Sensory-Motor Systems Lab PDF

Sensory-Motor Systems Lab Institute of Robotics and Intelligent Systems Balgrist University Hospital Rehabilitation & Inclusion: Introduction Prof. Dr. Dr. h.c. Robert Riener Key Facts About disability Over...

Sensory-Motor Systems Lab Institute of Robotics and Intelligent Systems Balgrist University Hospital Rehabilitation & Inclusion: Introduction Prof. Dr. Dr. h.c. Robert Riener Key Facts About disability Over 1 billion people worldwide live with some form of disability. In Switzerland it affects about 20% of the population (1/5). Due to demographic trends, the number of people with disability is increasing. Almost everyone is likely to experience some form of disability – temporary or permanent – at some point in life. People with disability often experience poorer quality services and discrimination, even when they access health care Sources: Menschen mit Behinderungen gemäss Gleichstellungsgesetz | Bundesamt für Statistik (admin.ch) WHO, 2021, https://www.who.int/news-room/fact-sheets/detail/disability-and-health Key Facts About rehabilitation Rehabilitation is not only about care, “curing” and health coverage. Rehabilitation is also about making a person as independent as possible in everyday activities and enable participation in education, work, recreation, etc. Globally, an estimated 2.4 billion people are currently living with a health condition that does or would benefit from rehabilitation. In some low-income and middle-income countries, more than 50% of people do not receive the rehabilitation services they require. Rehabilitation services were severely disrupted by the COVID-19 pandemic. WHO, 2021 https://www.who.int/news-room/fact-sheets/detail/rehabilitation 3 Challenge Diagnosis, Acute phase, Pre-rehab Early rehab Subacute phase, Therapy Secondary prevention Inclusion, Chronic phase, Monitoring Training Long-term phase, Assistance Competence Center for Rehabilitation Engineering and Science 5 Continuum of Care Acute phase, Early rehab Diagnosis, Pre-rehab Subacute phase, Therapy Society Secondary Environment Data prevention Technology Medicine Legislation Economy Organisation Inclusion, Monitoring Chronic phase, Training Long-term phase, Assistance 6  legal and Skills to Be Developed regulatory compensation models, financial modelling etc. in-depth ethical and holistic standards & health social sensors rehab policies economics knowhow knowhow detailed disability understanding of studies, clinical processes accessability, ICT & medical patient specialisations bevahiour robotics in-depth critical knowledge thinking an assistive in rehab- problem devices related solving develop technologie future care models & integrative care rapid pathways coordinate tackle and prototyping, multi-level develop the test novel projects in rehab continuum solutions multi-sector as a whole within given environments frameworks translational management precision of complex communication skills data science rehab projects skills develop and compromise data projects Competence Centre for Rehabilitation Engineering and Science 24.09.2023 8 ETH Zurich – University Education MSc in Health Sciences and Technology Majors Major in Rehabilitation and Inclusion Translational Science for Health & Medicine 3 CP Compulsory Practicing Translational Science 2 CP GCP Basic Course (Module 1 + 2) 1 CP Structure Science in Perspective min. 2 CP Elective Courses Rehabilitation Technology min. 3 CP Rehabilitation Medicine min. 3 CP Inclusion min. 3 CP Competence Center for Rehabilitation Engineering and Science 18.09.2024 9  existing courses MSc in HAST, Major «Rehabilitation & Inclusion» new courses Rehabilitation Technology Rehabilitation Medicine Inclusion Assistive Technology Challenge Motor Neurorehabilitation Disability (Studies), Inclusion and Human Rights Artificial Intelligence in Rehabilitation Physical Medicine and Rehabilitation Economic and Regulatory Principles of Rehabilitation and Reintegration Translation of Clinical Concepts into Angewandte Bewegungsanalyse Telerehabilitation Inclusion Praxis Biomechatronics Biomechanik von Sportverletzungen und Rehabilitation Architectural Design: Who cares? Clinical Challenges in Musculoskeletal Disorders Digital Health in Practice (UZH) Web and Mobile Accessability (UZH) Clinical Neuroscience (UZH) Technology Entrepreneurship Ethics in the Life Sciences and Biotechnology Clinical Exercise Physiology Human Computer Interaction Public Economics Physical Activities and Health Machine Learning for Healthcare Paraplegie und Sport Medical Technology Innovation - From Concept to Clinics Public Health Concepts Mobile Health and Activity Monitoring Rehabilitation and Inclusion Rehabilitation Engineering I: Motor Systems Rehabilitation Engineering II : Rehabilitation of Sensory and Vegetative Functions Transfer of Technologies into Neurorehabilitation Wearable and Mobile Technologies of the Future - Focus on Sports and Health Competence Center for Rehabilitation Engineering and Science 18.09.2024 12 Success Stories “Both people and technology played a significant role throughout my rehabilitation 7 months in process” intensive care unit 7 months in intensive inpatient rehabilitation Prof. Roger Gassert Back as ETH professor for Professor for Rehabilitation Engineering rehabilitation engineering Footer 18.09.2024 16  Success Stories “High-quality intensive rehab Son born services with CP and severe change motor impairments lives.” Mother founds “Nextherapy” center in Zurich Receives continuous intensive rehabilitation Nilofar Niazi with Nathanael Founder and CEO Nextherapy and lives with his family Footer 18.09.2024 17 Success Stories “Everything is possible, if there is a will combined with high-level training technologies” Accident when he was 20 years old Started to perform intensive therapy and sports Heinz Frei Won 35 Olympic medals Paralympic Gold Medalist and 14 world championships and World Champion 18.09.2024 18 Success Stories “People with disabilities should be involved in political decision Born with CP making” Lives with move- ment and speech impairments Motivator, speaker, & member of the Municipal Council Is member of Swiss Islam Alijaj Parliament since 2024 Disability Lobbyist and Social Entrepreneur Footer 18.09.2024 19  Rehabilitation Lecture Topics Acute phase, medicine Early rehab Diagnosis, Prevention Pre-rehab Subacute phase, Therapy Cost models Society Therapy technologies Secondary Environment Data prevention Barrier- Home & free living Technology Medicine remote Legislation Economy therapy Inclusion at work Organisation Inclusion, Assistive Social inclusion Monitoring Chronic phase, technologies Training Long-term phase, Parasports Assistance Device Certification 21 Overview of this Semester’s Course … … … … Overview of this Semester’s Course … … … … Learning Goals of the Course Rehabilitation in the context of economy, environment, and society Understand terminologies of disability, rehabilitation, and inclusion Understand technologies of therapy, assistance, and inclusion Learn about clinical methods related to rehabilitation Learn about health insurances and cost models Learn about device certification and health policy Learn about architectural and societal barriers Learn about parasports and prevention Generate an awareness about people with disability, sensibilization Source: WHO, 2021, https://www.who.int/news-room/fact-sheets/detail/disability-and-health Overview of Today’s and Next Week’s Lecture What is Disability, Inclusion, and Rehabilitation? Definition of terms impairment, disability, rehabilitation, inclusion Presentation of numbers of incidences, prevalences, demographics Causes and kinds of impairments and disabilities History of disability, rehabilitation