中德康复技术培训26.06康复技术培训骨骼肌肉康复课件

1、26.06.2015 Bad Eilsen26.06.2015 Bad EilsenRehazentrum Bad Eilsen 巴特艾尔森巴特艾尔森 康复中心康复中心Rehabilitation of musculoskeletal conditions 肌肉骨骼疾病的康复肌肉骨骼疾病的康复26.06.2015 Bad Eilsen26.06.2015 Bad EilsenGeneral information about task and infra-structure of Rehazentrum Bad Eilsen 巴特埃尔森康复中心职能和基础设施的基本情况Example for I

2、CF-based approach in rehabilitation (patients with Rheumatoid Arthritis) 以 ICF为基础的康复路径举例（患有类风湿性关节炎的病人）Illustration of therapeutic interventions:各种治疗介入的实例:Kinesitherapy 运动治疗Psychoeducation 心理教育Job related therapy 根据患者职业针对性的治疗Psychosocial therapy心理社会治疗2Presentation 报告报告26.06.2015 Bad Eilsen26.06.2015

3、Bad EilsenCentre for rehabilitation of musculoskeletal conditions and interdisciplinary concomitant diseases 肌肉骨骼疾病及其伴发疾病康复中心Part of rehabilitation-center-group of Deutsche Rentenversicherung Braunschweig-Hannover (regional pension insurance)附属于德国布伦瑞克-汉诺威养老保险康复中心集团（地区性的养老保险公司）365 in- and 20 out-pati

4、ents 365位住院病人和20位门诊病人 6000 medical rehabilitation treatments per year每年有超过6000次医学康复治疗Average age of patients: 51 years (60% male, 40% female)患者平均年龄：51岁（60%为男性，40%为女性）Treatment is financed by the pension insurance (in contrast to acute treatment in hospital) 治疗费用由养老保险金提供 （不同于院内急诊治疗）Rehazentrum Bad Ei

5、lsen 巴特埃尔森康复中心26.06.2015 Bad Eilsen26.06.2015 Bad EilsenFollow-up rehabilitation康复随访康复随访after surgical treatment手术治疗以后手术治疗以后post traumtic conditions外伤后的情况外伤后的情况Chronic musculoskeletal non-inflammatory diseases非炎性慢性肌肉骨骼疾病非炎性慢性肌肉骨骼疾病Inflammatory rheumatic diseases炎性风湿疾病炎性风湿疾病Rehazentrum Bad Eilsen 巴特艾

6、尔森巴特艾尔森 康康复中心复中心 Priorities 康复方案康复方案优先顺序优先顺序Muscoloskeletal diseases肌肉骨骼疾病肌肉骨骼疾病Psychatric and somatic Comorbidity, Pat. 55 J精神和躯体疾病精神和躯体疾病,病人病人年龄年龄55 岁岁Chronic pain Syndroms慢性疼痛症慢性疼痛症Medically AND professionally based rehabilitation (MBOR-Konzept) 定向于职业的医定向于职业的医疗康复疗康复 （MBOR 方案方案, 为对应为对应德德语语Medizini

7、sch-beruflich orientierten Rehabilitation 的的首字母首字母缩缩写写）behavior medical based therapy基于行为医学的治疗基于行为医学的治疗Aftercare to improve reintegration into employment 后期后期的再就业辅导的再就业辅导康复康复04.11.20135Range of indications in rehabilitation in Germany 德国各个康复适应症所占比例，肌肉骨骼系统疾病所占比例最大德国各个康复适应症所占比例，肌肉骨骼系统疾病所占比例最大26.06.201

8、5 Bad Eilsen26.06.2015 Bad EilsenPhysicians 医生Psychologists and social workers 心理治疗师和社工Nurses and medical assistants 护士和医师助手Physiotherapists and sports therapists 理疗师和运动理疗师Masseurs and medical bath helpers按摩师和医疗浴师Ergotherapists 职能治疗者Nutritionists and diet conusultants 营养师和饮食顾问Rehazentrum Bad Eilsen

9、巴特埃尔森康复中心Interdisciplinary rehabilitation-team 多学科康复团队多学科康复团队26.06.2015 Bad Eilsen26.06.2015 Bad EilsenInternational Classification of Functioning, Disability and Health (ICF) der WHO WHO的国际健康功能与身心障碍分类系统（ICF）Health Condition健康状况健康状况(Disorder or Disease)失调/疾病Body Functions and structures身体结构和功能身体结构和功

