Vertebral Fracture Assessment Using a Semi Quantitative Technique
Thermal rehabilitation in aged people after osteoporotic vertebral fracture
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Transcript of Thermal rehabilitation in aged people after osteoporotic vertebral fracture
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TRAUMATOLOGY AND ORTHOPEDIC II DIVISION - PISAUNIVERSITY
Chiefdirector : Prof. G. GuidoDEPARTMENT OF FUNCTIONAL ORTHOPEDICAL
REHABILITATIONResponsible: Prof.ssa G. Raffaet
Prof. G. Raffaet
in collaboration with Dr. F. Falossi, Dr. C. Genovesi
Techirghiol, 12 novembre 2012
Thermal rehabilitationin aged people after
osteoporotic vertebral
fracture
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ELDERLY PERSON
"Ageing is a privilege and a goal of society.Its also a challenge, that has an impact on all the aspects of
the XXI century societyOMS
In the worldin 2000 600 millions
in 2025 1,2 billionsin 2050 2 billions
DEMOGRAPHIC REVOLUTION OF OUR SOCIETYpeople > 60 years
In Europe1 in 5
In Italyin 2001 10.5 millionsin 2006 11.5 millionstoday > 20%
in 2051 1 in 3 data ISTAT
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the roleof Physical Medicine and Rehabilitationin the field ofgeriatricmust be understoodin its broadest sense
PHYSICAL AND REHABILITATIVE MEDICINE
PREVENTIVE THERAPEUTIC
. there is no true geriatrics withoutrehabilitationand there are no compelling recovery methods
that are not concernedat the same time
thephysicalandmentalaspects of the elderly
Antonini,1973
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but with aging
are gradually reduced the capacities of a prompt andreasonable "adjustment"to the environment
full and conscious use of all the opportunities for life that the
environment offers offers
Healthy Elderly
Physiologically
agedwith all the changes
quantitative andqualitative
of the various organsand systems
PathologicalElderly
The signs of old ageadd up to the results ofold diseases and chronicdevelopmental disorders
until the situations of
disabilityand loss of autonomy
Elderlyis not synonymous of disease
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The assessment of elderly patient
identify not only
what the patient is unable to do
negative
search in the subject the
psycho-biological residual potentialwith whichbuild day after day his recovery process
positive
GLOBAL ASSESSMENT :
1. Functional capacity : activities scales of daily livingindices of overall assessment (Barthel..)
2. Mental state : behavior, cognitive function ..3. Physical health : also as the absence of disease
or alteration of the welfare state
4. Social support : family, importance of the links, isolation of theelderly
5. Financial possibilities both personal that socialstructures involved
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In Italy almost 4,000,000 women with osteoporosis Prevalence more than 40% over 60 years
ESOPO study. Osteoporos Int 2003
OSTEOPOROSIS
Public health problem
continuously growing
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AGE-specific and SEX-specific incidence of osteoporotic fractures
OSTEOPOROTIC FRACTURES
vertebral fractures radiographically evident
hip fractures
wrist fractures
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There is a new osteoporotic vertebralfracture around the world
every 22
20-25% of Caucasian women and men over age 50 have avertebral fracture
VERTEBRAL FRACTURES
50% of women over age 80 have a vertebral fracture
M.L.Brandi, 2010
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UNDERSTIMATION OFVERTEBRAL FRACTURES
Fechtenbaum J et al. Reporting of vertebral frctures on spine x-rays
Osteoporos Int. 2005
Delma PD et al. Underdiagnosis of vertebral fractures is a world wide problem: theimpact study. J Bone Miner Res 2005
30 - 50 %
UNRECOGNIZED
studies conducted at European
and world level
oligo-symptomatic
The most of patientsNOT receive
correct diagnosis and appropriate therapy
Only 1/3 comes to medical attention
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50%MODERATE SEVERE - PAIN
SUBJECTS WITH 1 OR MORE
VERTEBRAL FRACTURES
CHRONIC
BACK PAINsleep disorders
difficult to wash and dress
uncertainty of gait
Ismail AA et al. 1999
40-89%10-15%
DISABILITY
Trevisan C., Mattavelli M. et AA, 2007
MORTALITY
Those who have a vertebral fracture has an increasedrisk of dying if compared to their peers withoutfractures
Riduction of 16% of the 5 year survival M.L.Brandi, 2010
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Domino effect
Emphasis kyphotic curve
Forward displacement axis gravitazional
INCREASEED FLEXOR MOMENT
A VERTEBRAL FRACTUREINCREASES BY 5 TIMES THE RISKOF A NEW VERTEBRAL FRACTURE
WITHIN ONE YEAR AFTER THE
EVENTRoss PD et al. Pre-existing fractures and bone mass predict vertebral
fracture incidence in women. Ann Intern Med, 1991.
