Physical Management in Neurological Rehabilitation

543 Pages·2004·42.551 MB·English

by  Maria Stokes (ed.)

Dedicated to the residents and staff at
the Royal Hospital for Neuro-disability, Putney
and to my father, Peter,
who cherished textbooks.
For Elsevier
Publishing Director and Senior Commissioning Editor:Mary Law and Heidi Allen
Project Development Manager:Dinah Thom
Project Manager:Derek Robertson
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© Mosby International Limited 1998
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First edition 1998
Second edition 2004
ISBN 0 7234 3285 6
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Prelims.qxd 31/7/04 16:48 Page vii
Contributors
Gillian Baer MSc MCSP ILTM Brian Durward MSc PhD MCSP
Senior Lecturer in Physiotherapy, Queen Margaret Dean, School of Health and Social Care, Glasgow Caledonian
University College, Edinburgh, UK University, Glasgow, UK
David Bates MA MB FRCP David Fitzgerald DipEng GradDipPhys GradDipManipTher MISCP
Consultant Neurologist and Senior Lecturer, Department of Private Practitioner/Lecturer, Dublin Physiotherapy Clinic,
Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK Dublin, Ireland
J Graham Beaumont BA MPhil PhD CPsychol FBPsS Elizabeth Green BA(Hons) MD DCH DipHthMan FRCPCH
Head of Clinical Psychology, Royal Hospital for Neuro- Consultant in Paediatric Rehabilitation, Chailey Heritage
disability, London; Honorary Professor, University of Surrey, Clinical Services, East Sussex, UK
Roehampton, UK
Bernhard Haas BA(Hons) MSc ILTM MCSP
Rolfe Birch MChir FRCS FRCSEng Head of Physiotherapy, University of Plymouth,
Consultant Orthopaedic Surgeon, Royal National Plymouth, UK
Orthopaedic Hospital NHS Trust, Middlesex, and
Visiting Professor at University College, London, UK Joanna Jackson EdD BSc(Hons) MSc CertEd(FE) MCSP DipTP
Principal Lecturer in Physiotherapy, Faculty of Health,
Thomas Britton MD FRCP London South Bank University, London, UK
Consultant Neurologist, King’s College Hospital,
London, UK Anju Jaggi BSc(Hons) MCSP
Senior I Physiotherapist, Royal National Orthopaedic
Maggie Campbell MCSP SRP Hospital NHS Trust, Middlesex, UK
Brain Injury Coordinator, Sheffield West Primary Care Trust,
Sheffield, UK Kathryn JohnsonDipCOT
Senior I Occupational Therapist, Royal National Orthopaedic
Barbara CookMCSP CertEd Hospital NHS Trust, Middlesex, UK
Senior Physiotherapist, Richmond and Twickenham Primary
Care Trust, Teddington Memorial Hospital, Middlesex, UK Diana Jones PhD BA GradDipPhys MCSP
Principal Lecturer, School of Health, Community and
Lydia Dean DipCOT Education Studies, University of Northumbria, Newcastle
Senior I Occupational Therapist, Royal National Orthopaedic
upon Tyne, UK
Hospital NHS Trust, Middlesex, UK
Carlos deSousa BSc MD MRCP Fiona Jones MSc PGCertEd DipPhys ILTM MCSP
Senior Lecturer in Physiotherapy, St George’s Hospital
Consultant Paediatric Neurologist, Great Ormond Street
Medical School – Physiotherapy, London, UK
Hospital for Children NHS Trust, London, UK
Lorraine De Souza BSc MSc GradDipPhys PhD FCSP Christopher Kennard PhD FRCP FRCOphth
Professor of Rehabilitation and Head of Department of Professor and Head of Division of Neuroscience and
Health and Social Care, Brunel University College, Psychological Medicine, Imperial College School of Medicine,
Middlesex, UK Charing Cross Hospital, London, UK
vii
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CONTRIBUTORS
Paula Kersten PhDBSc MSc Sue Paddison GradDipPhys MCSP SRP
Lecturer in Health Services Research, Health Care Research Superintendent III Physiotherapist/Clinical Specialist – Spinal
Unit, School of Medicine, University of Southampton, Injuries Unit, Royal National Orthopaedic Hospital Trust,