10、能Activities活动活动Participation参与参与Environmental Factors环境因素环境因素Personal Factors个人因素个人因素Diagnosis and somatic orientatedRehabilitation诊断和躯体方面的康复Partricipation and profession orientated Rehabilitation参与和职业方面的康复26.06.2015 Bad Eilsen26.06.2015 Bad EilsenFundamental approach in planning therapeutic interve

11、ntions 规划规划治疗干预计划的基本方法治疗干预计划的基本方法Detailed medical anamnesis and profound physical examination详细的医疗病历和全面的体格检查Consideration of current technical findings 参考现代诊断技术(i.e. x-ray, MRI, ultrasound, laboratory blood tests)（如X光、核磁共振、超声、实验室血液检查）In addition use of screening- and assessment-instruments (also for

12、 course assessment)辅以筛选和评估工具 (也可用于病程的评估)826.06.2015 Bad Eilsen26.06.2015 Bad EilsenExample: Rheumatoid Arthritis例：例：类风湿性关节炎类风湿性关节炎9System disease with main manifestation in musculoskeletal disorders主要表现在肌肉骨骼的系统性疾病Progressive chronic recurring course渐进的慢性复发过程Heatlth Condition (Disorder or Disease)Bod

13、y Functionsand -structuresActivitiesParticipationEnvironmental FactorsPersonal Factors26.06.2015 Bad Eilsen26.06.2015 Bad Eilsen10Joint swelling and stiffness关节肿胀和僵硬Mobility restrictions and joint destruction行动受限和关节损害General symptoms: fatigue, fever, loss of wheigt一般症状：疲乏、发热、体重降低Manifestations in ot

14、her organs: 其他器官的临床表现Skin, eyes, lung, heart, central and peripheral nervous system 皮肤、眼睛、肺、心脏、中枢和外周神经系统Pain is a central symptom疼痛是最主要的症状26.06.2015 Bad Eilsen26.06.2015 Bad EilsenICF-model: Rheumatoid Arthritis类风湿性关节炎类风湿性关节炎ICF模型模型 Rheumatoid Arthritis类风湿性类风湿性关节炎关节炎Body Functions + Structures:躯体结构和

15、功能：躯体结构和功能： Pain疼痛Impairment of 以下方面的损害：- joint mobility关节活动- Musclular strength肌肉力量 -sleep and energy休息与精力Systemic inflammation全身炎症Joint destruction关节损害 Activities: 活动：活动： Mobility: 移动： -Walking 步行 - Using transportation 使用交通工具 -Lifting and Carrying objects电梯和传送工具 -Fine hand use精细手工 Self Care:自我管理：

16、 -Washing oneself自己洗漱 -Dressing穿衣Participation: 参与：参与：professional activity and employment职业活动和就业Family relationship家庭关系community, social and civic life社区、社会和公民生活Recreation and leasure娱乐Religion and spirituality宗教信仰和灵性Political life and citizenship政治生活和公民权益Environmental Factors: 环境因素：环境因素：Products a

17、nd technology产品和技术Support and relationship支持和关系- Family friends, colleagues家庭、朋友和同事Attitudes: 态度 -leadership behavior at work工作中的领导行为Services, systems and policies服务、制度和政策 -Health and pension insurance健康和养老保险Personal Factors:个人因素个人因素 age and sex年龄和性别health behabior健康行为coping abilities应对能力other menta

18、l or physical impairments (comorbiditiy) 其他的精神和身体损伤（合并症）26.06.2015 Bad Eilsen26.06.2015 Bad EilsenBody Functions and Structures:身体身体结构和功能：结构和功能： Mobility of joints: neutral zero method 关节活动性：中间零度法Pain:疼痛疼痛Visual analog scale (VAS) 0-10 视觉模拟评分法0 = no pain, 10 = unbearable pain 0=没有疼痛，10=难以忍受的疼痛Diseas

19、e activity:疾病活动度：疾病活动度：Disease activity score (DAS-28)疾病活动评分(DAS-28)Number of swollen joints肿胀关节的数量Number of tender joints脆弱关节的数量ESR (erythrocyte sedimentation rate)红细胞沉降率Self estimation of disease activity疾病活动自我评估120 2,6 5,1Remission 缓解Low 低度Moderate中等Severe activity严重26.06.2015 Bad Eilsen26.06.201

