Rehabilitation and Inclusion: A Study on Disabilities PDF

1. Introduc on  Age is a risk factor for disabili es.  The goal of rehabilita on is to make a person as independent as possible and enable par cipa on in educa on, work etc.  A movement requires cogni ve, sensory, and motor structures and func ons. > Cogni ve impairments: stroke, Alzheimer and other demen as, Parkinson. > Sensory impairments: blindness, deafness, ves bular disorder, spinal cord injury. > Motor impairments: stroke, Mul ple Sclerosis, spinal cord injury, amputa on, fractures.  Impairments can be permanent (sight impairment, deafness, amputa on, spinal cord injury) or degenera ve (Chorea Hun ngton, Duchenne Muscular Dystrophy, Cys c Fibrosis, Alzheimer, Mul ple Sclerosis). Impairments can be inherent/congenital or acquired.  Origins and Phases of Impairments (if an injury s ll has an eﬀect a er 6 months, it’s classiﬁed as a disability):  Paresis: weakness or par al loss of voluntary movement, usually referring to limbs.  Paralysis, plegia: complete loss of muscle func on, can be accompanied by sensory loss.  Incidence: number of NEW cases per popula on (e.g. 100’000) in a given me period (e.g. 1 year) = the risk of developing said condi on.  Prevalence: total number of EXISTING cases in a popula on at a given me.  Ae ology of amputa ons: vascular diseases and diabetes (80%), trauma (10%), tumours (5%), infec on (3%), other (2%).  Causes of spinal cord injuries: vehicular accidents (40%), falls (30%), violence (15%), sports and other (15%).  Stroke: ischemic (block of blood ﬂow, 80%) or haemorrhagic (intracranial bleedings, 20%). Hemiplegia (paralysis of one side of the body leads to drop foot, cramped hand) or hemiparesis (weaker form of hemiplegia), further symptoms are neglect (neurological impairment of a en on, neglect of one half of the body or the room), apraxia (impairment of voluntary movements), cogni ve deﬁcits.  Trauma c brain injury: caused by an external force applied to the skull or by objects penetra ng the brain, has physical, cogni ve and emo onal eﬀects, can be similar to stroke.  Parkinson’s disease: idiopathic (cause unknown), major decrease in dopamine levels, neurodegenera ve. Symptoms are bradykinesia and hypokinesia (slower and less movements), rigor, tremor and problems with balance and reﬂexes, change of mood and pain. 1  Mul ple Sclerosis: autoimmune reac on against myelin that covers the axons of neurons. Symptoms include ataxia (no voluntary coordina on of muscle movements), spas city, vision and speech impairment.  Cerebral Palsy (CP): lesions in the brain lead to motor dysfunc on that arises during pregnancy or birth, permanent and non-progressive. Symptoms include motor dysfunc on, spas city, and cogni ve deﬁcits.  Muscular Dystrophy (MD): gene cal, certain proteins needed for healthy muscles cannot be formed by the body. Over me the skeletal muscles weaken and break down. Most common type is Duchenne Muscular Dystrophy (DMD).  Some terms and deﬁni ons: > Structures: anatomical body parts like organs, limbs, etc., e.g. eyes, legs. > Func ons: physiological func on of a structure, e.g. seeing, moving. > Ac vity: execu on of a task, e.g. reading, walking. > Par cipa on: involvement in a life situa on, e.g. read the card at a restaurant, run a marathon. > Environmental factors: products, technology, a tudes, rela onships, policies etc. that can be facilitators or barriers. > Personal factors: mo va on and self-esteem inﬂuence par cipa on in society. > Impairment: problem with a body func on. > Ac vity limita on (e.g. cannot read due to blindness) and par cipa on restric on (e.g. cannot go to a lecture because room is not accessible for wheelchair). > Disability: lack of ability to perform an ac vity or par cipate in life situa on (can result from an impairment). > Handicap: disadvantage resul ng from disability that prevents fulﬁlment of a role.  More females have disabili es because they have a higher life expectancy and prevalence is higher at a high age. Low-income countries have higher prevalence.  Capacity: what a person can do without considera on of barriers and facilitators. Performance: what a person does under considera on of all barriers and facilitators.  Disability is a human rights issue when disabled person is denied equal access to health care, employment, educa on, poli cal par cipa on, is subject to viola ons of dignity or is denied autonomy.  A tudes towards disabili es in historical context: > Middle Ages: impairment is god-given, cannot be ﬁxed. > ‘Dri es Reich’: the claim was promoted that disabili es were a danger to the en re popula on (BULLSHIT) so they could kill disabled people oﬀ. > A er 1945: impairment was viewed as an individual, medical problem that must be treated and healed. > Nowadays (social model of disability): it is environment and society that must be adapted if it creates limits for people with an impairment.  Barriers: factors in a person’s environment that, through their absence or presence, create disability, including physical environment (li or ramp), assis ve technology (hearing aid), nega ve a tudes (prejudice in a job interview), and services and policies. Barriers can be physical, a tudinal, communica onal, or ﬁnancial.  Disables people are more likely to not receive care, e.g. due to ﬁnancial reasons or because they were denied care.  Exclusion vs. segrega on vs. integra on vs. inclusion: > Integra on: adap on to the rules of a given framework. > Inclusion: framework itself if subject to nego a on. Inclusion isn’t always wished for! 2  Inclusion doesn’t aim to make everyone equal but to oﬀer equal opportuni es to people despite their diﬀerences. It aims to change established structures. It isn’t for free; it comes at a cost.  