Hjem > Rehabilitering og behandling af patienter med rygmarvsskader – tetra- og paraplegi

Rehabilitering og behandling af patienter med rygmarvsskader – tetra- og paraplegi

Traumatisk eller non traumatisk rygmarvsskade på cervikalt, thoracalt og lumbalt niveau. Rehabiliteringen/behandlingen varetages af 2 højt specialiserede centre.

I Øst Danmark på Afdeling for Rygmarvsskader i Hornbæk, Glostrup Hospital og i Vest Danmark på Vestdansk Center for Rygmarvsskade i Viborg. Rehabilitering/behandlingen foregår i tæt tværfagligt samarbejde med og omkring patienten. Patient og pårørende inddrages i alle beslutningsprocesser.

Formål

Formålet med den ergoterapeutiske behandling og rehabilitering af rygmarvsskadede patienter er at medvirke til, at patienten opnår så aktivt og deltagende et liv som muligt ved:

  • At møde patienten, dér hvor patienten er, ved at betragte situationen fra patientens perspektiv
  • At inddrage og indgå i et samarbejde med patienten i målsætning og planlægning af behandlingen
  • At have den coachende tilgang i kommunikationen med patienten i relation til aktivitetsproblematikker og målsætning
  • At motivere patienten til at træne til størst mulig grad af fysisk selvstændighed
  • At fokusere på patientens egne ressourcer og de ressourcer der står til rådighed omkring patienten
  • At formidle viden og erfaring til patient og pårørende om hvordan en hverdag med funktionsevnenedsættelser kan gribes an, bl.a. ved at introducere/møde andre rygmarvsskadede (rollemodeller) der har et velfungerende hverdagsliv samt etablere kontakt til bruger organisationer
  • At støtte patienten i den psykiske bearbejdning af hverdagslivets forandrede betingelser ved at hjælpe patienten med at komme til en forståelse med sig selv. Det gælder i forhold til den daglige livsførelse som rygmarvsskadet
  • At vejlede, rådgive og hjælpe patienten omkring boligmæssige, fritid- og sport, transport-, uddannelses- og erhvervsmæssige forhold
  • At introducere muligheder for nye aktiviteter og nye former for deltagelse

Fremgangsmåde

  • Vi benytter OTIPM som arbejdsprocesmodel
  • COPM til at identificere aktivitetsproblemerne
  • SCIM (Spinal Cord Independence Measure, version 3) som et tværfagligt scorings redskab på færdigheder

Målsætning: Der udarbejdes målsætning - mål på kort og på lang sigt i relation til aktivitet, grad, tid og sted - i samarbejde med patienten ca. hver 14. dag.

Den ergoterapeutiske behandling består af følgende områder:

  • Færdighedstræning (ADL)
  • Funktionstræning
  • Hjælpemidler
  • Boligtilpasning
  • Psykiske støtte og krise bearbejdning
  • Sundhedsfremme og forebyggelse
  • Sociale tiltag
  • Opfølgning

Færdighedstræning:

  • Spisning
  • Personlig hygiejne
  • Badning
  • Af- og påklædning
  • Arbejde fra en kørestol, arbejdsstol el. ståstøttestol
  • Køkkentræning
  • Træning i at færdes udendørs med fokus på tilgængelighed og anvende offentlige transportmidler
  • Dyrke fritidsaktiviteter
  • Ophold i træningslejlighed
  • Holdtræning efter behov

Funktionstræning:

  • Muskelkraft
  • Ledbevægelighed
  • Koordination
  • Kropsbalance
  • Kompenserende træning (ved nedsat eller ophævet muskelstyrke og sensibilitet)
  • Funktionel Elektrisk Stimulation
  • Robottræningsarm Armeo
  • Styrketræning
  • Udholdenhedstræning
  • Afprøvning/tilpasning af skinner/bandager
  • Profylaktisk behandling for at undgå ødem og kontrakturer

Undersøgelser, tests, beskrivelse og vurdering af funktionsproblematikker:

  • Håndfunktion - THT, Grasp/release test samt andre Trofiske forhold
  • Ledbevægelighed - passiv og aktiv Tonus - Spasticitet (Modificeret Asworth Scala)
  • Muskelkraft (muskeltest: Daniels and Worthingham´s, MULE: e-håndfunktionskraft)
  • Sensibilitet (test af stillingssans og 2 Pd)
  • Koordination (Grasp/realease test, Box & Block, Pegboard)
  • Smerter (Numerisk Rating Scale - NRS)
  • Lejring
  • Forflytning
  • Dysfagi (FOTT)
  • Færdigheder (SCIM og ADL skema)

Håndfunktion:
En af de væsentligste opgaver i forbindelse med træningen af tetraplegikere er generhvervelse af håndfunktion. Det drejer sig om vurdering og stillingtagen til hvilke typer af greb, det er muligt at opnå. For tetraplegikere med høje cervicale læsioner kan det ofte være nødvendigt med individuelt tilpassede skinner.