20、5 Bad EilsenICF-model: Rheumatoid Arthritis类风湿性关节炎类风湿性关节炎ICF模型模型 Rheumatoid Arthritis类风湿性关节炎类风湿性关节炎Body Functions + Structures:躯体结构和功能：躯体结构和功能： Pain疼痛Impairment of 以下方面的损害：- joint mobility关节活动- Musclular strength肌肉力量 -sleep and energy休息与精力Systemic inflammation全身炎症Joint destruction关节损害 Activities: 活动

21、：活动： Mobility: 移动： -Walking 步行 - Using transportation 使用交通工具 -Lifting and Carrying objects电梯和传送工具 -Fine hand use精细手工 Self Care:自我管理： -Washing oneself自己洗漱 -Dressing穿衣Participation: 参与：参与：professional activity and employment职业活动和就业Family relationship家庭关系community, social and civic life社区、社会和公民生活Recrea

22、tion and leasure娱乐Religion and spirituality宗教信仰和灵性Political life and citizenship政治生活和公民权益Environmental Factors: 环境因素：环境因素：Products and technology产品和技术Support and relationship支持和关系- Family friends, colleagues家庭、朋友和同事Attitudes: 态度 -leadership behavior at work工作中的领导行为Services, systems and policies服务、制度

23、和政策 -Health and pension insurance健康和养老保险Personal Factors:个人因素个人因素 age and sex年龄和性别health behabior健康行为coping abilities应对能力other mental or physical impairments (comorbiditiy) 其他的精神和身体损伤（合并症）26.06.2015 Bad Eilsen26.06.2015 Bad Eilsen14Activities活动活动Health Assessment Qustionre健康评估问卷健康评估问卷调查调查FFBH汉诺威问卷调查

24、表汉诺威问卷调查表Functional capacity 功能能力功能能力Low impairment低度受损低度受损70 FFBH/ 1,2 HAQ Moderate impairment 中等受损中等受损50-70 FFBH / 1,2 1,7 HAQSevere impairment严重受损严重受损 1,7 HAQ26.06.2015 Bad Eilsen26.06.2015 Bad EilsenActivities活动活动Evaluation of impairment of activities of daily life is conducted mainly by ergothe

25、rapists 日常活动的损伤主要由运动治疗师评估15Hand grip (and strength)手柄（力量）Precision grips 精密度手柄Handdynamometer握力计26.06.2015 Bad Eilsen26.06.2015 Bad EilsenICF-model: Rheumatoid Arthritis类风湿性关节炎类风湿性关节炎ICF模型模型 Rheumatoid Arthritis类风湿性类风湿性关节炎关节炎Body Functions + Structures:躯体结构和功能：躯体结构和功能： Pain疼痛Impairment of 以下方面的损害：-

26、joint mobility关节活动- Musclular strength肌肉力量 -sleep and energy休息与精力Systemic inflammation全身炎症Joint destruction关节损害 Activities: 活动：活动： Mobility: 移动： -Walking 步行 - Using transportation 使用交通工具 -Lifting and Carrying objects电梯和传送工具 -Fine hand use精细手工 Self Care:自我管理： -Washing oneself自己洗漱 -Dressing穿衣Participa

27、tion: 参与：参与：professional activity and employment职业活动和就业Family relationship家庭关系community, social and civic life社区、社会和公民生活Recreation and leasure娱乐Religion and spirituality宗教信仰和灵性Political life and citizenship政治生活和公民权益Environmental Factors: 环境因素：环境因素：Products and technology产品和技术Support and relationship

28、支持和关系- Family friends, colleagues家庭、朋友和同事Attitudes: 态度 -leadership behavior at work工作中的领导行为Services, systems and policies服务、制度和政策 -Health and pension insurance健康和养老保险Personal Factors:个人因素个人因素 age and sex年龄和性别health behabior健康行为coping abilities应对能力other mental or physical impairments (comorbiditiy) 其

29、他的精神和身体损伤（合并症）26.06.2015 Bad Eilsen26.06.2015 Bad EilsenParticipation 参与参与graphic representation of SF 36 SF36图示法图示法(Questionnaire of health associated quality of life, short form)健康相关生活质量问卷，简易格式）1726.06.2015 Bad Eilsen26.06.2015 Bad EilsenParticipation参与参与 Generic instruments (mainly used in scient

30、ific studies)通用量表（主要运用在科学研究中）i.e. SF 36 (Bullinger, Hogrefe, 1998) 例如 SF 36 Comparability with other diagnosis groups 与其他诊断组的可比较性 In daily routine with practical restrictions日常生活中的实用限制increasingly replaced by screening instruments逐渐被筛选量表替代 1826.06.2015 Bad Eilsen26.06.2015 Bad EilsenWrzburger Screen