Rehabilita on: ‘enable again’, (re)integra on of a disabled person into society either by enhancing exis ng capabili es or by providing alterna ve means.  Primary health condi on: star ng point for an impairment or ac vity limita on, e.g. depression, arthri s, cardiovascular disease, COPD, Down syndrome.  Secondary health condi on: presupposes a primary condi on, e.g. pressure ulcers (from lying in bed for a long me), urinary tract infec ons (from catheter), depression. O en mes preventable.  Co-morbid condi on: unrelated to primary condi on, e.g. cancer, hypertension etc. O en mes not detected or treated in people with disabili es.  People with disabili es require general health care needs like everyone else (e.g. preven ve care, treatment of acute or chronic illness) and may need addi onal specialist health care.  Goals of rehabilita on: treatment of symptoms and improvement of body func ons, preven on of disability (impairment is there but it shouldn’t become a disability) and secondary condi ons, learning of compensa on methods, promote autonomy, reintegrate into society.  Beneﬁts of rehabilita on: reduce the impact of diseases or injuries, minimize the disabling eﬀects of chronic health condi ons, investment with cost beneﬁts for individuals and society, enables par cipa on in educa on and employment.  Fields of rehabilita on: neurological, paraplegiological, musculoskeletal, orthopaedical, cardiovascular, pulmonal, oncological, psychiatric.  Core measures of rehabilita on: > Rehabilita on medicine: diagnosis and medical treatment of health condi ons, involving mainly physicians. > Therapy: restoring and compensa ng for the loss of func on, involving physiotherapists, psychologists, social workers, speech therapists etc. > Assis ve technologies: any item or product used to maintain or improve func onal capabili es of persons with disabili es. 3  Assis ve devices: > Prosthe cs: replace a lost func on. Motor (e.g. foot exoprothesis, hip joint endoprothesis) or sensory (e.g. cochlear implant) prothesis. > Ortho cs: support a weakened func on. Motor (e.g. crutches) or sensory (e.g. glasses, hearing aid) orthoses. > Subs tu on: replace a weakened or lost func on by another one. Motor (speech input for paralyzed persons) or sensory (acous c displays for blind people) subs tu on.  Physiotherapy was founded during renaissance. Most frequent diseases in children in the 1920s were cerebral palsy, polio (Kinderlähmung) and amputa ons. See slides 104-135 for more historical facts about rehabilita on.  Challenges today: decentralize service delivery (con nuum of care a er hospital stay, telerehabilita on), make assis ve technologies more aﬀordable, expand research (studies to ﬁnd out which therapy is most eﬀec ve for whom etc.)  UN-CRPD (United Na ons – Conven on on the Rights of Persons with Disabili es): > Ar cle 1 – Purpose: promote, protect and ensure human rights for all persons with disabili es. > Ar cle 2 – Deﬁni ons. > Ar cle 3 – General Principles: dignity and non-discrimina on. > More ar cles: equality, women and children, accessibility, educa on, employment etc. 4 2. Rehabilita on Medicine Introduc on  Deﬁni on rehabilita on medicine: goal isn’t to cure a disease but to improve func ons that are impaired by disease.  Rehabilita on medicine has shown posi ve eﬀects in: pulmonary condi ons, cardiac condi ons, neurological condi ons (mul ple sclerosis, stroke), musculo-skeletal disorders (fractures, chronic back pain).  Evidence levels: level 5 = only animal studies, level 1 = many RCTs and meta-analysis reviews.  Rehabilita on medicine has proven eﬀec ve in sudden onset diseases (stroke, acute coronary heart disease), in ﬂuctuant onset diseases (mul ple sclerosis, chronic back pain), and progressive diseases (Parkinson’s, Alzheimer’s). Rehabilita on Medicine Process  Classiﬁca ons: > Interna onal Classiﬁca on of Disease (ICD): describes diagnoses for diseases and injuries and the appropriate interven ons (diagnos c procedures, medical therapies, preven on of complica ons etc.). > Interna onal Classiﬁca on of Func oning, Disability and Health (ICF): describes func onal health status and social impact of disabili es. > Interna onal Classiﬁca on of Health Interven ons for Treatment, Preven on and Diagnos cs (ICDI?): medical nursing, rehabilita on, imaging, public health.  ICD provides a diagnosis and suggests interven ons, ICF provides informa on about the social and psychological impacts of a certain diagnosis on a person’s life.  Features of a (rehabilita on) team for best outcome: clear goal se ng to achieve tasks, mul disciplinary team mee ngs to maximise organisa on, central informa on pla orm to share good-quality informa on (e.g. transfer report from hospital to physician).  Basic services of rehabilita on (inpa ent): speciﬁc assessment of necessary length of stay, ICD- and ICF- related documenta on of progress, rehabilita on coordina on through se ng goals and assembling op mal treatment team, individual therapy plan, involvement of pa ent.  Problem of today’s rehabilita on system: there isn’t any data on pa ents a er discharge (no info on ‘ﬁnal outcome’), therefore outpa ent rehabilita on is diﬃcult to implement. Rehabilita on Medicine Team  Rehabilita on physician: head of rehab process, they design individual treatment plans with the goal to maximise a pa ent’s independence in daily life.  Rehabilita on nurses: present ‘24/7’ in inpa ent rehab clinic, help with rehabilita on ac vi es outside therapy me.  Physical therapists: preven on, assessment, treatment, and rehabilita on when movement func ons are aﬀected by ageing, injury, or disease.  