and rehabilitation technology Rehabilitation professions and benefits Therapy and assistance Convention on the Rights of Persons with Disabilities (CRPD) 27 Hands-On Games 28 Statements, Feedback, Questions 30 How Do We Generate Movement? Slide 32 How Do We Generate Movement? Cognitive structures & functions Sensory structures & functions Motor structures & functions Slide 33 How Movements Can Be Impaired? What can happen to us? Slide 34 How Movements Can Be Impaired? Cognitive impairments Sensory impairments Motor impairments Slide 36 How Movements Can Be Impaired? Cognitive impairments Brain injuries, stroke Alzheimer‘s disease Other dementias Parkinson‘s disease Etc. Slide 37 How Movements Can Be Impaired? Sensory impairments Visual disorders, blindness Auditory disorders, deafness Vestibular disorders Proprioceptive disorders Spinal cord injury etc. Slide 38 How Movements Can Be Impaired? Motor impairments Brain injuries, stroke Brain diseases Multiple Sclerosis Spinal cord injures Neuromuscular disorders Amputations Fractures Joint injuries, etc. Slide 39 Kinds of Impairments Permanent Degenerative Inherent, congenital Acquired 40  Origins and Phases of Impairments (Degenerative) Acute Subacute Chronic ~1 month ~1-3 months > 3 months Injury, intervention Patients Impaired, disabled > 6 months Persons with Disabilities/Impairments Congenital, inherent Some Definitions Paresis Weakness of voluntary movement, or partial loss of voluntary movement, impaired movement. Usually referring to limbs, but also used to describe the muscles of the eyes (ophthalmoparesis), the stomach (gastroparesis), etc. Paralysis, plegia Complete loss of muscle function Can be accompanied by a loss of feeling (sensory loss) 43 Some More Definitions Incidence, incidence rate Incidence is the number of new cases per population (e.g., 100‘000) in a given time period (e.g., 1 year). Thus, it is the risk of developing some new condition within a specified time. Prevalence Prevalence is the total number of existing cases of a disease in a population at a given time (sometimes divided by the number of individuals in that population). 44 Amputations Etiology of Amputations Vascular diseases, incl. diabetis 75-80% Trauma 10-15% Malignant tumors, etc. 5% Infection/Sepsis 1-3% Congenital malformation 0.5% Prevalences (2004) Switzerland 52.000 (2004) Amputations of lower extremities Germany 570.000 (2004) about 20 times more often than USA 1.600.000 (2004) amputations of upper extremities  Causes of Spinal Cord Injuries (SCI), USA Kuehner Law Firm (KLF), Syracuse, NY NSCISC: National Spinal Cord Injury Statistical Center, USA Causes of Spinal Cord Injuries (SCI), Queensland, AUS N=2073, 1995-2013 MVA: Motor Vehicle Accidents 47 Spinal Cord Injuries (SCI) Incidences Germany: 1‘800 – 2‘100 new SCI cases per year Europe: 11‘000 new SCI cases per year Prevalences Germany: 60‘000 – 80‘000 people with chronic SCI Europe: 200.000 - 380.000 people with chronic SCI Female 30%, male 70% Priorities of tetraplegic patients? 48 Spinal Cord Injuries (SCI) Number of patients SPZ, Schweizer Paraplegiker- Zentrum Nottwil, 1999-2003  Spinal Cord Injuries (SCI) Life expectancy for SCI in the US* *for those who survive at least one year post-injury as of 2019, by age and severity © Statista, 2022 Stroke Kinds of Stroke Ischemic: Block of blood flow (>80%) Hemorrhagic: Bleedings ( hemiparesis 54 Traumatic Brain Injury (TBI) Cause An external force is applied to the skull, which in turn injures the brain Also refers to objects penetrating the brain Symptoms Include physical, cognitive, social, emotional, and behavioral effects Can be similar to stroke 55 Parkinson’s Disease, Morbus Parkinson Cause In Parkinson’s disease there is a major decrease in the dopamine levels in the brain. Idiopathic (unknown) cause Neurodegenerative Dopamine Neurotransmitter, transmits chemical messages from one cell to another through the synapse. 56 Parkinson’s Disease, Morbus Parkinson Symptoms Bradykinesia & Hypokinesia: slower and more seldom movements (e.g., arm swing, face gestures, voice) Rigor: increased muscle tone Tremor: shaking, esp. during rest Postural disturbances: problems with balance and reflexes Non-Motor Symptoms Change of mood Cognitive performance reduction Pain, insomnia etc. 57 Multiple Sclerosis (MS) Cause Immune system has an abnormal response in which it attacks the myelin of neurons of the CNS. Myelin Protective cover around the axons of neurons, which aids in the transmission of action potentials. 58 Multiple Sclerosis (MS) Motor Symptoms Ataxia: lack of voluntary coordination of muscle movements (cerebellar, vestibular, sensory, proprioceptive) Increased muscle tone Spasticity Non-Motor Symptoms Vision impairments Speech impairments Emotional and perceptual disturbances Pain 59 Cerebral Palsy (CP), Paralysis of the Cerebrum Cause Lesions in the brain leading to motor dysfunction that arises during pregnancy or at the time of birth Appear at infancy or early childhood Permanent, but non-progressive effect on the motor abilities of the patient Symptoms Increased muscle tone Motor dysfunction and spasticity, can lead to contractures (tendon shortening) and deformations Often accompanied by sensory, perceptual, communicative and other cognitive deficits 60 Muscular Dystrophy (MD) Cause & symptoms Genetic conditions mean a patient is unable to create certain proteins needed for healthy muscles Increasing weakening and breakdown of skeletal muscles over time Many people will eventually become unable to walk Different types; most common type is Duchenne Muscular Dystrophy (DMD) There is no cure for MD 61 Some More Numbers Incidence/100‘000 Prevalence Parkinson: 200‘000 in DE Multiple Sklerosis: ~ 5-6 120‘000 in DE 208/100‘000 in CA Stroke: ~ 200 600/100‘000 Traumatic Brain Injury: 3‘500/100‘000 in CA Spinal Cord Injury: ~ 1.5-2.5 60’000 - 80’000 in DE 200’000 - 380’000 in Europe => 27-96/100’000 Cerebral Palsy: ~ 9 (0.2%/birth) 760.000 in US 211/100’000 in CA Muscular Dystrophy: 16/100’000 in CA Amputations: ~ 30 1.7 Mill in US => 515/100’000 What is a Disability? International Classification of Functioning, Disability and Health (ICF) World Report on Disability, WHO 2011 http://www.who.int/disabilities/world_report/2011/report.pdf Definitions Functions, structures, activity, participation Structures are anatomical parts of the body such as organs, limbs and their components fulfilling particular functions Functions are the physiological functions of body structures Activity is the execution of a task or action by an individual Participation is involvement in a life situation Definitions Factors Environmental factors make up the physical, social and attitudinal environment in which people live and act. These factors can be either facilitators or barriers, including products and technology, the natural and built environment, support and relationships, attitudes, and services, systems, and policies. Personal factors, such as motivation and self-esteem, which can influence how much a person participates in society. However, these factors are not yet conceptualized or classified. Definitions (Negation of Terms) Limitations, impairments, disabilities Impairments are problems in body function or alterations in body structure such as a significant deviation or loss Activity limitations are difficulties an individual may have in executing activities Participation restrictions are problems an individual may experience in involvement in life situations Disability is any restriction or lack of ability to perform an activity or participate in a life situation (which can result from an impairment) Handicap is a disadvantage (“Benachteiligung”) resulting from an impairment or a disability, that