31、ing 维尔茨堡筛选问卷维尔茨堡筛选问卷Hinweise auf Besondere Berufliche Problemlage: 特殊职业困境的提示特殊职业困境的提示1) Arbeitslosigkeit oder Zeitrente 失业或短暂期退休Schlechte Subjektive Erwerbsprognose 主观性工作预后较差Ggf. Hohe Berufliche Belastung 高工作压力 123451234512345BB 12SE 1; AHB 21111Professional problems:职业问题职业问题Unemployment失业Pension re

32、quest 津贴需求Subjective job prognosis主观职业预后Subjective professional burden主观职业负担主观职业负担Restriction of professional performance职业表现受限Professional influence on health健康对职业的影响Professional stress burden职业压力负担Professional Participation职业参与职业参与26.06.2015 Bad Eilsen26.06.2015 Bad EilsenICF-model: Rheumatoid Art

33、hritis类风湿性关节炎类风湿性关节炎ICF模型模型 Rheumatoid Arthritis类风湿性类风湿性关节炎关节炎Body Functions + Structures:躯体结构和功能：躯体结构和功能： Pain疼痛Impairment of 以下方面的损害：- joint mobility关节活动- Musclular strength肌肉力量 -sleep and energy休息与精力Systemic inflammation全身炎症Joint destruction关节损害 Activities: 活动：活动： Mobility: 移动： -Walking 步行 - Usin

34、g transportation 使用交通工具 -Lifting and Carrying objects电梯和传送工具 -Fine hand use精细手工 Self Care:自我管理： -Washing oneself自己洗漱 -Dressing穿衣Participation: 参与：参与：professional activity and employment职业活动和就业Family relationship家庭关系community, social and civic life社区、社会和公民生活Recreation and leasure娱乐Religion and spirit

35、uality宗教信仰和灵性Political life and citizenship政治生活和公民权益Environmental Factors: 环境因素：环境因素：Products and technology产品和技术Support and relationship支持和关系- Family friends, colleagues家庭、朋友和同事Attitudes: 态度 -leadership behavior at work工作中的领导行为Services, systems and policies服务、制度和政策 -Health and pension insurance健康和养

36、老保险Personal Factors:个人因素个人因素 age and sex年龄和性别health behabior健康行为coping abilities应对能力other mental or physical impairments (comorbiditiy) 其他的精神和身体损伤（合并症）26.06.2015 Bad Eilsen26.06.2015 Bad EilsenPsychic stress精神应急精神应急 Pain and burden of disease 疼痛和疾病负担Family burden家庭负担家庭负担 Occupational stress职业职业压力压力E

37、nvironment and personal factors环环境和个人因素境和个人因素 Example UKS(Ultrakurzscreening in der Rehabilitation) 超简易筛选26.06.2015 Bad Eilsen26.06.2015 Bad Eilsen35% of our patients show tripel or fourfold burden:我们我们35%的病人显示有的病人显示有3-4倍的压力倍的压力Psychic comorbidity伴随心理疾病Pain疼痛Family burden家庭负担Occupational burden职业负担2

38、6.06.2015 Bad Eilsen26.06.2015 Bad EilsenProfound diagnostics are performed in cases of positive screenig for severe psychosocial burden 如果筛选出严重的社会心理如果筛选出严重的社会心理负担负担,应当做进一步的诊断应当做进一步的诊断Exploration of occupational situation 职业情形探究Psychological individual interview社会心理学的个人谈话Possibly with other specific

39、 Assessments可能结合其他的评估i.e.HADS (Hospital Anxiety and Depression Scale) 如医院焦虑和抑郁量表Anxiety and Depression have severe impact on disease course and employment reintegration焦虑和抑郁严重影响疾病过程和重返社会就业and are seldom discoverd in first contact with the physican并且很少能在 第一次与医师接触时发现2326.06.2015 Bad Eilsen26.06.2015 B

40、ad EilsenICF-model: Rheumatoid Arthritis类风湿性关节炎类风湿性关节炎ICF模型模型 Rheumatoid Arthritis类风湿性类风湿性关节炎关节炎Body Functions + Structures:躯体结构和功能：躯体结构和功能： Pain疼痛Impairment of 以下方面的损害：- joint mobility关节活动- Musclular strength肌肉力量 -sleep and energy休息与精力Systemic inflammation全身炎症Joint destruction关节损害 Activities: 活动：活动