Southampton General Hospital, Southampton, UK Middlesex, UK
Madhu Khanderia PhD BSc MRPharmS Elia Panturin MEd RPT
Chief Pharmacist, Royal Hospital for Neuro-disability, Senior Instructor IBITA, Faculty of Physiotherapy,
London, UK Tel Aviv University, Ramat Aviv, Israel
Cherry Kilbride MSc MCSP Jeremy Playfer MD FRCP
Deputy Head of Therapy Services, The Royal Free Hampstead Consultant Physician in Geriatric Medicine, Royal Liverpool
NHS Trust, London, UK University Hospital, Liverpool, UK
Dawn Langdon MA MPhil PhD CClin Psych Teresa Pountney PhD MA MCSP
Senior Lecturer, Royal Holloway University of London, Surrey, Senior Paediatric Physiotherapist, Chailey Heritage Clinical
UK Services, East Sussex, UK
Nigel Lawes MBBS Samantha Prisley BSc(Hons) MCSP
Senior Lecturer, Department of Anatomy, St George’s Senior I Physiotherapist, King’s College Hospital, London, UK
Hospital Medical School, London, UK
Oliver Quarrell BSc MD FRCP
Sheila Lennon PhD BSc MSc MCSP Consultant in Clinical Genetics, Sheffield Children’s Hospital,
Lecturer in Physiotherapy, School of Rehabilitation Sciences, Sheffield, UK
University of Ulster at Jordanstown, Northern Ireland, UK
Ros Quinlivan BSc(Hons) MBBS DCH FRCPCH FRCP
Gillian McCarthy FRCP FRCPCH Consultant in Paediatrics and Neuromuscular Disorders,
Honorary Consultant Neuropaediatrician, Chailey Heritage Robert Jones and Agnes Hunt Orthopaedic Hospital,
Clinical Services, East Sussex, UK Shropshire, UK
Rory McConn Walsh MA MD FRCS(ORL) Hillary Rattue MSc CertEd MCSP
Consultant Otolaryngologist, Beaumont Hospital, Dublin, Clinical Specialist in Paediatric Physiotherapy, St George’s
Ireland Hospital, London, UK
Dara Meldrum BSc MSc MISCP John C Rothwell PhD MA
Lecturer in Physiotherapy, Royal College of Surgeons in Professor of Human Neurophysiology, Institute of Neurology,
Ireland, Dublin, Ireland Queen Square, London, UK
Fred Middleton FRCP Maria Stokes PhD MCSP
Director, Spinal Injuries Unit, Royal National Orthopaedic Professor of Neuromuscular Rehabilitation, School of Health
Hospital NHS Trust, Middlesex, UK Professions and Rehabilitation Sciences, University of
Southampton, Southampton, UK
Jane Nicklin MSc MCSP
AHP Clinical Development and Research Project Manager, Nicola Thompson MSc MCSP SRCS
Essex Workforce Developmental Confederation, UK Clinical Specialist in Gait Analysis, Nuffield Orthopaedic
Centre NHS Trust, Oxford, UK
Caroline Nottle BSc(Hons) MCSP
Senior I Physiotherapist, King’s College Hospital, London, UK Heather Thornton MBA MCSP PGCE
Senior Lecturer, Department of Physiotherapy, University of
Betty O’Gorman MCSP Hertfordshire, Hatfield, Herts, UK
Superintendent Physiotherapist, St Christopher’s Hospice,
London, UK Sue Tripp MSc CertPCAT RGN
Clinical Nurse Specialist, Royal National Orthopaedic
David Oliver BSc FRCGP Hospital NHS Trust, Middlesex, UK
Consultant in Palliative Medicine and Honorary Senior
Lecturer in Palliative Care, Kent, Institute of Medicine and Karen Whalley Hammell PhD MSc OT(C) DipCOT
Health Sciences, University of Kent, Canterbury, UK Researcher and Writer, Oxbow, Saskatchewan, Canada.
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Preface
This book is intended to provide undergraduate stu- ● use of case studies to illustrate clinical practice
dents in health professions, primarily physiotherapy, (chapters on specific conditions).
with a basic understanding of neurological conditions
An important area of care is to provide patients and
and their physical management. Qualified therapists
carers with information and support, which includes
may also find it a useful resource, particularly for con-
directing them to appropriate specialist organisations
ditions they only see rarely in routine clinical practice.
(see Appendix).