Occupa onal therapists: help people to par cipate in ac vi es of everyday life.  Speech therapists: experts in area of communica on, voice, speech, hearing, swallowing, social aspects of communica on. 5  Clinical psychologist: promote psychological well-being, work with individuals, families, and groups. Evalua on and Planning  Evalua ng a pa ent: > Neurological examina on (sensory pa erns, atrophy, reﬂexes, cranial nerve func on). > Mental status examina on (a en on, orienta on, memory). > Communica on (aphasia, dysphonia, verbal apraxia). > Motor Control (strength, coordina on). > Cardiopulmonary capacity (VO2max, voluntary ven la on).  Mental status examina on: it’s important to be sure a pa ent understands what you are saying (e.g. when giving instruc on or explaining something), possible test is MMSE (mini-mental state exam).  Cranial nerve examina on: smell (olfactory nerve), ﬁeld of vision, colour vision (op c nerve), frown, smile (facial nerve).  Musculoskeletal examina on: palpa on (joint stability, range of mo on), provoca ve manoeuvres, muscle strength. Treatment Techniques  Therapeu c Exercises: > Cardiovascular exercise: engage large muscle group in aerobic ac vi es (e.g. jogging, cycling, rowing, aerobic dance) with the goal to improve cardiorespiratory endurance. > Strength training: 8-10 exercises that target major muscle groups for about 1h at least 2 days per week. > Flexibility: sta c and dynamic stretching of major muscle groups without discomfort at least 2-3 days per week. > Neurofacilita on approaches: for pa ents with injury or disease of the central nervous system (o en resul ng in paralysis). Problem: hard to standardise these therapies and make studies about their eﬃcacy because of diﬀerences among pa ents and small sample sizes.  Spinal manipula ve therapy and massage: currently not recommended as a treatment for lower pack pain because there are no studies to prove its eﬀect.  Integra ve Medicine: medita on, crea ve therapy, yoga, pilates. Measurement of Outcome  PROMs (= pa ent-reported outcome measures): standardized self-repor ng instruments using a pa ent’s view to assess their health status.  PREMs (= pa ent-reported experience measures): self-repor ng instruments measuring a pa ent’s percep on of their experience whilst receiving care.  CROMs (= clinician-related outcome measures): measurable changes in symptoms, overall health, and quality of life that require knowledge of a medical professional to be interpreted. 6 Rehabilita on Pathways Cerebral Palsy Hip Replacement Myocardial Infarc on Pre-rehab / Strength and / coordina on training Hospital Diagnosis and ini al Surgery and ini al Diagnosis and ini al treatment mobilisa on treatment Rehab Clinic Management of / Pa ent educa on, associated disabili es management of risk factors, exercises Outpa ent ““ Management of pain, ““ mobility, coordina on Home Care Family involvement Pa ent educa on, Risk factor telerehabilita on management Inclusion Appropriate care Adjustment at Adjustment at se ng, assis ve workplace workplace technology Current Trends in Rehabilita on Medicine  Outpa ent (ambulant) before inpa ent (sta onär, stay overnight at hospital).  Rehabilita on close to home and work environment. 7 3. Social Inclusion I (Brian McGowan)  Models of disability: > Individual / medical model: disability is an individual problem, deﬁcit at focus. > Social model: disability is a social model, one is being disabled. > Human rights model (UN-CRPD): disability results from interac on of between impairment and environmental factors (impairment is just one side of this interac on).  Equality: elimina on of obstacles and barriers so everyone has equal opportuni es.  About 20% of people in Switzerland are disabled (ca 1.8 million).  Exclusion < segrega on < integra on < inclusion.  Core elements of inclusion: accessibility, freedom of choice, par cipa on. Inclusion is the equal coexistence of structures that accord to the needs of all.  Integra on is the adap on to a given framework, inclusion is the adapta on of the framework itself.  UN Conven on on the Rights of People with Disabili es (CRPD): > Mo va on: People with disabili es are o en forgo en when interpre ng the general human rights conven on, they face barriers in par cipa on and human rights viola ons. > It was created by people who have disabili es to provide guidance and a frame of reference when new policies are introduced etc. > Paradigm shi : people with disabili es are self-determined people, not objects of charity. > Goal of CRPD is to grant accessibility, freedom of choice, and par cipa on.  Rehabilita on professionals should invite people with disabili es to the table and empower them to share their opinion because they know their needs and the problems they are currently facing the best. Rehabilita on should rely on the exper se of people with disabili es and professionals without disabili es should understand how disability is (partly) constructed by society.  Status right now in Switzerland: hardly any inclusive structures, mostly integra on or segrega on, medical is dominant over social model. 8 4. Therapy Technologies Example: Stroke  Primary Complica ons: gate and movement dysfunc ons, ataxia, cogni ve dysfunc ons.  Secondary Complica ons: muscle atrophy, cardiopulmonary problems, pressure sores, osteoporosis, incon nence.  Infants and children ‘train’ a lot before they are able to properly do sth, e.g. 10’000 leg movements per day before they can run, 2’000 reach and grasp mo ons per day for ﬁne motor skills  similar to pa ents with stroke who have to re-learn many things.  