prevents the fulfilment of a role Prevalence of Disability in Switzerland Definition von «Menschen mit Behinderung» gemäss BFS Personen, die ein dauerhaftes Gesundheitsproblem haben und die bei Tätigkeiten des normalen Alltagslebens (stark oder etwas) eingeschränkt sind, gemäss Behindertengleichstellungsgesetz (BeHiG) Definition of «Persons with Disability» w.r.t BFS Persons, who have a permanent health problem und who are (heavily or slightly) impaired in their normal daily life, according to the «Behindertengleichstellungsgesetz» (BeHiG) BFS: Bundesamt für Statistik Menschen mit Behinderungen gemäss Gleichstellungsgesetz | Bundesamt für Statistik (admin.ch) Prevalence of Disability in Switzerland Menschen mit Behinderungen gemäss Gleichstellungsgesetz | Bundesamt für Statistik (admin.ch) Worldwide Prevalence of Disability ??? https://apps.who.int/iris/rest/bitstreams/53067/retrieve 73 Worldwide Prevalence of Disability WHS World Health Survey GBD Global Burden of Disease https://apps.who.int/iris/rest/ bitstreams/53067/retrieve 74 Disability Demographics World Health Survey. Geneva, World Health Organization, 2002–2004 75 Relevance of the Environment Influence of the environment on disability assessed by capacity and performance: Capacity: What a person can do in a standardized environment, without barriers or facilitators Performance: What a person does in a usual environment with all barriers and facilitators in place. https://apps.who.int/iris/rest/bitstreams/53067/retrieve 76 Disability and Poverty: Need of Services https://apps.who.int/iris/rest/bitstreams/53067/retrieve 77 Disability and Human Rights Disability is a Human Rights issue, because: People with disabilities experience inequalities – for example, when they are denied equal access to health care, employment, education, or political participation because of their disability. People with disabilities are subject to violations of dignity – for example, when they are subjected to violence, abuse, prejudice, or disrespect because of their disability. Some people with disability are denied autonomy – for example, when they are subjected to involuntary sterilization, or when they are confined in institutions against their will, or when they are regarded as legally incompetent because of their disability WHO, 2011, https://apps.who.int/iris/rest/bitstreams/53067/retrieve Disability: Legal Aspects in the Past Chicago City Code 1881 “Any person who is diseased, maimed, mutilated, or in any way deformed, so as to be an unsightly or disgusting object, or an improper person to be allowed in or on the streets, highways, thoroughfares, or public places in this city, shall not therein or thereon expose himself to public view, under the penalty of a fine of $1 for each offense.” Disability: Legal Aspects in the Past World War I: 1914-1918 Many more soldiers survived «Schussbrüche» compared to previous wars due to better medical treatment 1918 about 2.7 million soldiers physically or mentally impaired only in Germany. They were very visible in the society and lead to many discussions Disability: Legal Aspects in the Past 1915 Speech of Dr. Konrad Biesalski (1868–1930) “… es ist selbstverständlich, dass wir nicht, wie in früheren Jahren, es zulassen können, dass diese Verwundeten und Krüppel nun als Leierkastenmänner oder als Hausierer durch die Strassen ziehen. … Wir können einfach den Gedanken nicht ertragen, dass diese Leute als Bettler herumlaufen; wir müssen dafür sorgen, dass sie wieder aufrechte, selbständige Männer werden, wie vor dem Kriege, d.h. wir müssen ihnen Arbeit schaffen und eine freie selbständige Existenz, damit sie vor sich selber Hochachtung haben, und ihre Nachkommenschaft vor ihnen…” Disability: Legal Aspects in the Past 1915 Speech of Dr. Konrad Biesalski (1868–1930) “… Wenn Hunderttausende statt Werte zu schaffen, nur Werte verzehren, so ergibt das einen Unterschied zuungunsten des Volksvermögens, der, vielfach multipliziert, in die Millionen geht.” People with amputations should receive better prostheses, that allow them to work in factories. This lead to the development of “Arbeitsarme” and “Schmuckarme” Disability: Legal Aspects in the Past The Rehabilitation Acts of 1973 and 1974 There are several federal laws prohibiting discrimination against individuals with disabilities. The Rehabilitation Act of 1973 covers federal contractors and programs receiving federal funds. 83 Disability: Legal Aspects in the Past The American Disabilities Act of 1990 (ADA) It prohibits discrimination in employment, public services, public accommodations and telecommunications. Consequently, Americans with disabilities were guaranteed equal rights to employment opportunities, transportation, and public access. Employers are prohibited from discriminating against qualified applicants and employees with disabilities and are required to provide reasonable accommodations for such individuals, unless doing so would cause an “undue hardship” on the business. 84 Disability in the Middle Ages Religious model of disability Cognitive and motor impairments were thought to be caused by 1480 demons or any higher instance Impairment is given by god, thus, it cannot be fixed Chicago City Code 1881: Appearance in the public was punished by law Disability in the «Dritte Reich», 1933-1945 Genetic model of disability Impairments are inherited Enhancement over generations Claimed to be dangerous for the entire population Thus, «humans with impairments must get distinguished» Disability after 1945 Medical/individual model of disability Impairment can be explained as an individual, medical problem Thus, human must get treated and healed from impairment Disability: Modern Definition Social Model of Disability* Physical and mental barriers are made by the environment and society Impairments are a normal aspect of diversity in our society Thus, environment and society that limits a person with an impairment needs to be adapted or fixed. *Also known as “Human rights model of disability”, defined in the UNCRPD: Disability is mutual interaction between impairment and environmental factors Disability: Legal Aspects in the Past and Today §3 Gesetz zur Gleichstellung behinderter Menschen, BGBI 2002 “Menschen sind behindert, wenn ihre körperliche Funktion, geistige Fähigkeit oder seelische Gesundheit mit hoher Wahrscheinlichkeit länger als sechs Monate von dem für das Lebensalter typischen Zustand abweichen und daher ihre Teilhabe am Leben in der Gesellschaft beeinträchtigt ist. Sie sind von Behinderung bedroht, wenn die Beeinträchtigung zu erwarten ist.” Deutschland: §3 Gesetz zur Gleichstellung behinderter Menschen, BGBl I 2002, 1467, 1468 (Bestimmung nicht mehr in Kraft) Disability: Legal Aspects in the Past and Today Bundesverfassung der Schweiz, Art. 8 Rechtsgleichheit Abs. 2: Niemand darf diskriminiert werden, namentlich nicht wegen der Herkunft, der Rasse, des Geschlechts, des Alters, der Sprache, der sozialen Stellung, der Lebensform, der religiösen, weltanschaulichen oder politischen Überzeugung oder wegen einer körperlichen, geistigen oder psychischen Behinderung. (since 2000 in this version) Disability: Legal Aspects in the Past and Today UN Convention on the Rights of Persons with Disabilities, 2006* Article 1, Purpose: The purpose of the present Convention is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity. Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others. *Ratified in CH in 2014; German: «UN Behindertenrechtskonvention» Definition of Barriers World Health Organisation (WHO) Barriers are factors in a person's environment that, through their absence or presence, limit functioning and create disability. These include aspects such as a physical environment that is inaccessible, lack of relevant assistive technology, and negative attitudes of people towards disability, as well as services, systems and policies that are either nonexistent or that hinder the involvement of all people with a health condition in all areas of life. 95 Disability and Barriers Attitudinal barriers Communication barriers Many people in our society have limited Disability can lead to lack of knowledge and understanding of rights of communication via language, people with disability and their needs for vision, gesture, mimics education, employment, healthcare etc. Physical barriers Financial barriers People with disability experience barriers Many people with disability cannot that hinder them to access buildings, afford the costs associated with machines, devices, public transport, cars technical assistance, extra service, etc. healthcare etc. 96 Costs of Disability Public spending on disability programs For OECD countries an average of 1.2% of GDP is spent on contributory and non-contributory disability benefits, covering 6% of the working age population in 2007. The benefits include full and partial disability benefits, as well as early retirement schemes specific to disability or reduced work capacity. The amount reaches 2% of GDP when sickness benefits are included, or almost 2.5 times the spending on unemployment benefits. The expenditure is particularly high in the Netherlands and Norway (about 5% of GDP). The cost of disability is around 10% of public social expenditure across OECD (up to 25% in some countries). https://apps.who.int/iris/rest/bitstreams/53067/retrieve 97 Disability and Health Reasons for Lack of Care? 99 Disability and Health Reasons for Lack of Care https://apps.who.int/iris/rest/bitstreams/53067/retrieve 100 101 Definition: Exclusion, Integration, Inclusion Segregation = Separation Definition: Exclusion, Integration, Inclusion Segregation = Separation Inclusion = «Teilhabe» Definition: Exclusion, Integration, Inclusion Integration Adaptation to the rules of a given framework Inclusion (“Teilhabe”) Framework itself is subject of negotiation Inclusion = «Teilhabe» Definition: Exclusion, Integration, Inclusion Segregation Attention: Do not inforce inclusion; = Separation sometimes people prefer integrative or separative solutions Inclusion = «Teilhabe» Definition: Inclusion Different kinds of definitions Inclusion also means “deceleration”, empathy, solidary, reduction of competition, tolerance, avoidance of economic rationality. Areas of inclusions include aspects of education, employment, prevention, health and care, rehabilitation, children and youth, family and partnerships, elderly, women, building and living, mobility, culture and leisure, social and political inclusion, personal rights, etc. Definition: Inclusion Inclusion is not Inclusion is to make everyone to offer equal opportunities – and give people with equal disabilities chance to live their life as they want to. the inclusion into an change of existing and established structures established structure the enforcement of the combination of diversity and about empowerment norms (normalization) and enabling about “in” or “out” about sharing and joining of vital spaces in our society for free expensive 110 Definition: Rehabilitation 111 Origin and Definition of the Term Rehabilitation Lat. habilis = getting settled; Lat. habilitare = enable; re-habilitare = enable again (to practical & independent life) Staatsrat Graf Ritter von Buss, founder of the idea (1844): „Vielmehr soll der heilbare Kranke vollkommen rehabilitiert werden. Er soll sich von der Stellung wieder erheben, von welcher er herabgestiegen war. Er soll das Gefühl seiner persönlichen Würde wieder finden und mit ihr ein neues Leben.“ This classical definition includes even the aspect of „Inclusion“ Charles Robinson (1993): “…is the (re)integration of an individual with a disability into society. This can be done either by enhancing existing capabilities or by providing alternative means.” Origin and Definition of the Term Rehabilitation Article 26, Habilitation and Rehabilitation, of the United Nations Convention on the Rights of Persons with Disabilities (CRPD): “... appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life”. World Health Organisation, WHO 2021: “…a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”. WHO, 2021; https://www.who.int/news-room/fact-sheets/detail/rehabilitation 113 Some More Terminology, WHO 2011 Primary health condition The possible starting point for impairment, an activity limitation, or participation restriction. Examples: depression, arthritis, chronic obstructive pulmonary disease, ischemic heart disease, cerebral palsy, bipolar disorder, glaucoma, cerebrovascular disease, Down syndrome. Secondary conditions An additional condition that presupposes the existence of a primary condition. It is distinguished from other health conditions by the latency from the acquisition of the primary condition to the occurrence of the secondary condition. Examples: pressure ulcers, urinary tract infections, depression. Secondary conditions can reduce functioning, lower the quality of life, increase health care costs, and lead to premature mortality. Many such conditions are preventable. 114 Some More Terminology, WHO 2011 Co-morbid conditions An additional condition independent of and unrelated to the primary condition. The detection and treatment of co-morbid conditions are often not well managed for people with disabilities and can later have an adverse affect on their health. Examples: co-morbid conditions such as cancer, hypertension, etc. General health care needs People with disabilities require health services for general health care needs like the rest of the population. Examples: preventive care (immunization, general health screening), treatment of acute and chronic illness. Specialist health care needs Some people with disabilities may have a greater need for specialist health care than the general population. 115 Rehabilitation Goals Rehabilitation includes aspects of therapies and inclusion Reduction of impairments due to disease or trauma by treatment of symptoms and improvement of body functions Reduction, avoidance and prevention of disability Prevention of secondary complications such as contractures, decubitus, etc. Learning of compensation methods and trick movements Promotion of autonomy and self-responsibility Reintegration in the society to enable social and professional participation in relation to the respective environmental factors 116 The Rehabilitation Process Identify problems and needs Relate problems to Assess effects modifiable and limiting factors Define target Plan, implement, and problems and target coordinate mediators, select interventions measures Source: Steiner WA et al. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. 11 Physical Therapy, 2002,82:1098-1107. PMID:124058 9 Rehabilitation Benefits Rehabilitation … can reduce the impact of a broad range of health conditions, diseases, injuries, or impairmens. It can also complement other health interventions, such as medical and surgical interventions. helps to minimize or slow down the disabling effects of chronic health conditions, such as pain, cardiovascular disease, cancer and diabetes by self- management and assistive devices. is an investment, with cost benefits for both the individuals and society. It helps to avoid costly (re-)hospitalization and reduce hospital length of stay. enables individuals to participate in education and employment, promote well- being, remain independence at home, and minimize the need for financial or caregiver support. 