Since publication of the first edition in 1998 (previ-
ously entitled Neurological Physiotherapy), research has
enabled neurological rehabilitation to advance consid- SECTION 1: BASIC CONCEPTS IN NEUROLOGY
erably in certain areas. Asurvey of the views of clinical
physiotherapists, lecturers and students on the first These chapters provide a basis for understanding sub-
edition received extensive feedback, and their sugges- sequent sections and are referred to widely throughout
tions have produced three additional chapters, with the book. Adegree of basic knowledge is assumed in
other areas being incorporated into topics already Chapter 1, in which motor control mechanisms are
covered. These include the specialist area of vestibular discussed. Assessment by the neurologist (Ch. 2) and
and balance rehabilitation (Ch. 24) and the controver- physiotherapist (Ch. 3) is then outlined, including out-
sial use of exercise in neurological rehabilitation come measures. Chapter 3 also reviews the revised
(Ch. 29). Relatively new terms and concepts relating to classification system produced by the World Health
clinical practice have been discussed in a new chapter Organization (WHO), which is now termed the
‘The rehabilitation process’ (Ch. 22). International Classification of Functioning, Disability and
All chapters are based on research and refer exten- Health, and referred to as ICF (WHO, 2001).
sively to the scientific and clinical literature, to ensure This section ends with discussion of abnormalities
clinical practice is evidence-based, although some of muscle tone and movement (Ch. 4) and the adaptive
areas still have a way to go. changes in neural and muscle tissue involved in
Common themes throughout the book, the prin- neuroplasticity (Ch. 5).
ciples of which are discussed in the specific chapters
indicated, include:
SECTION 2: NEUROLOGICAL AND
● a non-prescriptive, multidisciplinary, problem- NEUROMUSCULAR CONDITIONS
solving approach to patient management (Ch. 22)
● involvement of the patient and carer in goal-setting The neurological conditions in Chapters 6–12 are not
(Ch. 3) and decision-making (client-centred practice; presented in any particular order but the subsequent
Ch. 22) neuromuscular conditions are organised from prox-
● an eclectic approach in the selection of treatments imal to distal parts of the motor unit. Disorders of
and consideration of their theoretical basis (Ch. 21) nerves are presented in two sections: I, motor neurone
● scientific evidence of treatment effectiveness (Ch. 22) disease (Ch. 13), which involves the anterior horn cell
● use of outcome measures to evaluate the effects of (but also upper motor neurones) and II, polyneuro-
treatment in everyday practice (Ch. 3) pathies (Ch. 14), which involve the motor nerves.
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PREFACE
Disorders of muscle (Ch. 15) are then covered, Vestibular and balance rehabilitation is a recently
including the neuromuscular junction (myasthenia recognised clinical specialty within physiotherapy and
gravis) and muscle fibres (muscular dystrophies). is included in a new chapter (24). This is followed by
Post-polio syndrome is now included in this chapter management of abnormal tone and movement in
but it is not strictly a muscle disorder, as it involves Chapter 25.
damage to motor neurones. Pain (Ch. 26) and psychological issues (Ch. 27),
Muscle disorders of childhood onset are dealt with which may influence physical management are then
in Section 3 and mainly include muscular dystrophies discussed. The final chapter in this section covers drug
and spinal muscular atrophy (the latter being a prob- treatments used in neurology and provides a useful
lem of the anterior horn cell, but so placed as the onset glossary, with details of effects and side-effects of
is in childhood). drugs, some of which may influence physical manage-
Specific issues related to each disorder are given ment (Ch. 28).
and, to avoid repetition of aspects common to all
disorders, reference is made to chapters on general
topics, such as assessment, treatment concepts and SECTION 5: SKILL ACQUISITION AND
techniques and drugs. Case histories illustrate certain NEUROLOGICAL ADAPTATIONS
aspects of each condition, focusing on physical man-
agement, using a problem-solving approach. This is a new section covering areas introduced rela-
tively recently into clinical practice in neurology.
Aerobic exercise and strength training in people with
SECTION 3: LIFETIME DISORDERS OF neurological conditions were traditionally avoided in
CHILDHOOD ONSET case they exacerbated symptoms, particularly spastic-
ity. Chapter 29 reviews the research emerging from dif-
This section is not simply termed paediatric condi- ferent patient populations that suggests this fear of
tions, since children with disorders such as muscular adverse effects is unfounded and that both forms of
dystrophy and cerebral palsy are surviving more fre- exercise are beneficial.
quently into adulthood. The introduction to paediatric Two treatment concepts, originally developed in
neurology discusses some of the rarer conditions musculoskeletal conditions, are being applied increas-
which physiotherapists may come across (Ch. 16). The ingly in neurological rehabilitation and are discussed
continuation of care into adulthood is stressed in the final two chapters: muscle imbalance (Ch. 30)
throughout Chapters 16–20. and neurodynamics (Ch. 31).