41、： Mobility: 移动： -Walking 步行 - Using transportation 使用交通工具 -Lifting and Carrying objects电梯和传送工具 -Fine hand use精细手工 Self Care:自我管理： -Washing oneself自己洗漱 -Dressing穿衣Participation: 参与：参与：professional activity and employment职业活动和就业Family relationship家庭关系community, social and civic life社区、社会和公民生活Recreatio

42、n and leasure娱乐Religion and spirituality宗教信仰和灵性Political life and citizenship政治生活和公民权益Environmental Factors: 环境因素：环境因素：Products and technology产品和技术Support and relationship支持和关系- Family friends, colleagues家庭、朋友和同事Attitudes: 态度 -leadership behavior at work工作中的领导行为Services, systems and policies服务、制度和政策

43、 -Health and pension insurance健康和养老保险Personal Factors:个人因素个人因素 age and sex年龄和性别health behabior健康行为coping abilities应对能力other mental or physical impairments (comorbiditiy) 其他的精神和身体损伤（合并症）26.06.2015 Bad Eilsen26.06.2015 Bad EilsensupplementaryPhysical therapy 补充物理疗法补充物理疗法25 Sulfur bath (local natural s

44、pring)硫磺浴（当地的天然泉） Hydrotherapy水疗法 Elektrotherapy电疗法 Heat transferring mediums (i.e. peloids)热传导媒介（例如疗效泥） Massage按摩 Cryotherapy 冷冻疗法26.06.2015 Bad Eilsen26.06.2015 Bad EilsenCore elements of therapy治疗的核心要治疗的核心要素素Kinesitherapy运动疗法运动疗法 Mobility灵活度Endurace耐力Strength力量 Coordination协调InformationPsychoeduc

45、ation信息心理教育信息心理教育CompetenceSelf-mangement胜任自我管理Job related therapy根据患者职业针对性的治疗Professional Perfomance职业表现Psychosocial Therapy心理社会心理社会治疗治疗Emotional and psychic balance情绪和精神的平衡26.06.2015 Bad Eilsen26.06.2015 Bad Eilsen Prochaska&DiClemente 1982Motivation动机动机Transtheoretical Model of Change阶段变化模型阶段

46、变化模型Unawareness无意识Intention意图Preparation准备Implementation实施Continuation延续26.06.2015 Bad Eilsen26.06.2015 Bad EilsenActivating therapies激活疗法激活疗法28Physiotherapy (individual and in groups)物理疗法（个人和成组）Mobility, coordination, muscular strength 活动、协调和肌肉力量Ergotherapy运动疗法Training of acitivities of daily life日

47、常活动训练Sports therapy体育疗法Trainig of muscle strength with equipments通过器械锻炼肌肉力量Training of endurance: Walking, Nordic Walking, Ergometer训练耐力：散步、越野行走、测力计Reduction of cardiovascular risk降低心血管疾病风险Improvement of psychic health促进心理健康26.06.2015 Bad Eilsen26.06.2015 Bad EilsenPsychic and emotional balance精神和情绪

48、平衡精神和情绪平衡29 Relaxation techniques放松的技巧 Individual psychological advice个体化的心理指导 Bio-psycho-social influences in chronic pain (syndroms)生物-心理-社会对慢性疾病的影响（综合征） Reduction of fear- and avoidance behavior减少恐惧-回避行为 Interacitve groups to cope with stress 互动小组去应对压力26.06.2015 Bad Eilsen26.06.2015 Bad EilsenJob

49、 related therapy / back to work职业相关治疗职业相关治疗/重回工作重回工作30Reintegration into last job: Work hardening重新回到上一份工作：努力工作Psycho-mental stress: Groups to cope with stress at work 心理精神压力：分组去应对工作压力Physical capacity inadequat to job-requirements: 体能不满足工作要求Information, advice for reorientation 给与更多信息和建议去再定位Testing

50、 of mental capacity心智能力测试Inadequat pension request:津贴需求不能满足Information, confrontation, reorientation信息、对质、调整26.06.2015 Bad Eilsen26.06.2015 Bad EilsenPsychoeducation心理教育心理教育competence / self-mangement胜任/自我管理31 Information信息 Interactive groups for disease related education成立疾病相关互动小组(Rheumatoid Arthritis, Ankylosing spondylitis, chronic back pain, chronic pain syndroms)（类风湿性关节炎、强直性脊柱炎、慢性背疼、慢性疼痛症状） Dietary advice and education 饮食建议和教育Teachi