120 Fields of Rehabilitation Rehabilitation targets different kinds of impairments Neurological rehabilitation and paraplegiological rehabilitation Musculoskeletal or orthopaedical rehabilitation Geriatric rehabilitation Pediatric rehabilitation Cardiovascular or cardiac rehabilitation Pulmonal rehabilitation Internistic and oncologic rehabilitation (related to any organ disfunctions, infections, intensive care treatment, malnutrition) Psychosomatic or psychiatric rehabilitation 121 WHO Rehabilitation Need Estimator Prevalence Age Ranges https://vizhub.healthdata.org/rehabilitation/ https://www.healthdata.org/results/data-visualizations 122 Rehabilitation Professions Today Physicians Rehabilitation medicine, physical medicine, orthopaedics Neurology, neurorehabilitation medicine Cardiology, pulmonology Psychiatrist, psychologist Therapists & Care persons Other professions Physiotherapy & occupational therapy Food and nutrition Speech therapy Social/welfare work Medical care, other care Complementary medicine 123 Core Measures of Rehabilitation Rehabilitation medicine Tries to improve functioning through diagnosis and medical treatment of health conditions, reducing impairments, and preventing or treating complications. This includes mainly physicians of different areas. Therapy Is concerned with restoring and compensating for the loss of functioning and preventing deterioration in functioning in every area of a person’s life. This includes occupational therapists, physiotherapists, orthotists, prosthetists, psychologists, technical assistants, social workers, and speech therapists, etc. Assistive technologies Can be defined as any item, piece of equipment, or product that is used to increase, maintain, or improve the functional capabilities of persons with disabilities. 124 Rehabilitation Technology Therapy & training devices Assistive devices … for patients …. for people with disabilities Assistive Devices Prosthetics: Replace a lost modality (i.e. function) Motor prosthesis: Foot, knee, arm exoprosthesis, joint endoprosthesis, tooth implant, etc. Sensory prosthesis: Cochlear implant, retina implant, etc. Orthotics: Support a weak modality (i.e. function) Motor Orthoses: Crutches, orthoses, etc. Sensory Orthoses: Glasses, hearing aids, etc. 126 Assistive Devices Substitution: Replace a weak/lost modality by another one Motor Substitution: Speech input for paralyzed persons Sensory Substitution: Acoustic displays for blind persons, tactile (Braille) displays for blind persons 127 History of Rehabilitation Medicine and Technology Prior to the 20th century, most treatments were decentralized Midwives provided delivery Mobile doctor provided herbs or surgery Nursing done by relatives New knowledge and devices reinforced centralization Sulfanilamide (mid 1930s) & Penicillin (early 1940s): reduction of infections Novel technologies and facilities were large, heavy, expensive, e.g. X-ray, ECG, iron lung. 128 History of Rehabilitation Medicine and Technology Hand of A.v. Kölliker (1896) Early x-ray device from Siemens & Reiniger 131 History of Rehabilitation Medicine and Technology The first Electrocardiograph (ECG) uses a string galvanometer (W. Einthoven 1903) 132 History of Rehabilitation Medicine and Technology Iron Lung Respirator, “Drinker Respirator”, to care paralytic polio patients, 1929 133 History of Rehabilitation Medicine and Technology Further Examples of New Technologies 1930s: X-ray visualization of practically all organ systems, thanks to application of Barium salts and radiopaque materials 1930s: Blood banks due to advances in hematology (blood differentiation, sodium citrate prevents clotting) & refrigeration 1939: first heart-lung bypass 1940s: Cardiac catherization and angiography 1950s: Electronics, ultrasound, telemetry, computers 1980s-1990s: 3D imaging technologies (CT, MRI, PET, SPECT) 134 History of Physiotherapy Galen of Pergamon Turnvater F.L. Jahn Ritter von Buss 131 – 1778 1803 201 AC –1852 – 1878 First physician for The «father of He defined the term gladiators movement training» rehabilitation in 1844 135 History of Physiotherapy Physiotherapy during the Renaissance Progress in the study of human anatomy Systematic understanding of the role of physical activity and exercise; medical rehabilitation started to become a discipline Andreas Vesalius (1514–1564) published in 1543 his fundamental book “De humani corporis fabrica” (On the Fabric of the Human Body) Hieronymus Mercurialis (1530–1606) printed in 1569 his milestone text entitled “De Arte Gymnastica” (The Art of Gymnastics) Ambroise Paré (1510–1590) provided important contributions in the fields of surgery, pathology, wound care, war mutilations, amputations, phantom pain (“Verstümmelung”) 136 History of Physiotherapy Physiotherapy in the 17th century Century of “scientific methods”: period of quantitative systematic approaches to the study of biological phenomena, precise numeric measurements of natural events. Trend of “iatromechanics”: a medical trend to explain human physiological events in mechanical terms, driven by physiologist and mathematician Alfonso Borelli (1608–1679). He achieved relevant scientific results in the field of biomechanics, e.g., about contractile movement of muscles and provided a conceptual framework for the understanding of movement in ill and disabled people. 137 History of Physiotherapy Physiotherapy in the 17th century French physician Nicolas Andry de Bois-Regard (1658–1742) established a solid link between the muscular-skeletal apparatus and physical exercise. Published in “Traité d’orthopédie” (Treatise on Orthopaedics, 1741). Swiss physician Joseph Clément Tissot (1747–1826) was a pioneer in the area of medical and surgical gymnastics (mobilization of surgical patients). In “Gymnastique Médicinale et Chirurgicale” (Medical and Surgical Gymnastics, 1780) In addition, Tissot provided accurate indications for the clinical-rehabilitative management of hemiplegic subjects. Therefore, today many authors consider his book the first organic treatise specifically devoted to functional (neuro-)rehabilitation. 138 History of Physiotherapy Physiotherapy in the 18th century In 1793 Guts-Muths published his text “Gymnastik für die Jugend” (Gymnastics for Youth), which is considered the first systematic textbook of gymnastics. It was strongly promoted by the Swedish teacher of medical gymnastics and physical therapist Pehr Henrik Ling (1776–1839) who founded “Swedish gymnastics”. He was convinced of the beneficial effects of structured physical activity for a variety of human diseases and had to fight against the opposition of practitioners of his time, whose technics were limited to simple massages and light physical activity. Scottish anatomist and neurologist Charles Bell (1774–1842) distinguished between motor and sensory nerves and laid the foundations of the relationship between brain, nervous system, muscles, and feedback mechanisms. 139 History of Physiotherapy Physiotherapy in the 19th century Turnvater Jahn (1778–1852): Father of movement exercise as sports Staatsrat Graf Ritter von Buss (1803–1878), founded the term „Rehabilitation“ in 1844 French neurologist Fulgence Raymond (1844–1910) introduced the concept of “motor re-education”, which was of paramount importance for the management of disabled persons and was functional to the elaboration of different rehabilitative techniques, developed in the course of the nineteenth century. German neurologist Johannes Karl Goldscheider (1858–1935) added important contributions to the clarification of the human proprioceptive apparatus. 