Disadvantages of manual training: physically exhaus ng for therapist, limited me and subop mal gait pa ern for pa ent, cost intensive for health care system. Lower Limb Therapy Devices  Advantages of robot-aided therapy: gait pa ern consistent, more complex movements possible (e.g. stair climbing), longer training dura on and increased mo va on and safety for pa ent, may become cost beneﬁcial over me.  Disadvantages of robot-aided therapy: less ﬂexible (each training modality needs a separate machine, e.g. walking, standing up, upper extremity movements), expensive.  Endeﬀector-based: easy to enter and faster to use, but no control of joints (knees) and therefore possibility of injury or risk of learning an unhealthy gait pa ern.  Body-weight support systems: Sta c: adjustable to pa ent’s height but unphysiological feeling when walking because no up- down movement possible. Counterweights: up-down movement possible but chopped. Elas c springs: smooth up-down-movement but fric on is a problem. Actuated: best solu on, electrical, constant and smooth movement.  Only body weight support system without gait func on allows training without risk of falling.  S ﬀ exoskeletons provide maximal support and force but people can only walk and not sit in them. So exosuits are comﬁer and allow si ng down etc. but provide less force and support.  Exomuscle: three-layer support against gravity, supports muscle during those parts of walking that require the most muscle force (standing up, pushing-up phase of gait), consist of garment layer, ligament layer (for hip & knee ﬂexion), power layer (for hip & knee extension).  Studies have shown that electromechanical-assisted training in ﬁrst 3 month a er stroke are the most beneﬁcial. Upper Limb Therapy Devices  Challenges: more precise movements, more variety in movements, movements not periodic. 9  Complex anatomy of shoulder: many joints and bones involved.  Two mechanical interac on concepts: endeﬀector-based vs. exoskeleton.  Main challenge of exoskeletons: alignment of robo c axes with anatomic joint axes.  Main challenge of endeﬀector-based: control of posture and movements (only simple movements like turning wrist or angling elbow possible).  Endeﬀector-based is easier to apply, exoskeletons allow more complex movements and bigger range of mo on.  Myoshirt: a scapular orthosis that provides stability for shoulder instability (passive) and mobility for muscular weakness (ac ve). Passive part alone already greatly improves range of mo on.  Studies have shown that electromechanical and robot-assisted arm training improved ac vi es of daily living, arm func ons, and arm muscle strength. Virtual Reality Technologies  Therapy Devices like exoskeletons can be combined with VR technologies (e.g. a game) to increase mo va on and engagement of pa ents.  Objec ves of VR: > Provide a prac cal training se ng: simulate realis c tasks of everyday life (like cooking), individual and gradual diﬃculty adjustments, visual context makes instruc ons more intui ve. > Improved feedback and assessment: pa ent is informed about their eﬀorts (graphics or sound when they succeed at a task), measured scores inform therapist about rehabilita on status. > Stronger neurophysiological eﬀects: increased cogni ve s mula on and mo va on.  Mul modal input (biochemical & psychophysiological s muli like treadmill speed, body weight support, task, sound) and output (mul -sensory recording of heart rate, force, posi on, speed).  VR-supported psychotherapy: exposure therapy of phobias for decondi oning (e.g. treat claustrophobia through exposure to a virtual narrow room). Intensive Care Devices  Early and safe mobilisa on through a powered lt table so pa ents can be brought into an upright posi on but are s ll secured to the table.  Cardiovascular stabilisa on with a lt table: measuring heart rate and blood pressure during early mobilisa on.  Decubitus preven on: intensive care beds with several air chambers, intelligent pressure management via sensors and controls, and automa c postural changes to avoid large pressure peaks in pa ents who have to lie for a long me.  Help pa ents sleep: rocking beds, detec on of sleep apnea induces a change of head angle so pa ents don’t wake up because of the apnea. Robot-Aided Care  ‘Robo c nurses’ for li ing, turning, and transferring pa ents, for delivery services (food or medicine), for decubitus preven on, for wellbeing.  Robo c pets to improve wellbeing and communica on.  Sor ng and delivery of medica on to pa ent’s hospital room where staﬀ provides pa ent with the medica on. 10 Electrical S mula on  FES (func onal electrical s mula on) of leg muscles for gait, e.g. s mula on of ﬂexion reﬂex (reﬂex that makes you angle your hip and knee joints when you step on sth that hurts) to induce a gait pa ern.  Diﬀerent types of brain s mula on. 11 5. Assis ve Technologies Prostheses: Ar ﬁcial Limbs  Foot prostheses: solid ankle, (0 degree of freedom), single-axis (1 DOF), mul -axial (several DOF).  Knee prostheses: manual locking, mechatronic or ﬂuidic damping, powered.  Challenge of powered prostheses: detec on of inten on  actua on  sensory feedback  …  Upper extremity prostheses: challenges regarding func on and appearance like large variety of 3D movements of arm, ﬁne motor func ons of ﬁngers, non-periodic and non-ballis c movements, sensory feedback required for task execu on, aesthe c appearance.  Arm protheses: shoulder-powered, motor-powered, myoelectric (electrodes sense muscles). Wheelchairs  Manual wheelchairs: “hand-bikes”, special wheelchairs for diﬀerent sports (marathon, ska ng).  Powered wheelchairs: e.g. if person cannot use arms to move wheels  input devices can be joys cks or switches (if hand movements are possible) or chin, mouth, and tongue s cks.  