GOAL-ORIENTED APPROACH FOR LIFE'S QUALITY (GOAL-Q) IN STROKE REHABILITATION
Satoshi Ueda (Teikyo Heisei University, Ichihara, Chiba, Japan)
Goal - Oriented Approach for Life's Quality (GOAL-Q) is a newly formulated clinical way of thinking as well as a concrete guideline for everyday clinical practice. It is a successor to Problem-Oriented System (POS) and attempts to develop it further and integrate it with quite a few new elements so that this new way of clinical thinking and practice can help professionals to fulfill their now established task of materializing the highest possible quality of life (QOL) of the patient/client. This approach is based on the fundamental philosophy of "rehabilitation" as the "restitution of human rights and dignity" and has been actually developed through painstaking efforts to innovate rehabilitation programs. However, once established, it can and must become the common basic approach in every field of clinical medicine and should be extended to include care and welfare activities for the elderly and people with disability as well.
In this approach the greatest emphasis is put on "pluses" rather than "minuses". The starting point of the approach is an accurate prognosis of disease, impairment, disability and, most important, handicap of the patient based on the detailed diagnostic evaluation on disease, impairment, disability and wider environmental and personal factors (job, family, friends, house, life style, value system, faith, hobby, social contacts, etc.). The goal setting follows: 1) The Main Goal that is a detailed personalized goal on the social QOL is of utmost importance; and 2) The Subgoals on disability and impairment levels are set in conjunction with it. Then the personalized rehabilitation program is made toward these goals. The main features of the "Positive Rehabilitation Program" that embodies GOAL-Q is 1) Emphasis on higher levels in ADL in close relation with higher QOL; 2) ADL training in the actual time, location and situation; 3) Activation of daily life through early independence in ADL, frequent small-amount exercise including "self-exercise", encouragement of greater amount of gait, etc.; and 4) Shortest possible inpatient program followed by a long outpatient program with greater emphasis on practical advice and counseling.
Much better results by the Positive Program compared with conventional program were confirmed.
NEUROLOGICAL ASSESSMENT IN SPINAL CORD INJURY (SCI)
J.F. Ditunno, Jr., Jefferson Medical College of Thomas Jefferson University, Phila., PA
Precise and reliable neurological assessment is a necessary tool for determining the extent and pattern of recovery after SCI. Recently agreed upon International Standards establish a uniform neurological classification to measure clinical outcomes. The purpose of this paper will be to review the use of these measures in determining the extent of the neurologic recovery in the upper and lower extremities, the functional implications, and possible underlying mechanisms. The Model System SCI centers report the use of these measures such as impairment grades and neurological levels in almost 15,000 cases over the past 20 years, and more recently, motor scores in 3,500 subjects. The NASCIS II multicenter trial on methyprednisolone utilized motor and sensory scores as end points, in close to 500 subjects, but have incorported the International Standards, which include a disability measure in NASCIS III.
In more focused studies, neurological assessment soon after injury can predict walking in motor complete injuries based on pin prick sensation, and in motor incomplete based on impairment grade and age. Upper extremity function can be estimated based on the motor examination within 72 hours of injury. Both the motor score and motor level are more reliable in predicting upper extremity function that the single sensory level. Some suggest, the pattern of muscle recovery in the upper extremities at the lesion site may relate to anatomical relationships. The proximal muscles of the lower extremities distal to the lesion site recovers before distal muscles, and this may be related to the ventral tracts.