140 History of Physiotherapy Physiotherapy in the 1920s (@ Balgrist) 141 History of Physiotherapy Physiotherapy in the 1920s (@ Balgrist) 142 History of Physiotherapy Physiotherapy in the 1920s (@ Balgrist) 143 History of Physiotherapy Physiotherapy in the 1920s (@ Balgrist) 144 History of Physiotherapy Physiotherapy in the 1930s (@ Balgrist) 145 History of Physiotherapy Physiotherapy in the 1920s (@ Balgrist) 146 History of Physiotherapy Mechanotherapy with Meridianappart ~1930 (@ Balgrist) Actuate by Sepp Lei Different kind of supports (passive, assistive, agains resistance) Trains concentric and eccentric contractions 147 History of Physiotherapy Physiotherapy in the 1940ies Biomedical technology has an exponential development and in which the diffusion of specific diseases, such as poliomyelitis, determines the elaboration of prostheses and devices useful for the global rehabilitation of people disabled because of disease. 148 History of Physiotherapy Physiotherapy in the 20th century In 1938 the Society for Physical Therapy Physicians had been established, in 1939 US doctor Frank H. Krusen (1898–1943) proposed the term “physiatrist.” High number of injured soldiers in WW2 led to the introduction of the first rehabilitative units within military hospitals. US physician Howard A. Rusk (1901–1989) was a pioneer in this field. He founded the Army Air Forces Convalescent Training Program (1942). The physician Karel Bobath (1906–1991) and his wife Berta (1907–1991) elaborated an innovative rehabilitation strategy for persons with impairments of the CNS, i.e., stimulating motor learning for an appropriate and efficient motor control, while promoting functional recovery and active participation. 149 History of Electricity in Rehabilitation Roman physicians used electrically charged sea creatures 200 AD 151 History of Electricity in Rehabilitation Luigi Galvani, fundamental contribution to electrophysiology 1791 152 History of Electricity in Rehabilitation Electric shocks, electric baths, electric belts, Magnets, etc. 1885 153 History of Electricity in Rehabilitation Cardiac therapy devices Cardiac Defibrillator pacemaker 1950 1955 154 History of Electricity in Rehabilitation Cardiac therapy devices: First fully implantable pacemaker 1958 Ake Senning & Rune Elmqvist, KTH (sold by Siemens) 155 History of Electricity in Rehabilitation Motor neuroprosthesis 1995 156 History of Assistive Devices First Exoskeleton: «Yagn’s Running Aid» Apparatus facilitating walking, running and jumping; US Patent 1890, No. 420‘179 & 438‘830 157 History of Assistive Devices «Wearable Gait Device» Cobb’s windup orthosis US Patent 1935, No. 2‘010‘482 158  History of Assistive Devices Greek Cane, 200 B.C. Canes and Prostheses Egyptian Mummy, 600 B.C. Pirate‘s wodden Leg, 15th c. Iron Leg from Capua 300 B.C. Berlichen‘s Iron Hand, 1504 159 History of Assistive Devices Wheelchairs King Phillip of Late Middle Spain II, 1596 Ages, 1480 History of Assistive Devices H. Jennings Wheelchairs 1932 foldable wheelchair 1830 1995 iBOT 1880 Rehabilitation: Challenges and Trends of Today Expanding and decentralizing service delivery -> Continuum-of-care, telerehabilitation Increasing the use and affordability of technology -> Assistive technology Expanding research and evidence-based practice -> ETH Rehab Initiative, Rehabilitation 2030 162 Challenge Diagnosis, Acute phase, Pre-rehab Early rehab Subacute phase, Therapy Secondary prevention Inclusion, Chronic phase, Monitoring Training Long-term phase, Assistance Competence Center for Rehabilitation Engineering and Science 163 Continuum of Care Acute phase, Early rehab Diagnosis, Pre-rehab Subacute phase, Therapy Society Secondary Environment Data prevention Technology Medicine Legislation Economy Organisation Inclusion, Monitoring Chronic phase, Training Long-term phase, Assistance 164  Rehabilitation Lecture Topics Acute phase, medicine Early rehab Diagnosis, Prevention Pre-rehab Subacute phase, Therapy Cost models Society Therapy technologies Secondary Environment Data prevention Barrier- Home & free living Technology Medicine remote Legislation Economy therapy Inclusion at work Organisation Inclusion, Assistive Social inclusion Monitoring Chronic phase, technologies Training Long-term phase, Parasports Assistance Device Certification 165 Convention on the Rights of Persons with Disabilities 167 UN-CRPD Overview Convention on the Rights of Persons with Disabilities (CRPD) In German: “Behindertenrechtskonvention” (BRK) The Convention on the Rights of Persons with Disabilities (CRPD) is an international human rights treaty of the United Nations intended to protect the rights and dignity of persons with disabilities. Founded 2006 in New York at the United Nations Headquarters, active since 2008 In force in Switzerland: since 2014 Signed by 175 states 168 UN-CRPD Overview Why a Convention? A response to an overlooked development challenge: approximately 10% - 20% of the world’s population are persons with disabilities (over 650 million persons). Approximately 80% of whom live in developing countries Persons with disabilities are continually being denied their human rights and were kept on the margins of society in all parts of the world. The Convention sets out the legal obligations on States to promote and protect the rights of persons with disabilities. It does not create new rights. 169 UN-CRPD Overview What is unique about the Convention? Both a development and a human rights instrument A policy instrument which is cross-disability and cross-sectoral Legally binding They came into existence through a forceful call from persons with disabilities around the world to have their human rights respected, protected and fulfilled on an equal basis with others. The Convention celebrates human diversity and human dignity. Its main message is that persons with disabilities are entitled to the full spectrum of human rights and fundamental freedoms without discrimination. 170 CRPD: Some Articles Article 1 – Purpose To promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity Article 2 – Definitions Article 3 – General principles a) Respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons; b) Non-discrimination; 171 CRPD: Some Articles Article 5 – Equality and non-discrimination Article 21 – Freedom of expression & opinion, Article 6 – Women with disabilities and access to info Article 22 – Respect for privacy Article 7 – Children with disabilities Article 9 – Accessibility Article 23 – Respect for home and the family Article 10 – Right to life Article 24 – Education Article 25 – Health Article 12 – Equal recognition before the law Article 13 – Access to justice Article 26 – Habilitation and rehabilitation Article 27 – Work and employment Article 14 – Liberty and security of person Article 29 – Participation in political & public life Article 17 – Protecting the integrity of the person Article 19 – Living independently and being Article 30 – Participation in cultural life, included in the community recreation, leisure and sport Etc. Article 20 – Personal mobility 172 Additional Slides CRPD: Purpose and General Principles Article 1 – Purpose To promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity Article 2 – Definitions Article 3 – General principles a) Respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons; b) Non-discrimination; 174 CRPD: Purpose and General Principles Article 3 – General principles c) Full and effective participation and inclusion in society; d) Respect for difference and acceptance of persons with disabilities as part of human diversity and humanity; e) Equality of opportunity; f) Accessibility; g) Equality between men and women; h) Respect for the evolving capacities of children with disabilities and respect for the right of children with disabilities to preserve their identities. 