Stair elevators. Walking Aids, Crutches  Sta onary and mobile suspension systems: to train walking during rehabilita on.  Diﬀerent types of crutches: cane, white cane (blind people), below elbow crutches (classic), armpit crutches, crutches with cushions (arthri s crutches).  Walkers: four-point crutches or wheeled walkers. Mechanical Joint Orthoses  Passive single-joint (wrist, elbow, knee) or mul -joint orthoses (corset for shoulders & back).  Weight compensa ng arm orthoses: mobile arm support, e.g. for wri ng.  Mechatronic knee-ankle-foot orthoses with controlled damper.  Powered exoskeletons for gait.  Mechatronic orthoses for arm and hand: ﬁnger movements. Func onal Electrical S mula on (FES)  Same that are used for therapy technologies.  FES bikes: electrical s mula on of leg muscles to make pedalling possible. Assistance of Ac vi es of Daily Life  Robots suppor ng ac vi es of daily life like grabbing things, ea ng, cutlery that reduces tremor for Parkinson pa ents. Assistance of Sensory Func ons  Magniﬁers, glasses, re na implants.  RaVis 3D: radar-based device (looks like a ﬂashlight), captures user’s surroundings and translates them into audio signals, which are displayed via hearing aid. Not on market yet.  Subs tu on: braille (Blindenschri ) is a wri ng based on dot pa erns. Braille display is a computer output device that displays characters in braille 12  Screen readers: computer so ware that reads texts aloud.  Braille typewriter, also used as an input device for computers.  Braille embosser: prints texts or images in braille on thick paper or plas c.  Braille e-book and braille tablet (electroac ve polymers rather than mechanical pins to raise braille so is ‘refreshable’).  Hearing aids and cochlear implants. Assistance of Vegeta ve Func ons  Cardiac pacemakers: MRI safe, light, long-las ng ba ery (up to 10 years).  Ar ﬁcial implantable heart: only a few dozen pa ents so far.  Bladder simulator (electrical s mula on). 13 6. Home and Remote Training  Home and remote monitoring, assistance, and therapy.  Therapy at home at the moment: no possibility to check if tasks are executed and quality of movement.  Deﬁni ons: > e-Health: overall use of electronic technology in health care system. > m-Health (mobile): medical support via mobile devices for measuring, analysing, and transmi ng pa ent data. > Telehealth: health care services carried out in online/remote environment, educa on of medical staﬀ, database systems to store data. > Telemedicine: remote clinical healthcare interac on between provider, doctor, and pa ent. > Telecare: special care and long-term supervision of pa ents with impairments over distance.  Technologies of telemedicine: portable diagnos cs, body sensors (measurement of health parameters), gamifying health (mo va on of pa ents and collec ng data in diagnosis and treatment).  Teleacquisi on: > Digital medical sensor devices: sensing devices that generate digital outputs to visualise and analyse physiological signals. > Web- or app-based computer so ware: organise and have access to pa ent data and individual home-based programs from anywhere. > Data storage systems.  Teletreatment: > Areas: physical therapy, speech-language pathology, psychology. > Formats: individual or community-based therapy sessions, modali es used include webcams, videoconferencing, webpages.  Slides 16,17  Advantages of telemedicine: > Improves data-driven clinical decision making: remote pa ent monitoring (RPM) improves clinical insight of therapists, see changes in symptoms over me, alter care plan accordingly. > Helps pa ents with self-management and adhering to care plan. > Cost of care is reduces for pa ents and providers: reduc on in unnecessary hospital admission, enables early acute discharge, RPM reduces inpa ent treatment. > Infrastructural advantages: reduces pressure on hospital emergency sta on 14 > Improves access to care: solves the problem of physical barriers and provides care where and when it is needed, reach pa ents in rural areas and make specialists more available for people in other areas, reduce missed appointments. > Prevents spread of infec ous diseases and hospital-acquired infec ons.  Telemedicine empowers pa ents (diagnose and treat themselves), re-thinks medical curriculum (prepare future doctors for e-pa ents and technologies), provides personalised medicine.  Barriers in telemedicine: Home and Remote Therapy  Teletreatment technologies: VR glasses (interac on with simulated environment), hap c and robo c devices (interac on with contact force and vibra on, robo c support for surgery and therapy).  Player modes for rehabilita on: compe ve or coopera ve modes preferred over single mode.  Therapeu c ball for home therapy: hand therapy ball improves ﬁne motor skills a er stroke, gymnast ball for posture, balance, and stability.  Akina AG: > Rehab and gamiﬁca on at home through a digital service for physical therapy, e.g. a er comple ng an inpa ent stay at rehabilita on clinic. > Combina on of interac ve environments, AI-based assistance, mo on detec on, and telerehabilita on. > AI mo on suite: webcam registers movements (e.g. measure angle of shoulder eleva on) and summarises those so therapist can see outcome.  Exoskeletons in domes c se ngs: increase func onal mobility of pa ents and increase physical ac vity.  Factors inﬂuencing exoskeleton use: ease of pu ng on and taking oﬀ (goal: under 5 minutes), transport possible, ba ery life, environmental factors.  SleepLoop: device to wear on face and head, predic on and s mula on of deep sleep and slow- wave ac vity, es ma on of sleep phase.  Robo c bed for treatment at home: produces smooth movements for ves bular s mula on, which helps with sleep disorders. Sleep quality is an important aspect of health and rehabilita on and is o en forgo en!  