Vurdering af OE i samarbejde med håndkirurg: Tilbud til alle patienter med tetraplegi inden udskrivelse med henblik på eventuelle håndkirurgiske indgreb.

Vurdering af OE i samarbejde med ortopædkirurg: I forhold til behov for Botox i spastiske muskler med henblik på mulighed for seneforlængelser.

Hjælpemidler:

  • Afprøvning og tilpasning af hjælpemidler
  • Fremstilling og tilpasning af individuelle hjælpemidler
  • Afprøvning af større tekniske hjælpemidler
  • Udvikling af nye hjælpemidler
  • Kontakt til forhandlende firmaer og hjælpemiddelmarkedet
  • Ansøgning af hjælpemidler

Med specialtilpassede ”håndremme” og ”håndklemmer” til bestik, køkkenredskaber, computer og redskaber til personlig pleje kan patienten træne i at spise, lave mad, benytte computer og at klare personlig hygiejne helt eller delvist.

Boligtilpasning:

  • Vurdering af eksisterende bolig og eventuelt at medvirke til at finde ny bolig
  • Vejlede og rådgive kommune og patient med at ændre bestående eller ny bolig
  • Udarbejdelse af hjemmebesøgsrapport

Psykisk støtte og krise bearbejdning:

  • Støtter og motivere patienten og dennes pårørende i at finde frem til og afprøve nye handlemuligheder samt at hjælpe til at få kontrol over eget liv
  • At støtte patient i at få en forståelse for en fremtidig identitet, der indeholder aktivitet og deltagelse trods nedsat funktionsevne
  • At støtte patienten i at udvikle nye roller og reorganisere sin identitet

Forebyggelse og sundhedsfremme:

  • Forebyggelse har til formål at forhindre yderligere funktionsnedsættelser og sygdom. Det betyder, at den ergoterapeutiske behandling skal være profylaktisk eksempelvis i relation til ødem, kontrakturer, tryksår med fokus på livsstil. Ergoterapeuten har undervejs i behandlingsforløbet den profylaktiske tankegang med i alle behandlingstiltag. Vi formidler, kontinuerligt den viden vi har til patient og pårørende.
  • Sundhedsfremme satser på mobilisering af ressourcer, handlekompetencer og mestringsstrategier. Ergoterapeutens opgave er at vende opmærksomheden væk fra sygdom over mod sundhed og afdække de faktorer, der støtter sundhed med fokus på livsvilkår.

Sociale tiltag:

  • Familie
  • Sexualitet (individuel rådgivning til kvinder ved ergoterapeut og sexolog - for mænd ved læge og sexolog eller i et tværfagligt team)
  • Borgerstyret Personlig Assistance (§96)
  • Venner
  • Fritidsinteresser
  • Sport
  • Job
  • Uddannelse

Opfølgning:
Patienterne følges livslangt i hospitalets regi. De ergoterapeutiske opgaver er opfølgning af samtlige ovennævnte punkter.

Målgruppe

Patienter med rygmarvsskade.

Hyppighed

Indlæggelsestiden for nytilskadekomne er afhængig af skadens omfang typisk mellem 3-10 måneder. Patienter med para- og tetraplegi deltager i ergoterapeutisk behandling/træning individuelt og/eller i grupper under indlæggelsen. Behandlingsbehovet vurderes af den behandlende ergoterapeut sammen med patienten og fortsætter så længe, der er træningspotentiale.
I praksis foregår den ergoterapeutiske behandling for tetraplegikere ved individuel træning ca. 45 min. 4 til 5 gange ugentligt. For paraplegikeres vedkommende 1 til 5 gange ugentligt.

