or prescribe a milder medication. Managing Medications Self management programs and patient education along with support groups help people to become more informed and participate in their self care. The patient can take active participation in self management program by knowing the effects of each medicine and cautiously imbibing the program set by the physician. Alternatives to medication Special diets, vitamin supplements, care of joints, stress reduction and other alternative approaches such as physical exercise, surgery have been suggested for the treatment of rheumatoid arthritis. Some of these alternative or complementary approaches may help the patient cope or reduce some of the stress associated with living with a chronic illness. The patient must exercise regularly despite, the pain and other obstructions for better recovery. IMPACT ON FAMILY UNIT The patient’s family plays an imperative role in the rehabilitation process. Family members are the first person to be affected by the disability and experience numerous changes in the process. Such changes are not positive at all times because such changes may also lead to distress and conflict. Financial problems due to excessive costs in provision of extra facilities, medication, physiotherapy and other interventions just add on to more stress level on the family. Changes in community re-entry can also pose different kinds of problems for the family (Johnson W R, 2008). The family members experience the similar feelings of anxiety, fear, depression, frustration as what the patient undergoes as they too have a transformed role to play in the future. Disability does not happen to an individual, it happens to the entire family. It changes the life course of the family as a unit and in response how the family reacts towards the disability and its challenges affects the person development suffering from the disability. Disability poses extra demand and challenges on the family in terms of disability type, age etc. financial burden associated with social services, transportation, special diet, buying or renting equipment or devices etc is also increased ((Johnson W R, 2008). Some of the families though have alternative measures for it such as insurance etc yet getting awared about the kind of services and programs one is eligible for and then working with a bureaucracy to certify that eligibility is another daunting challenge to be faced by the family. Based on the case study, the impact of the disability of the client is reflected both on the family and the client. However, the support provided by the family in the development of the client’s condition is acknowledgeable yet all requirements are not being able to cope with due to internal and external constraints. The client’s social restriction in terms of visiting her friends and family as per her own will has reduced due to the unavailability of assistance which may have been provided by the family members due to their own commitments. The family is also bounded to be present on all occasions as the client needs continual assistance for carrying out the daily activities. Commuting is another problem where the family has an important role to play as the client is dependent on them to move from one place to another, but the family members are unable to provide ongoing transportation as they have their own responsibilities. Coordination of services, day to day strain of providing care and assistance, grieving over the clients state, affect the family unit on a very large extent. Not only the patient’s but the family social role is also disrupted as there is lack of time , money and energy to accomplish those tasks. (Johnson W R, 2008) The adverse or the negative stress levels can however be controlled if they are properly identified. A collaborative effort by the rehabilitation team, patient and the family can help in designing realistic solutions to the relevant problems, family education and counselling can also prove to be beneficial under such circumstances. REFERENCES Altman D R. 2008. Rheumatoid Arthritis. Retrieved on 16th Jan, 2009, http://www.merck.com/mmhe/sec05/ch066/ch066b.html Brodin N; Eurenius E; Jensen I; Nisell R; Opava CH; 2008.Coaching patients with early rheumatoid arthritis to healthy physical activity: a multicenter, randomized, controlled study. Arthritis Rheum.  2008; 59(3):325-31 Bagheri-Nesami M, Mohseni-Bandpei MA, Shayesteh-Azar M. 2006. The effect of Benson Relaxation Technique on rheumatoid arthritis patients: extended report. Int J Nurs Pract. , 12(4):214-9. Blue Care 2008, Uniting Care Queensland, Toowong, Qld, Australia, viewed on 16th Jan,2009, . Cunnamulla Primary Health Care Centre 2008, Queensland Government, Queensland Health, Cunnamulla, QLD,, viewed on 16th Jan,2009, Read More