175 CRPD: Participation, Inclusion, Non-Discrimination Article 4 – General obligations Article 5 – Equality and non-discrimination Article 6 – Women with disabilities Article 7 – Children with disabilities Article 8 – Awareness-raising Article 9 – Accessibility Article 10 – Right to life Article 11 – Situations of risk and humanitarian emergencies 176 CRPD: Article 7 – Children with disabilities Article 7 – Children with disabilities a) States Parties shall take all necessary measures to ensure the full enjoyment by children with disabilities of all human rights and fundamental freedoms on an equal basis with other children. b) In all actions concerning children with disabilities, the best interests of the child shall be a primary consideration. c) States Parties shall ensure that children with disabilities have the right to express their views freely on all matters affecting them, their views being given due weight in accordance with their age and maturity, on an equal basis with other children, and to be provided with disability and age- appropriate assistance to realize that right. 177 CRPD: Article 10 – Right to Life Article 10 – Right to life States Parties reaffirm that every human being has the inherent right to life and shall take all necessary measures to ensure its effective enjoyment by persons with disabilities on an equal basis with others. 178 CRPD: Obligations towards Persons with Disabilities Article 12 – Equal recognition before the law Article 13 – Access to justice Article 14 – Liberty and security of person Article 15 – Freedom from torture or cruel, inhuman or degrading treatment or punishment Article 16 – Freedom from exploitation, violence and abuse Article 17 – Protecting the integrity of the person Article 18 – Liberty of movement and nationality Article 19 – Living independently and being included in the community 179 CRPD: Article 19 – Living independently Article 19 – Living independently and being included in the community … equal right of all persons with disabilities to live in the community, with choices equal to others, and shall take effective and appropriate measures to facilitate full enjoyment by persons with disabilities of this right and their full inclusion and participation in the community, including by ensuring that: a) … choose their place of residence and where and with whom they live on an equal basis with others… not obliged to live in a particular living arrangement; b) … access to a range of in-home, residential and other community support services, including personal assistance necessary to support living and inclusion in the community, and to prevent isolation … from the community; c) Community services and facilities for the general population are available on an equal basis to persons with disabilities and are responsive to their needs. 180 CRPD: Obligations of States Parties Article 20 – Personal mobility Article 21 – Freedom of expression &opinion, and access to info Article 22 – Respect for privacy Article 23 – Respect for home and the family Article 24 – Education Article 25 – Health Article 26 – Habilitation and rehabilitation Article 27 – Work and employment 181 CRPD: Article 23 - Respect for Home and the Family Article 23 - Respect for home and the family 1. States Parties shall take effective and appropriate measures to eliminate discrimination against persons with disabilities in all matters relating to marriage, family, parenthood and relationships …: a) The right of all persons with disabilities who are of marriageable age to marry and to found a family on the basis of free and full consent … b) The rights of persons with disabilities to decide freely and responsibly on the number and spacing of their children and to have access to age-appropriate information, reproductive and family planning education are recognized … c) Persons with disabilities, including children, retain their fertility on an equal basis with others. 182 CRPD: Article 23 - Respect for Home and the Family Article 23 - Respect for home and the family 2. States Parties shall ensure the rights and responsibilities of persons with disabilities, with regard to guardianship, wardship, trusteeship, adoption of children or similar institutions, where these concepts exist in national legislation; in all cases the best interests of the child shall be paramount. States Parties shall render appropriate assistance to persons with disabilities in the performance of their child-rearing responsibilities. 3. … 4. … 5. … 183 CRPD Article 24 - Education CRDP Article 24 - Education 1. States Parties recognize the right of persons with disabilities to education. …without discrimination and on the basis of equal opportunity, States Parties shall ensure an inclusive education system at all levels and lifelong learning …: a. The full development of human potential and sense of dignity and self-worth, and the strengthening of respect for human rights, fundamental freedoms and human diversity; b. The development by persons with disabilities of their personality, talents and creativity, as well as their mental and physical abilities, to their fullest potential; c. Enabling persons with disabilities to participate effectively in a free society. Etc. 2., 3., 4., 5. 184 CRPD: Article 27 - Work and Employment Article 27 - Work and Employment 1. States Parties recognize the right of persons with disabilities to work, on an equal basis with others; this includes the right to the opportunity to gain a living by work freely chosen or accepted in a labour market and work environment that is open, inclusive and accessible to persons with disabilities. States Parties shall safeguard and promote the realization of the right to work, including for those who acquire a disability during the course of employment, by taking appropriate steps, including through legislation, to, inter alia: a) Prohibit discrimination on the basis of disability with regard to all matters concerning all forms of employment, including conditions of recruitment, hiring and employment, continuance of employment, career advancement and safe and healthy working conditions; 185 CRPD: Article 27 - Work and Employment Article 27 - Work and Employment b) Protect the rights of persons with disabilities, on an equal basis with others, to just and favorable conditions of work, including equal opportunities and equal remuneration for work of equal value, safe and healthy working conditions, including protection from harassment, and the redress of grievances; c) d) e) f) g) h) i) j) k) 2. States Parties shall ensure that persons with disabilities are not held in slavery or in servitude, and are protected, on an equal basis with others, from forced or compulsory labor. 186 CRPD: Obligations of States Parties Article 28 – Adequate standard of living and social protection Article 29 – Participation in political and public life Article 30 – Participation in cultural life, recreation, leisure and sport Article 31 – Statistics and data collection Article 32 – International cooperation Article 33 – National implementation and monitoring Article 34 – Committee on the Rights of Persons with Disabilities Article 35 – Reports by States Parties 187 CRPD: Article 29 - Participation in Political & Public Life Article 29 - Participation in Political & Public Life States Parties shall guarantee to persons with disabilities political rights and the opportunity to enjoy them on an equal basis with others, and shall undertake: a) To ensure that persons with disabilities can effectively and fully participate in political and public life on an equal basis with others, directly or through freely chosen representatives, including the right and opportunity for persons with disabilities to vote and be elected, inter alia, by: Ensuring that voting procedures, facilities and materials are appropriate, accessible and easy to understand and use; Etc. 188 CRPD: Article 29 - Participation in Political & Public