Der dokumenteres løbende, min. hver 14. dag i elektronisk patient journal (OPUS og SCi basen)

Referencer

  • OTIPM, the Occupational Therapy Intervention Process Model (Fisher A.G 2009)
  • COPM, Canadian Occupational Performance Measure, (Mary Law, Sue Baptiste, Anne Carswell, Mary Ann McColl, Helene Polatajko,and Nancy Pollock) Dansk oversættelse af det Canadiske undersøgelsesredskab,
  • COPM, ved Ane Andersen, Ulla Ross, Jytte Tjørnov og Eva Wæhrens, 2000. Revideret version af 3. udgave; revideret af Anette Enemark Larsen, MScOT, 2007.
  • Biering-Sørensen Fin, Rygmarvsskader. I: Danneskjold-Samsøe, Lund, Avlund (red.) Klinisk reumatologi for ergoterapeuter og fysioterapeuterred. 2002 Kap. 47 s. 711-725 Munksgaard, Danmark
  • Grasp/release test, Wuole et al. 1994, Smith et al. 1996
  • THT - Tetra Hand Test, Gregersen H. et al, 1999 +2004
  • SCIM, Spinal Cord Independence Measure (SCIM III) Cats et al. 2007
  • Preservation of Upper Limp Function Following Spinal Cord Injury: A clinical practice Guideline for health-care Professionals, Consortium for Spinal cord medicine by Paralyzed Veterans of America 2005
  • Holtz A. og Levi R., Rygmärgsskador, Studentlitteratur 2006
  • Para- og tetraplegi – en håndbog for rygmarvsskadede 2002
  • Brudstykker – rygmarvsskadede fortæller 2002
  • Pårørende – tæt på rygmarvsskadede 2009
  • E-learning, http://www.iscos.org.uk/elearning 2012
  • Wangdell J, Fridén J. Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia. J Hand Surg Eur Vol. 2010 Sep;35(7):563-8.
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  • Moberg E. The upper limb in Tetraplegia. A new approach to surgical rehabilitation. Stuttgart: Georg Thieme; 1978.
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  • Woulle KS, Bryden AM, Peckham PH, Murray PK, Keith M. Satisfaction with upper extremity surgery in individuals with tetraplegia. Arch Phys Med Rehabil 2003; 84:1145-9.
  • Rothwell AG, Sinnott A, Mohammed KD, Dunn JA, Sinclair SW, Upper limb surgery for tetraplegia: A 10-year re-review of hand function. The Journal of Hand Surgery Vol. 28A No 3 May 2003.
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  • Biering-Sørensen F, Holst-Nielsen F. Tetraplegi-håndkirurgi. Hvad hjælper håndkirurgi tetraplegikere? (Tetraplegia-hand surgery. What does hand surgery help tetraplegics?) Paraplegi 1988; 10(1):¬16-8 (In Danish).
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Sidst opdateret
20.02.2014

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Um Olhar Sobre A Mulher Da Terceira Amazônia, Em O Naturalista No Rio Amazonas

Para as mães solteiras arranjar um namorado é muito mais fatigante,
pois caso de experienciar um filho parece afugentar os
homens. Estimula sua libido e disposição no ato sexual por possuir ingredientes Cem
por cento naturais fornecendo inúmeros benefícios para apimentar a relação a dois, oferecendo a intensidade princípio de prazer, sua ereções serão mais prazerosas e duradouras.

Eventualmente estima-se que single "Take on Me" vendeu entre 6 bem como 7 milhões de cópias no
mundo afora; chegou a ser número um na Billboard Hot 100 dos Estados Unidos e segunda colocada na parada melodioso da
Grã-Bretanha.5 As vendas da canção nos Estados Unidos foram ajudadas pelo videoclipe exibido na MTV que imitou
as cenas climáticas do filme, Altered States,
de Ken Russell.

Comecei a ingerir Power Blue no mesmo dia aguardando os primeiros resultados aparecerem.
Quer as indivíduos que saibam sejam poucas ou muitas, há, aqui,
qualquer vida par simples, que abrange aqueles que pensam que conhecem aquele homem totalmente e aqueles
que "realmente" conhecem.

Abri na sala da minha casa uma sala de aula saí no bairro com um caderno na participação recrutando crianças para alfabetizar,
produzir reforço, ajudar nas atividades escolares ? Durante
a nossa essência inteira, fomos ensinadas que homem está sempre acima da mulher,
logo sucesso deve seguir primeiramente dele e, se possível, sempre sucesso do homem deve ser maior que da
mulher.

Não foi porque Freud colocava toda a alarde na
sexualidade, no quadro da primeira teoria das pulsões (Freud 1962 1905), que a agressividade não tempo já um problema para
discurso freudiano. A velocidade da circulação da moeda depende, nessa perspectiva, com fatores institucionais e culturais e só
sofre mudanças brandas ao longo do tempo.

