Principles of physical and rehabilitationmedicines part 2

Zsuzsanna Vekerdy MD, PhD

UMCSCDepartment ofRehabilitation andPhysical Medicine,Debrecen Hungary

INTERVENTION APPROACHES – AN OVERVIEW

1. Remediation2. Compensatory

strategies1. Enviromental modifications2. Use of assistive technology

devices

Remediation

Definition: remediation pertaines to the resolution offunctional or structural deficits or the aqusition of newskills in the area of skilled movement, cognition or socialfunction. – usually an ACITVE LEARNING PROCESS

Setting a GOAL – remediation strategy (e.g. operantconditioning, etc.)

Learning process (Snel): aquisitionmaintenance

„Scaffolding” fluencygeneralization

Remediation strategies cont.

Restoration of self-esteem– positive social reinforcement for the patient and the family members

- negative reinforcement – avoiding unpleasent experiences andconsequences

Remediation strategies cont.

Restoration of biological, physiologic orneurologic processes – technics derivedfrom neuroscience, biomechanics, motor control, etc.

Objective: to recover sufficient perception, cognition, voluntary movement to enable taskperformance in safe and effective manner

Combine / alternate with adaptive or /andcompensatory approaches

Compensatory strategies

1. To teach an individual to perform a taskt within his orher capacities – example: conductive education (Pető)

2. To modify the enviroment to permit accomplishment ofthe task despite limitations in ability or skills – example: use of systems, devices

3. To provide an agent or assisting person with taskrequirements or perform them entirely – example: mom-child diad

Enviromentalmodifications

Personal barrier

Enviromental barrier

Assistive Technology Devices (ATDs)

Low-techSimple, inexpensive

devices

High-teche.g. Remote control

Crucial issue is to define the self-care andADL activities that will require assistance

• daily based• regularly based (weekly)• rare tasks

Personal Care Attendance (PCA)

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

Pharmacotherapy• Spasticity control• Pain management• Treatment of depression, epilepsy, mood disorders• Continuation of previous medications (MD,

hypertonia, arrythmia, etc.)

Consultation in acute / intensive careDecision about rehabilitation (need / time / type )Leading the teamManaging the care of patientsHome care / rehabilitation: eligibility, prescriptions, advice

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 problems1. Spasticity and pain management2. Continence3. Immobility syndrome (pressure sores,

contractures, PAO, osteoporosis, etc.)4. Eating and swallowing disorders

(malnutrition)5. Behavioral and mood disorders,

complience problems

Treatment of spasticity

general

reversible irreversible

focalBTX-A: Botulinum-A toxin SDR: Selective dorsalITB: Intrathecalis Baclophen rhizotomy

SDRITB

BTX-AOrthopedic

surgery

physiotherapyp.o.pharmacot.

orthoses

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 inmuscles

• fatigue• Muscle atrophy• contractures• Fibrotic degeneration of muscles• osteoporotic – high risk of fractures

Heterotop ossificationX-ray / MRI

Skin

• Infecions(bacterial,

fungal)

Occupational therapy

Occupational therapyGoal: to reach as much independence as possible with

people who have functional limitations in everyday lifeactivities

Objectives: activities specifically aim at improving personalskills

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 chronicneurological disorders

Speech and language problems afterbrain injury

• Aphasia• Motor• Sensory• mixed

• Dysarthria• Dystonic cerebral palsy

• Mutism

Communication

SpeechWritingGesturesSign languageSymbols (Bliss)Communation

devices

Bliss symbols

*

man woman humanlogos

roof parent family

Augmentative communication devices

Augmentative communication devices

Further readings

• J.A.DeLisa (ed): Physical Medicine andRehabilitation /Principles and practice/ 4th ed. 2005. Lippincott Williams and Wilkins, Philadelphia, Baltimore, NY, London, BA, HK, Sydney, Tokyo

• White Book On Physical and RehabilitationMedicine in Europe. 2006 www.euro-prm.org

• M.P.Barnes, A.B.Ward (eds): Textbook ofRehabilitation Medicine. 2000. Oxford UniversityPress

• 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