SECTION 4: TREATMENT APPROACHES IN CURRENT ISSUES AFFECTING CLINICAL AND
NEUROLOGICAL REHABILITATION RESEARCH PRACTICE
This section begins with a review of the theoretical New initiatives, that are still evolving, relating to the
basis of neurological physiotherapy (Ch. 21). Adequate management and conduct of practice include the
evaluation has not been conducted of the different following.
concepts and it is likely that no single approach has all
the answers. An eclectic approach is being applied in
Clinical and research governance
all areas of physiotherapy, as rigid adherence to one
school or another is progressively thought not to be Clinical governance was introduced in the UK by the
in the best interest of patients. Department of Health (DoH) in the late 1990s and is
The new chapter on ‘The rehabilitation process’ defined by the Chief Medical Officer as: ‘A system
(Ch. 22) discusses: evidence-based practice; client- through which NHS organisations are accountable for
centred practice; the problem-solving process; and continuously improving the quality of their services
clinical reasoning. and safeguarding high standards of care, by creating an
Specific treatment techniques are discussed in environment in which clinical excellence will flourish’
Chapter 23, explaining the types of treatments avail- (DoH website for clinical governance). To achieve such
able, their proposed mode of action (if known) and situ- excellence, systems need to be in place which: are
ations in which they might be applied. Limb casting patient-centred; monitor quality; assess risk and deal
and special seating are not discussed in detail, and are with problems early; have clear lines of accountability;
covered in depth by Edwards (2002). are transparent; and provide information to professionals
x
Prelims.qxd 31/7/04 16:48 Page xi
Preface
and the public. The clinical governance initiative recog- heart disease (DoH website for national service frame-
nises the importance of education and research being works). Guidelines for the physical management of
valued. specific conditions are also produced by other organ-
TheResearch Governance Framework for Health and Social isations, such as the Stroke Association, the Inter-
Carewas released by the DoH in 2002 and ‘is intended collegiate Working Party on Stroke and the Association
to sustain a research culture that promotes excellence, of Chartered Physiotherapists Interested in Neurology
with visible research leadership and expert management (ACPIN); these guidelines are referred to in relevant
to help researchers, clinicians and managers apply stan- chapters throughout this book.
dards correctly’ (DoH website for research governance).
The framework sets out targets for achieving compliance International Classification of Functioning,
with national standards, developing and implementing Disability and Health (ICF)
research management systems covering general man-
The revised ICF, which is discussed in Chapter 3,
agement arrangements, ethical and legal issues, scien-
focuses on ‘how people live with their health condi-
tific quality, information systems, finance systems and
tions and how these can be improved to achieve a pro-
health and safety issues. In addition to closer monitoring
ductive, fulfilling life’ (WHO, 2001).
of research activities, the new framework involves other
A colourful illustration of how a young man has
requirements, such as involving consumers, informing
achieved such a fulfilling life, despite complex disabili-
the public and ownership of intellectual property. As
ties, is provided in an autobiography (Colchester, 2003).
well as reassuring the public by minimising fraud and
Jonathan Colchester’s story is a prime example of how
misconduct, these robust, transparent management sys-
we can learn from patients, as alluded to by Professor
tems should also provide a healthy environment for all
Richard HT Edwards in the foreword of that book.
grades of researchers to be suitably supported and
As professionals and society, it is not for us to dic-
recognised, thus enhancing the quality and productivity
tate how people should live. We do, however, have an
of clinical research.
important contribution to make in creating optimal
conditions for individuals to express their natural abil-
ities and live as full a life as possible, within the limit-
National standards and guidelines
ations of their disabilities. This book aims to address
for clinical practice
some of the issues involved in achieving this objective,
Practice standards and guidelines have been produced specifically relating to physical management.
by the DoH through NICE (National Institute for
Clinical Excellence) and national service frameworks Maria Stokes
for different clinical conditions, e.g. cancer, coronary London, 2004
References
Colchester J. ALife Worth Living: Abilities, Interests and Travels Edwards S (ed.) Neurological Physiotherapy. London:
of a Young Disabled Man. Northwich, Cheshire: Churchill Livingstone; 2002.