Com uma pitada de bom compleição, Dr Goldstein disse
sugerir festival da melancia a fim de aumentar desempenho sexual dos homens,
seria equivalente a alguém despejar qualquer garrafa de cerveja
em Minneapolis, onde rio Mississipi começa, e
esperar que certo impacte ser em Nova Orleans.

marco teórico da pesquisa realizada é obra Teoria Geral dos Contratos e Contratos
em Espécie do mestre Flávio Tartuce que faz menção em sua excelente sobre os fundamentos contratuais, classificando os requisitos para a
confecção de um negócio seguindo todos os pressupostos determinados por princípio para
sua plena eficácia entre as exigências contratantes.

" luta é um porte fundamental da vida por atender às necessidades humanas, tanto do momento de vista material como espiritual, já que através das tarefas concretas homem se sustenta e, ao mesmo tempo, expressa seu modo original de realizar valores dentro de um determinado tempo e lugar.

Destinado a Braga, (2006) a sexualidade sempre foi qualquer fonte de inúmeros preconceitos e fantasias. Outros dizem, com considerável desrespeito e mágoa, como parceiro se esquiva de momentos íntimos, optando por outras atividades ou mesmo criando qualquer desculpa para não trepar.

Foi-se sazão em que só os homens tinham a obrigação de iniciar uma conteúdo com uma mulher e tomar a atitude para determinado possível relacionamento. A carta fala em cima de as tentativas de Paulo para orientar os fieis na edificação da comunidade, baseadas em sua percepção dos valores fundamentais da fé em Jesus Cristo (BIBLIA, 2003).

Como já dissemos, homens e mulheres salubre diferentes. Propicia ereções mais duradouras e mais rígidas, aumento da desejo, e, consequentemente, aumento do prazer e satisfação venéreo seu e a sua parceira. Tanto homens quanto mulheres precisam ter verdadeiros companheiros de vida, por essa razão, a liberdade parece tão atrativa. http://www.e-mfp.org/ojs/index.php/MFP/user/viewPublicProfile/64045

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O Paraíso Na Ótica Dos Viajantes Do Século XVI

Droga natural para impotência sexual masculina os populares afrodisíacos naturais a fim de tratar a disfunção erétil.
Percebe-se na história da cidadania, que desde a
antiguidade as diferenças na ordem das sociedades entre
senhores bem como escravos, nobres e servos, patrão e empregado, ricos e pobres, geram um contexto de antagonismo conflituoso de classes onde se busca superar as injustiças e as desigualdades sociais.

È constituído de certo ambulatório especializado em
Saúde Mental e uma unidade assistencial de
atenção secundária, CAPS III, destinada ao atendimento
multiprofissional (farmacêutico, médicos clínicos, psiquiatras, psicólogos, assistentes
sociais, sociólogos, enfermeiros, terapeutas ocupacionais, entre outros profissionais de
nível médio e técnico) dos pacientes neuróticos
graves e psicóticos, que permite tanto um
sistema de referência na atenção com os gastos hospitalares
quanto determinado incipiente deslocamento do financiamento
no saúde mental.

homem fica jacente com as pernas abertas e a mulher se deita sobre ele com as pernas fechadas, ela
abraça carinhosamente, esfregando os seios no parceiro, narcisismo recomendo e uso
muito esta, pois consigo sentir corpo todo da mulher em cima de meu.

Pesquisadores classificaram tempo de latência de ejaculação intravaginal, ou seja, tempo
que transcorre entre ocorrer a penetração vaginal e a
ejaculação, chegando a certo bom senso, que homens com valores de
inferior 1,0 minuto apresentam ejaculação precoce.

Nascida em 1º de setembro de 1886, na Fazenda São Bernardo, em Capivari, nuclear a Salubre Paulo, Tarsila do Amaral tempo filha de José Estanislau do Amaral Filho e de Lydia Dias de Aguiar do Amaral,
e neta de José Estanislau do Amaral, cognominado " milionário" no virtude da imensa fortuna acumulada em fazendas do interior paulista.

Bernardi (1985) nos alerta destinado a a direção que
algumas propostas de pedagogia sexual tem seguido, baseadas numa estratégia pedagógica com "socialização para a apatia", exercitada seja na família,
seja na escola, seja nos programas políticos, seja na sociedade em geral.

entrevistado (R) respondeu que a formação religiosa que teve, de
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exemplo, ele citou fato a ter se arrebatado, durante
a adolescência, por uma garota que fazia parte de uma religião que
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que no caso é a protestante.

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relação entre a teoria e a prática de forma a aprovar ao aluno
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Parto vem sendo como a essencial causa que leva adolescentes saudáveis a
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