Life Article 29 - Participation in Political & Public Life b) To promote actively an environment in which persons with disabilities can effectively and fully participate in the conduct of public affairs, without discrimination and on an equal basis with others, and encourage their participation in public affairs, including: Participation in non-governmental organizations and associations concerned with the public and political life of the country, and in the activities and administration of political parties; Etc. 189 CRPD: Article 30 - Participation in Cultural Life etc. Article 30 - Participation in cultural life etc. recreation, leisure, sport 1. States Parties recognize the right of persons with disabilities to take part on an equal basis with others in cultural life, and shall take all appropriate measures to ensure that persons with disabilities: a) Enjoy access to cultural materials in accessible formats; b) Enjoy access to television programs, films, theatre and other cultural activities, in accessible formats; c) Enjoy access to places for cultural performances or services, such as theatres, museums, cinemas, libraries and tourism services, and, as far as possible, enjoy access to monuments and sites of national cultural importance. 190 CRPD: Article 30 - Participation in Cultural Life etc. 2. States Parties shall take appropriate measures to enable persons with disabilities to have the opportunity to develop and utilize their creative, artistic and intellectual potential, not only for their own benefit, but also for the enrichment of society. 3., 4., 5. 191 CRPD: International Monitoring Mechanism Article 36 – Consideration of reports Article 37 – Cooperation between States Parties and the Committee Article 38 – Relationship of the Committee with other bodies Article 39 – Report of the Committee Article 40 – Conference of States Parties Article 41 – Depositary Article 42 – Signature Article 43 – Consent to be bound 192 CRPD: Final Clauses Article 44 – Regional integration organizations Article 45 – Entry into force Article 46 – Reservations Article 47 – Amendments Article 48 – Denunciation Article 49 – Accessible format Article 50 – Authentic texts Convention on the Rights of Persons with Disabilities – Articles | United Nations Enable www.un.org/disabilities; www.ohchr.org; ;[email protected] 193 Measuring Disability WHO, 2011, https://apps.who.int/iris/rest/bitstreams/53067/retrieve Challenges Disability is a complex multidimensional experience, which poses several challenges for measurement. Approaches to measuring disability vary across countries and influence the results. Operational measures of disability vary according to the purpose and application of the data, the conception of disability, the aspects of disability examined – impairments, activity limitations, participation restrictions, related health conditions, environmental factors. 194 Measuring Disability WHO, 2011, https://apps.who.int/iris/rest/bitstreams/53067/retrieve 195 Measuring Disability WHO, 2011, https://apps.who.int/iris/rest/bitstreams/53067/retrieve 196 Measuring Disability WHO, 2011, https://apps.who.int/iris/rest/bitstreams/53067/retrieve 197 Definition: Inclusion Different kinds of definitions Do you want to be “normal”? Do you want to be “special”? Do you want to belong to a group? 198 Definition: Inclusion Different kinds of definitions “How would YOU like to live, if YOU had a disability?” Inclusion is the common, equal co-existence in structures that have emerged according to the needs of all. Be involved in different life situations, barrier-free living and self-determination (autonomy, freedom of decisions and action) Enablers of inclusion: rehabilitation, assistive technology, accessibility, freedom of choice, inclusive/barrier-free design, empowerment (knowledge transfer to the disabled, compliance, information) 199 Global Prevalence of Conditions Benefitting from Rehab 2019 Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019 Alarcos Cieza, Kate Causey, Kaloyan Kamenov, Sarah Wulf Hanson, Somnath Chatterji, Theo Vos https://www.thelancet.com/action/showPdf?pii=S0140 -6736%2820%2932340-0 200 Prevalence and Years Lived with Disability Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019 Alarcos Cieza, Kate Causey, Kaloyan Kamenov, Sarah Wulf Hanson, Somnath Chatterji, Theo Vos https://www.thelancet.com/action/showPdf?pii=S0140 -6736%2820%2932340-0 201 History of Rehabilitation 202 Rehabilitation: Challenges Today Reforming policies, laws, and delivery systems Global survey of the implementation of the non-binding UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities found (2005): in 48 of 114 (42%) country’s rehabilitation policies were not adopted; in 57 (50%) of the country’s legislation for people w. disabilities didn’t pass; in 46 (40%) of the country’s rehabilitation programs were not established. South-North Centre for Dialogue and Development. Global survey of government actions on the implementation of the standard rules of the equalisation of opportunities for persons with disabilities. Amman, Office of the UN Special Rapporteur on Disabilities, 2006:141. 203 Rehabilitation: Challenges Today Reasons for existing challenges Lack of strategic planning Lack of resources and health infrastructure Lack of agency responsible to administer, coordinate, and monitor services Inadequate health information systems and communication strategies Complex referral systems Absence of engagement with people with disabilities South-North Centre for Dialogue and Development. Global survey of government actions on the implementation of the standard rules of the equalisation of opportunities for persons with disabilities. Amman, Office of the UN Special Rapporteur on Disabilities, 2006:141. 204 Rehabilitation: Challenges Today Developing funding mechanisms for rehabilitation, including: Reallocation or redistribution of resources International cooperation Inclusion of rehabilitation services in foreign aid for humanitarian crises Combination of public and private financing Target poor people with disabilities Evaluation of coverage of health insurance, including criteria for equitable access WHO, 2011 205 Rehabilitation: Challenges Today Increasing human resources for rehabilitation Many countries, developing and developed, report inadequate, unstable, or nonexistent supplies, and unequal geographic distribution of, rehabilitation professionals. Developed countries such as Australia, Canada, and the United States report shortages of rehabilitation personnel in rural and remote areas. Global atlas of the health workforce. Geneva, World Health Organization, 2008 206 Rehabilitation: Challenges Today Physiotherapists per 10’000 inhabitants in selected countries Global atlas of the health workforce. Geneva, World Health Organization, 2008 207 Rehabilitation: Challenges Today Increasing human resources for rehabilitation Rehabilitation specialists in the WHO EU region The need to scale up rehabilitation. Geneva: World Health Organization; 2017 208 Filme Movies to watch about inclusion and more - Das Experiment https://www.youtube.com/watch?v=TX94T3T6o3w - Die neue Nähe https://www.youtube.com/watch?v=NJbAjxkaxnA - Das erste Mal https://www.youtube.com/watch?v=gZFHK3OwzFM&t=288s - https://www.srf.ch/play/tv/sternstunde-philosophie/video/menschen- sind-nicht-behindert-sie-werden- behindert?urn=urn:srf:video:a23a8423-7374-470c-89b6-52519c772b9f - Rising Phoenix: Netflix Docu about Paralympics: https://www.youtube.com/watch?v=7XdNSAQeR2I (Trailer - über Klassifikation im Behindertensport: https://lexi.global/ 209  Sensory-Motor Systems Lab Institute of Robotics and Intelligent Systems Balgrist University Hospital Prof. Robert Riener [email protected]