Home-based arm rehabilita on: robo c device for exercises a er stroke. 15 Home and Remote Monitoring  Instrumented apartment to monitor human behaviour: infrared cameras, radars, mo on trackers, microphones, monitoring cameras.  In-home sensors to recognise ac vi es of daily life (sleeping, hygiene, go to toilet, ea ng, cooking, visitors) to create ac vity maps and help ﬁnd a daily structure:  Telemonitoring: e.g. wear a wrist watch with sensors that measure the parameters of interest.  Home gait assessments: ankle braces or belts with sensors to measure gait.  Telemonitoring important for con nuum of care.  Wearables for diabe cs that measures blood glucose and gives a warning in case of hypoglycemia. Home and Remote Assistance  Remote call assistance: online speech therapist for children, phone therapy session and psychological consul ng, phone calls for the elderly.  Pillcounter: helps with organisa on of when to take which medica on, important for pa ents with cogni ve impairments (e.g. Alzheimer’s disease).  See previous lecture for rest. 16 7. Reimbursement of Health Care in Switzerland Sta s cs  Switzerland expends 11% of GDP for health.  60% of health expenditure is shouldered by private households, 35% by state.  How much mandatory healthcare costs diﬀers in each canton. Health Insurance in Switzerland  Universal and mandatory but not free!  Coverage of illness, maternity, and accidents (as long as not employed yet).  Health insurance providers are private but approved by state.  Basic (OKP = obligatorische Krankenpﬂegeversicherung) vs. supplementary health insurance:  OKP schemes:  Risk compensa on: insurers who have many high-risk groups (old, women, ill) under insurance receive contribu ons from insurers who have low-risk groups under insurance (young, male, healthy). Reimbursement of Medical Services  Financing: inpa ent 55% paid by canton, outpa ent 100% paid by insurer.  Types of medical care: acute care, psychiatric care, rehabilita on  SwissDRG Inc. develops and maintains 3 tariﬀ structure.  Over 30 diﬀerent categories of out-pa ent treatments and corresponding tariﬀs: eye prothesis, physiotherapy, nursing, hearing aid, den stry, spitex, pharmacists.  TARMED (‘ärztliche Leistungsstruktur’): tariﬀ (reimbursement of medical treatment) conducted by physicians  see video on slide 29. 17 Accident Insurance in Switzerland  Employer covers accidents if you work: < 8h / week: occupa onal accidents & illness. > 8h / week: occupa onal accidents & illness AND non-occupa onal (not during work) accidents.  Accident insurance coverage includes: accident-related medical expenses (no deduc ble and no co-payment), daily allowance (e.g. 80% of salary while unable to work).  Legal deﬁni ons of “illness” and “accident”:  Accident insurance cover following bodily injuries, as long as they aren’t due to wear or illness: frac ons, muscle or ligament or tendon tears. Complete list deﬁned by SUVA, these condi ons count as accidents even if they are not “unusual” (it’s predictable that you might break a bone while skiing).  Occupa onal illness: diseases caused predominantly by harmful substances (e.g. chemicals, sth that triggers an allergy) or speciﬁc ac vi es (heavy li ing leading to back pain) during work. Most common are diseases of respiratory tract, musculoskeletal system, and skin, noise-induced hearing loss, and asbestos-related cancer.  Ventures (‘Risiko/Wagnis’): SUVA pays all medical costs (hospital bills, medica on) in any case, but cash beneﬁts (daily allowance, invalidity pensions) can be reduced or cancelled. Key Diﬀerences between KVG (Krankenversicherung) & UVG (Unfallversicherung)  KVG: objec ve is coverage of costs, insurance includes only direct costs (treatment), selec ve contrac ng not permi ed.  UVG: objec ve is provision of healthcare, insurance includes direct and indirect costs (treatment and loss of work), selec ve contrac ng permi ed. Invalidity Insurance in Switzerland  IV beneﬁts: > Early interven ons: prevent health-related problems in workplace. > Reintegra on measures: improve or maintain a person’s ability to work. > Invalidity pensions: compensate for the loss of earnings due to invalidity. > Helplessness allowance and personal assistance allowances: ﬁnancial support if disabled person is dependent on help of third par es.  Invalidity: a person is invalid if they lose the ability to work due to an impairment or a disability.  Eligibility for an IV pension: capacity to work reduced by 40% for at least a year and situa on irreversible. Example: Wheelchair Tariﬀ  Wheelchair tariﬀ dis nguishes 5 types of wheelchair categories (basic, adap ve, children, special, electric) and 4 degrees of disability (walk short distance independently, walk few steps with support, can’t walk at all, can’t walk and can’t use a hand wheelchair). 18 8. Social Inclusion II (Blindspot) Inklusionsprojekte von Blindspot:  Inklusiver Arbeitsmarkt: Gastronomiebetriebe, Foodtrucks, Popups.  Inklusiv Wohnen: Wohnungen mieten für WGs  soziales Umfeld erweitern.  Inklusive Feriencamps: Ziel sind soziale Netzwerke zu knüpfen, Social Skills entwickeln.  Inklusive Schulklasse: Klassen so zusammenstellen, dass 20% der Kinder in einer Klasse eine Behinderung haben sta nur 1 Kind (und dann gibt’s halt Klassen ohne Kinder mit Behinderung). 3 Phasen Modell der Inklusion:  Phasen I und II haben noch nicht viel mit Inklusion zu tun, sondern erst mit Verständnis der nö gen Arbeit und Normalisierung in Phase III beginnt Inklusion.  Meiste Schulen in Schweiz sind in Phase II hängengeblieben, Poli k will eher zurück zu früher, sta weiter zu pushen und weiter nach Lösungen zu suchen für Erreichen von Phase III. Inklusion in Unternehmen:  Normalisierung und Gleichbehandlung (auch Leuten mit Behinderung Verantwortung und Herausforderungen geben).  