Greenridges Press; 2003. World Health Organization. International Classification of
Department of Health. Clinical Governance.Available online Functioning, Disability and Health: ICF. Geneva: World
at: www.doh.gov.uk/clinicalgovernance. Health Organization, 2001. Available online at:
Department of Health. National Service Frameworks. Available http:/www.who.int/classification/icf.
online at: www.doh.gov.uk/nsf.
Department of Health. Research Governance Framework for
Health and Social Care. Available online at:
www.doh.gov.uk/research.
xi
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Acknowledgements
Firstly, I wish to acknowledge the major contribution for her hard work and dedication. I wish her well on her
to this book from Professor Ann Ashburn and to thank retirement and will always remember her kindness and
her for advising on its content, assisting with recruit- sense of humour.
ing new authors, reviewing a number of chapters and I thank the Royal Hospital for Neuro-disability in
for her constant support. Putney, the Neuro-disability Research Trust, The
The revised format would not have been possible Peacock Trust and the team at Elsevier, particularly
without suggestions for new topics from physiotherap- Dinah Thom and Heidi Harrison for supporting me in
ists. Professor Ashburn and the following, who peer- this project. I also thank the following friends and col-
reviewed this work by feeding back on the first edition leagues for their help in various ways: Margaret Hegarty
and/or reviewing chapters for the current edition, can for administrative assistance (in the early days of her
have a sense of ownership of the book: Maggie Bailey, recovery from foot surgery!); Rosaleen Hegarty, George
Jane Burgneay, Monica Busse, Mary Cramp, Lousie Kantrell and Gerard Cullen for IT support; Dr Keith
Dunthorne, Phyllis Fletcher Cook, Nicola Hancock, Andrews, Jo Babic, Jo Lawrence and Professor Di
Wendy Hendrie, Angela Johnson, Nicky Lamban, Anne Newham for helpful feedback on parts of the text; help-
McDonnell, Fiona Moffatt, Alex Morley, J Ramsay, Sue ful discussions with fellow ex-London Hospital physio-
Richardson, Ros Wade, Martin Watson, Trish Westran, therapy students at a reunion weekend in Bath in
those who responded to the survey anonymously, and October 2003; and Dr Elaine Pierce for keeping life man-
the Association of Chartered Physiotherapists Interested ageable in the day-job.
in Neurology (ACPIN) for distributing the survey to its Special thanks go to Miss Anne Moore (Consultant
members and encouraging them to respond. Neurosurgeon) and Dr De Gaulle Chigbu (Optometrist)
My thanks go to the authors who generously shared for making my involvement in this project possible, and
their knowledge and expertise, as senior clinicians and to my family and friends who encouraged, entertained
academics, despite busy workloads. The time and effort and supported me throughout.
they invested in this book are much appreciated. I am
very grateful to Lilian Hughes, who has worked along- Maria Stokes
side me as research administrator for a number of years, London, 2004
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Abbreviations
5HT 5-hydroxytryptamine ART applied relaxation training
ABI acquired brain injury ASBAH Association for Spina Bifida and
ACA anterior cerebral artery Hydrocephalus
ACC anterior cingulate cortex ASCS Advice Service Capability Scotland
ACE angtiotensin-converting enzyme ASIA American Spinal Injury Association
Ach acetylcholine ASPIRE Association of Spinal Injury Research,
ACPIN Association of Chartered Rehabilitation and Reintegration
Physiotherapists Interested in ATNR asymmetric tonic neck response
Neurology ATP adenosine triphosphate
ACPIVR Association of Physiotherapists with an ATPase adenosine triphosphatase
Interest in Vestibular Rehabilitation AVM arteriovenous malformation
ACPOPC Association of Chartered BAEP brainstem auditory evoked potential
Physiotherapists in Oncology and BAN British approved name
Palliative Care BDNF brain-derived nerve growth factor
ACTH adrenocorticotrophic hormone BIPAP bivalent/bilevel intermittent positive
ADEDMD autosomal dominant Emery Dreifuss airway pressure
muscular dystrophy BMD Becker muscular dystrophy
ADEM acute disseminated encephalomyelitides BOT Bruininks Oseretsky Test
ADHD attention deficit–hyperactivity disorder BP blood pressure
