Principles Of Physical Rehabilitation Medicine
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EMG Diagnosis and Biomechanical and Neuroscience of Health and Vascular Disease...
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UMCSC Department of Rehabilitation and Physical Medicine, Debrecen Hungary
Principles of physical and rehabilitation medicines part 2 Zsuzsanna Vekerdy MD, PhD
INTERVENTION APPROACHES – AN OVERVIEW
1. Remediation 2. Compensatory strategies 1. Enviromental modifications 2. Use of assistive technology devices
Remediation Definition: remediation pertaines to the resolution of functional or structural deficits or the aqusition of new skills in the area of skilled movement, cognition or social function. – usually an ACITVE LEARNING PROCESS Setting a GOAL – remediation strategy (e.g. operant conditioning, etc.) Learning process (Snel): aquisition maintenance „Scaffolding” fluency generalization
Remediation strategies cont.
Restoration of self-esteem – positive social reinforcement for the patient and the family members - negative reinforcement – avoiding unpleasent experiences and consequences
Remediation strategies cont. Restoration of biological, physiologic or neurologic processes – technics derived from neuroscience, biomechanics, motor control, etc.
Objective: to recover sufficient perception, cognition, voluntary movement to enable task performance in safe and effective manner Combine / alternate with adaptive or /and compensatory approaches
Compensatory strategies 1.
To teach an individual to perform a taskt within his or her capacities – example: conductive education (Pető)
2.
To modify the enviroment to permit accomplishment of the task despite limitations in ability or skills – example: use of systems, devices
3.
To provide an agent or assisting person with task requirements or perform them entirely – example: momchild diad
Enviromental modifications
Enviromental barrier
Personal barrier
Assistive Technology Devices (ATDs) Low-tech Simple, inexpensive devices
High-tech e.g. Remote control
Personal Care Attendance (PCA) Crucial issue is to define the self-care and ADL activities that will require assistance • daily based • regularly based (weekly) • rare tasks
ROLE OF THE PRM SPECIALISTS
European definition of Physical and Rehabilitation Médicine (PRM) This proposal was set up during the General Assembly of Ljubljana (March 2003) and validated in Antalya (October 2003
Specialists in PRM have a holistic approach
to people with acute and chronic conditions, examples of which are
musculo-skeletal and neurological disorders, amputations, pelvic organ dysfunction, cardio-respiratory insufficiency and the disability due to chronic pain and cancer.
Medical tasks in rehabilitation Management
Consultation in acute / intensive care Decision about rehabilitation (need / time / type ) Leading the team Managing the care of patients Home care / rehabilitation: eligibility, prescriptions, advice
Pharmacotherapy • • • •
Spasticity control Pain management Treatment of depression, epilepsy, mood disorders Continuation of previous medications (MD, hypertonia, arrythmia, etc.)
Medical tasks in rehabilitation • Surgical interventions • Corrective surgery (amputations, deformities, etc.) • Pain releif (PAO, revision of amputees, etc.) • Reconstructive sugery
• Other • Manual therapy • Nutrition / special feeding technics • Prescription of assistive technology devices, orthoses and protheses
Special problems 1. Spasticity and pain management 2. Continence 3. Immobility syndrome (pressure sores, contractures, PAO, osteoporosis, etc.) 4. Eating and swallowing disorders (malnutrition) 5. Behavioral and mood disorders, complience problems
Treatment of spasticity physiotherapy p.o.pharmacot.
general SDR
ITB
reversible
irreversible
orthoses Orthopedic surgery
BTX-A
focal BTX-A: Botulinum-A toxin ITB: Intrathecalis Baclophen
SDR: Selective dorsal rhizotomy
Pain control • Analgetic drugs – baseline pain control • Paracetamol / non-steroid anti-inflammatory drugs, tramadol, slow-release narcotics, etc.
• • • • • •
TENS (transcutan electric nerve stimulation) Distraction Aromatherapy Relaxation technics Reinforcement and coping strategies Virtual realty therapy Visual Analogue Scale (VAS)
Immobility syndrome Involved body structures and functions • Central nervous system (CNS) • Cardiovascular system • Respiratory system • Gastrointestinal organs • Urinary system • Musculosceletal system • Skin
CNS • • • • • •
Axiety Sleep disorders depression Behavioral problems Mood disorders Intellectual deterorientation EACH ONE INFLUENCES NEGATIVELY THE REHABILITATION PROCESS
Cardiovascular function • Orthostatic hypotension (SCI ! – sitting / standing position) • Tachycardia • Reduced cardiac reserv capacity • Thrombosis or /and embolisation
Gastrointestinal • Loss of apetite • Weight loss • Hypoalimentation / hypoproteinemia / malnutrition • constipation
Respiratory function • Reduced vital capacity and functional vital capacity • Weak expectoration capacity • Pneumonia, brochitis
Urinary system
• Bladder incontinence • Recurrent uro-infections (PERMANENT CATHETER!! / INTERMITTENT) • Bladder-stones • Secondary spastic bladder
continence • Bowel and bladder control – – – – – – – – –
Oral pharmacotherapy Intravesical pharmacotherapy Neuromodulation Electrotherapy Intravesical Physical training (bladder training) Special assistive devices Behavioral therapy Surgical interventions Urodinamical assessment
Musculosceletal system • • • • • •
Weakness /reduces strength in muscles fatigue Muscle atrophy contractures Fibrotic degeneration of muscles osteoporotic – high risk of fractures
Heterotop ossification X-ray / MRI
Skin • Infecions (bacterial, fungal)
Occupational therapy
Occupational therapy Goal: to reach as much independence as possible with people who have functional limitations in everyday life activities Objectives: activities specifically aim at improving personal skills Main activity areas: – Development of motor functions – Training with prostheses – Development of cognitive functions
– ADL activity training – Assistive devices training – Preparations for active life – Social training
Objectives of OT • Improving motor and sensory abilities • Relearn skills in self-directed activities (personal grooming, household activities, etc.) • Teach compensatory stretegies • Use special tools • Changes in home enviroment – safety, barrier-free, facilitate functioning • Apraxia treatment
Example for occupational therapy: feeding /eating problems
Main goals • Feeding (oral) • Independent eating skills with special assistance • Independent eating without assistive devices
Target groups • Adults • Stroke • TBI
• Children • • • • •
Cerebral palsy TBI Other CNS lesions Mental retardation Autism
Special utensils
Other facilities
Communication and speech Speech and language disorders (speech, language, fluency, voice) Communication problems Commonly assotiated disorders: stroke, TBI, MS, CP, other chronic neurological disorders
Speech and language problems after brain injury • Aphasia • Motor • Sensory • mixed
• Dysarthria • Dystonic cerebral palsy
• Mutism
Communication Speech Writing Gestures Sign language Symbols (Bliss) Communation devices
Bliss symbols man
roof
logos
parent
woman
*
human
family
Augmentative communication devices
Augmentative communication devices
Further readings • J.A.DeLisa (ed): Physical Medicine and Rehabilitation /Principles and practice/ 4th ed. 2005. Lippincott Williams and Wilkins, Philadelphia, Baltimore, NY, London, BA, HK, Sydney, Tokyo
• White Book On Physical and Rehabilitation Medicine in Europe. 2006 www.euro-prm.org • M.P.Barnes, A.B.Ward (eds): Textbook of Rehabilitation Medicine. 2000. Oxford University Press
• G.E. Molnar (ed): Pediatric Rehabilitation. 3rd Ed. 1999. Lippincott Williams and Wilkins, Philadelphia, Baltimore, NY, London, BA, HK, Sydney, Tokyo
www.rehab.dote.hu
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