Oﬀenheit, Transparenz, Feedbackkultur (lernen mit Kri k umzugehen, Selbstbewusstsein stärken).  Wertschätzung, gebraucht werden (Wert soll nicht mit Leistung gleichgesetzt werden, ein 40% Pensum kann 100% Leistung / Energie der Person entsprechen).  Barrierefreie Arbeitsorganisa on, Potenzialfokus (= auf Stärken bauen, das betonen was man kann).  Zweiter Arbeitsmarkt: geschützt, vom Staat subven oniert, muss nicht rendieren (d.h. Beschä igungen sind gewissermassen ‘sinnlos’, z.B. Rechnungen in Couverts verpacken, was Maschinen viel schneller könnten). 19 Inklusion ist ein Mehrwert: 20 9. Barrier-Free Living  Barriers result from misconcep ons about people with disabili es (‘they don’t go out much’, ‘they are happy to ask for help’ etc.).  Types of barriers: a tudinal, communica on, physical, ﬁnancial.  Coding of environmental factors: should be coded from the perspec ve of the person whose situa on is being described (so disabled person describes their own situa on rather than an able-bodied person describing it). Environmental factors include products, technology, natural and human-made environment, support and rela onships, a tudes, services, and policies.  Design types: equitable (‘gerecht’, can be used by all, e.g. ramp) vs. adaptable (provides a separate op on for people with disabili es, e.g. stairs + elevator).  Adaptable designs have basic universal features, that can be easily adapted to the need of a speciﬁc user (e.g. person with hand impairment, wheelchair etc.).  Fixed accessible features: alarms must signal via more than just one sensory func on (visual AND auditory), doors must be wide, clear ﬂoor spaces before ﬁxtures like toilet, stove, showers, sinks, etc.  Access for people with disabili es: physical (buildings, public transport), communica ve (signs, telephones, internet), programs (health care, entertainment), employment, educa on, community.  Barrier-free building inside: > Accessibility: ramps, li s, wide corridors, doors that open automa cally or that don’t require much force to open manually, things stored at wheelchair height. > Signages: large enough and good contrast, braille, height that is visible for wheelchair users, alarm systems. > Toilets: provide public toilets for people with disabili es. > Good ligh ng (evenly distributed, not too bright or dark) and visual contrasts (to dis nguish diﬀerent structures like walls and ﬂoors, furniture, doors, etc.). > Emergency plan: evacua on paths for wheelchair users.  Barrier-free building outside: big enough parking spaces, enough space in public transport, tac le lines on the ground at train sta on.  Access to communica on and informa on, e.g. visual and auditory cues about sta ons in public transport.  Microso Hearing AI App: provides visualisa on of sound volume, no ﬁca on of sudden changes in sounds, and speech-to-text func ons  no ce an alarm that a deaf person otherwise couldn’t hear.  Accessibility depends on wealth of countries and of individuals. 21 10. Parasports  Classiﬁca on: determines whether an athlete is eligible for compe ng in a certain sport based on how their impairment impacts sport performance. Classiﬁca on is sport speciﬁc.  Sport classes: athletes are grouped into sport classes based on degree of their impairment (similar to grouping by age, sex, weight, etc.).  Impairment criteria: minimal threshold of impairment athlete must have to be eligible as paralympic athlete.  Paralympics eligible impairments:  Athlete must fulﬁl impairment criteria to be admi ed for a certain sport (cycling, swimming, hockey). Athlete can then choose their division (for cycling  handcycle, tricycle, tandem). Within that division, they will be sorted into one of the sport classes.  Special Olympics: sports training and athle c compe ons for children and adults with intellectual disabili es due to gene c condi ons, (Down syndrome, Fragile X syndrome), pregnancy complica ons (foetal alcohol syndrome), birth problems, or toxic exposures.  Deaﬂympics: for deaf athletes, adhering to ideals of Olympics.  Invictus Games: for injured or sick servicepersons, use sport to make them more visible and support recovery and rehabilita on.  Cybathlon categories: arm prothesis race, assistance robot race, exoskeleton race, FES (func onal electrical s mula on) bike race, vision assistance race, wheelchair race, leg prothesis race.  Chemical doping: banned substances same as Olympics (glucocor coids, cannabinoids, narco cs, s mulants), gene and cell doping, manipula on of blood, diure cs, hormone modulators, beta blockers.  Techno-doping: complicated and controversial because it’s not clear whether sport can be isolated from inﬂuence of technology  running shoes, full body swimsuits, blade runners, etc. 22 11. Device Cer ﬁca on Regula on of Medical Devices  USA: Food and Drug Administra on (FDA), classiﬁca on into classes I-III,  Europe: European Medicines Agency (EMA), classiﬁca on into classes I, IIa, IIb, III, based on European Medical Device Regula on (MDR).  Switzerland: Swissmedic, authorisa on and supervision of therapeu c products, agreements with other agencies (FDA, EMA).  Players: manufacturers have to ensure a device is safe and func oning, competent authority monitors market, no ﬁed body assesses conformity to essen al requirements. What is a Medical Device  Medical device = any instrument, reagent, material, so ware, implant intended to be used by humans for diagnosis, preven on, treatment of disease, injury, disability.  