ADHD-MD attention deficit-hyperactive disorder BPL brachial plexus lesion
and motor dysfunction BPPV benign paroxysmal positional vertigo
ADL activities of daily living BSID Bayley Scales of Infant Development
AFO ankle–foot orthosis BSRM British Society of Rehabilitation Medicine
AGSD Association for Glycogen Storage Ca calcium
Disorders cAMP cyclic adenosine monophosphate
AIDP acute inflammatory demyelinating CAOT Canadian Association of Occupational
polyradiculopathy Therapists
AIDS acquired immune deficiency syndrome CBIT Children’s Brain Injury Trust
AIMS Alberta Infant Motor Scale CDC Child Development Centre
ALS amyotrophic lateral sclerosis CHART Craig Handicap Assessment and
AMPA (cid:2)-amino-3-hydroxy-5-methyl- Reporting Technique
4-isoxazole propionate CIC clean intermittent catheterisation
AMRC Association of Medical Research CIDP chronic inflammatory demyelinating
Charities polyradiculopathy/polyneuropathy
AMT adverse mechanical tension CIMT constraint-induced movement therapy
ANT adverse neural tension CISC clean intermittent self-catheterisation
ARGO advanced reciprocal gait orthosis CK creatine kinase
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ABBREVIATIONS
CLA Chailey Levels of Ability FES functional electrical stimulation
CMD congenital muscular dystrophy FET forced expiratory technique
CMT Charcot–Marie–Tooth FIM Functional Independence Measure
CNS central nervous system FLAIR fluid-attenuated inversion recovery
CO carbon dioxide FMRP fragile X-linked mental retardation protein
2
COMT catechol-O-methyltransferase FO foot orthosis
COX2 cyclo-oxygenase 2 FSH fascioscapulohumeral muscular dystrophy
CPG central pattern generator FVC forced vital capacity
CPK creatine phosphokinase GABA gamma-aminobutyric acid
CPM continuous passive movement GAP43 growth-associated protein
CPP cerebral perfusion pressure GAS Goal Attainment Scaling
CPTII carnitine palmitoyl transferase type II GBS Guillain–Barré syndrome
deficiency GCS Glasgow Coma Scale
CRPS complex regional pain syndrome GEF guanine nucleotide exchange factor
CSF cerebrospinal fluid GFR glomerular filtration rate
CSP Chartered Society of Physiotherapy GHJ glenohumeral joint
CST cranial sacral therapy glu glutamate
CT computed tomography GMCS Gross Motor Classification Scale
CTSIB Clinical Test of Sensory Interaction and GMFM Gross Motor Function Measure
Balance GP general practitioner
CVA cerebrovascular accident GPe globus pallidus external nucleus
DA dopamine GPi globus pallidus internal nucleus
DAG diacylglycerol GSDV glycogen storage disease type V
DAI diffuse axonal injury H reflex Hoffman reflex
DAMP disorders of attention, motor and HASO hip and spinal orthoses
perception HD Huntington’s disease
DCD developmental co-ordination disorder HGO hip guidance orthosis
DEBRA Dystrophic Epidermolysis Bullosa Research Hist histamine
Association HIV human immunodeficiency virus
DL dorsolateral HKAFO hip–knee–ankle–foot orthosis
DLF Disabled Living Foundation HLA human leukocyte antigen
DM dermatomyositis HMSN hereditary motor and sensory neuropathy
DM1 dystrophic myotonica HO heterotopic ossification
DMD Duchenne muscular dystrophy HOT hyperbaric oxygen therapy
DMSA dimercaptosuccinic acid IASP International Association for the Study of
DNA deoxyribonucleic acid Pain
DoH Department of Health IBM inclusion body myositis
DSD detrusor sphincter dyssynergia ICD-10 International Classification of Diseases
DTPA diethylenetriamine penta-acid ICF International Classification of Functioning,
DVT deep venous thrombosis Disability and Health
ECG electrocardiogram ICIDH International Classification of
ECHO echocardiogram Impairments, Disabilities, and Handicaps
EDMD Emery Dreifuss muscular dystrophy ICP integrated care pathway (Ch. 3)
EEG electroencephalography ICP intracranial pressure
EMG electromyography IgG immunoglobulin G
enc encephalin IN irradiation neuritis
ENG electronystagmography IP inositol triphosphate
3
EP evoked potentials IPA Impact on Participation and Autonomy
EPIOC electric-powered indoor/outdoor chair IPPB intermittent positive-pressure breathing
ES electrical stimulation IPPV intermittent positive-pressure ventilation
ESD early supported discharge KAFO knee–ankle–foot orthosis
ESR erythrocyte sedimentation rate KP knowledge of performance
FAM Functional Assessment Measure KR knowledge of results
FCMD Fukuyama congenital muscular dystrophy LACI lacunar infarcts
xvi