Intended use is what deﬁnes whether sth qualiﬁes as a medical device. Its intended ac on cannot be achieved by pharmacological, immunological, or metabolic means (e.g. medica on).  Deﬁne intended purpose and intended use: deﬁne pa ent popula on, list poten al indica ons, determine foreseen users (e.g. disclaimer not tested during pregnancy), describe context of use, deﬁne medical purpose and claims. How to Cer fy Medical Devices  Class I devices can be self-tested (e.g. wheelchair, hospital bed).  Class I* (special func on), IIa, IIb, III need to be tested and approved by no ﬁed body.  Class I*: sterile (bandages), surgical reusable, measuring func on (thermometer).  22 Rules of MDR split into 4 categories: non-invasive devices, invasive devices, ac ve devices (deﬁbrillator), special rules for all devices.  Non-invasive devices that are only in contact with intact skin are class I.  Ac ve therapeu c devices intended to administer are class IIa (hearing aid), unless used in a poten ally hazardous way then class IIb (deﬁbrillator).  So ware that provides informa on used for diagnos c or therapeu c decision is class IIa or higher. Blood sugar monitor for diabetes class IIb, dosage calculator for painkillers class III.  Device development pathway: idea  prototype  feasibility tes ng  study  regulatory aﬀairs  product launch  post-market surveillance.  CE mark: indicates that device complies with European health, safety, and environmental protec on standards. Allows product to be sold freely in European Economic Area (EEA). 23 12. Global Access to Assis ve Technology (WHO) Introduc on to WHO  WHO: specialised agency of United Na ons to promote health globally. Main goals are advancing universal health coverage, addressing health emergencies, and promo ng healthier popula ons.  Governance of WHO: member states at bo om of pyramid, execu ve board and world health assembly at top.  Core func ons of WHO: provide leadership and partnership concerning health issues, shape research agenda, se ng norms and health policies, monitoring health situa ons.  WHO deﬁni on of health: state of complete physical, mental, and social well-being, not merely absence of disease.  Milestones: global strategy of diet, physical ac vity, and health, WHO conven on on tobacco control, commission on social determinants of health (barriers, s gmas, religious intolerance).  Challenges: noncommunicable (‘nichtansteckend’) diseases leading cause of death, popula ons become older, urbanisa on, migra on. WHO Work on Assis ve Technologies (ATs)  Assis ve technology = applica on of organised knowledges related to assis ve products (hearing aids, wheelchairs, glasses, protheses, pill organiser), including systems and services.  Categories of assis ve products: communica on, cogni on, hearing, mobility, self-care, vision.  Four groups of health products: medicines, vaccines, medical devices and diagnos cs, assis ve technologies.  Access to ATs is a human right and is key to advancing sustainable development goals (SDGs).  Beneﬁts of AT: supports well-being, promotes economic growth, enables inclusion and par cipa on.  World health assembly resolu on of 2018: member states should improve access to AT within universal health coverage. WHO provides standards, guidelines, and country support.  5P framework for ATs: people, policy, products, provision, personnel.  Need for AT is predicted to rise in the future because popula on becomes older (2/3 of people >60 y/o need an AT).  Range of access to ATs: 3-90%, meaning in some places only 3% of people who need an AT have access to it, in other places 90% have access.  Factors limi ng access to ATs: ﬁnancial barriers, no availability, loca on, lacking educa on and support, s gma. Greatest weakness of system in most countries is service delivery and workforce (services and personnel for ATs are lacking). 24 13. Preven on of Disease and Injury  Goal to improve public health split into health promo on and disease preven on:  Health determinants: individual implementa on of human rights, provision of healthcare.  Health promo on: advocate, enable, and mediate. > Advocate: health as a resource for social, economic, and personal development. > Enable: people cannot achieve full health unless they are in control of the things that determine their health (suppor ve environment, life skills, access to informa on). > Mediate: health cannot be ensured by health sector alone, coordina on with government, economic sector, industry, media, etc.  Disease preven on classiﬁca ons:  Health promo on and primary preven on overlap, e.g. both recommend physical ac vity.  Behavioural preven on: ac ons apply to individuals and their behaviour, mainly through educa on and health informa on (e.g. do sports).  Condi on preven on: ac ons apply to the environment (living and working condi ons), mainly through laws, policies, prohibi ons (e.g. no smoking inside buildings).  Achievements of preven on: eradica on of smallpox and reduc on of child morbidity due to vaccines, reduced number of unwanted pregnancies and HIV infec ons due to sex ed, reduced numbers of traﬃc accidents due to speed limits and alcohol tests.  Challenges: ageing popula on, increase in social inequality, cost explosion in healthcare, occurrence of new diseases, loss of trusts in science and appearance of conspiracy theories.  Federal Oﬃce of Public Health (FOPH, in German BAG): responsible for public health in CH, should ensure CH has an eﬃcient, aﬀordable, and sustainable health care system.  Na onal health strategies on addic on, demen a, STIs, hospital infec ons, non-communicable diseases (NCDs), vaccina on.  EKAS (eidgen. Koordina onskomission für Arbeitssicherheit) federal oﬃce for accident preven on at work. 25

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