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Vicious circles triggeredby osteoporotic vertebral fractures .
1) REFRACTURE
1 FRACTURE
PAIN,DISABILITY,
BALANCE DISORDERS
PSYCHOLOGICALPROBLEMS
REDUCTION INPHYSICAL ACTIVITY
INCREASEDRISK
OF FALL
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INCREASEDMORTALITY
OF 25%
2) INCREASED MORTALITY
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CONSERVATIVE SURGICAL
Reley 2001
Kyphoplasty
Herv Deramond 1987Vertebroplasty
TREATMENT of
VERTEBRAL FRACTURES
Whatever the type of treatment undertakenconservative or surgical
the rehabilitation plays an important rolebecause
Allows a mobility and functionality rahidearecovery as complete as possible
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Its essential that prevention, maintenance and recoveryprograms of the elderly find an appropriate locations
HOSPITAL EXTRA-HOSPITAL
REHABILITATION SITES
Day hospitalAmbulatory
(zona or district)
Home programs
Rehabilitation centres
Early and protecteddischarges without losing
the terapeutic programeffectivness
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SPAA very appropriate places to address the rehabilitation needsof these patients and that thanks to
natural water rich active ingrediens
climate
health facilities
Ideal location for the overall management of the
elderly both thephisicaland the psychic
in line with the concept of Health dictation OMS
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RECOVERY OF PATIENT WITH OSTEOPOROTICFRACTURE
TAKING CHARGE GLOBAL
of Subject
REHABILITATION PROJECT
CUSTOM MADE
FACTORS RELATED TOPATIENT
GENERAL CONDITIONS
teamwork
FACTORS RELATED TO
FRACTURE
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REST IN BED 2 weeks onaverage (min. 10 days, max.30days)
BRACE A LOAD WITH THREEPOINTS on average 60 days
GRADUAL WEANING FROMTHE BRACE on average 20 days
TP DRUG
CONSERVATIVETREATMENT
REHABILITATIONPROJECT
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WE CANNOT FIND CLINICAL STUDIES
BASED ON THE EVIDENCE OFCONSERVATIVE TREATMENT FOR
PATIENTS WITH SPINALOSTEOPOROTIC FRACTURES
In literature
1. PAIN CONTROL
2. PREVENTION AGGRAVATION DEFORMITY
3. EARLY FUNCTIONAL RECOVERY
OBJECTIVES OF TREATMENT
REHABILITATION PROJECT
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REHABILITATION PROJECT
2- CONTROL OF PAIN
1- PREVENTION OF IMMOBILITY COMPLICATIONSpressure ulcers, TVP, respiratory complications, etc..
correct positioning on the bed
anti-decubitus mattress, latex mattress, etc.
breathing exercises
manteining a regular alvo
drug therapy
physical therapy(Elettroterapia antalgica: tens, correnti diadinamiche,magnetoterapia,
etc..)
BEDDIG PHASE
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BEDDIG PHASE
3- MAINTENANCE RANGE OF MOTION AND MUSCLETONE-TROPISM
Ex. mobilization passive, assisted and attive
oculomotricit Arch support
RotationsLifting
REHABILITATION PROJECT
O O C
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4- STATIC STRETCHES
isometric muscle girdle
Become aware of the active muscle control of the trunk
BEDDIG PHASEREHABILITATION PROJECT
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1-ISOMETRIC AND ISOTONIC EXERCISES MM SPINAL
Active axial stretching of the muscles of the trunk and of the back
Vertical load sitting position
When the verticalstation is without pain
Maximum mechanical
stress induced muscolarcontractions
3- TRAINING OF STEP AND WALKING
2- EXERCISES OF BALANCE AND COORDINATION
PHASE LOAD WITH BRACEREHABILITATION PROJECT
REHABILITATION PROJECT
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REHABILITATION PROJECT
PHASE OF WEANING THE BRACE
1- ACTIVE EXERCISES for the MOBILIZATION OF THE COLUMN
in the gym or/and in the water
Isometric and isotonic exercises of the mm. ANTICIFOTIZZANT
(mm. spinal extensors)
Only Isometric exercises of the mm. ABDOMINAL
REHABILITATION PROJECT
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REHABILITATION PROJECT
PHASE OF WEANING of THE BRACE
2- CORRECTION OF POSTURAL ALTERATIONS exercises for balance control
of motor coordination
of responsiveness
ATTITUDE CIFO-LORDOTIC
increased risk of falls
REHABILITATION PROJECT
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GRADUAL avoid excessive loads and stress fractures VARIABLE dynamic mechanical stimulation to the bone toobtain an effect of type osteoblastic
ADAPTED to the individual subject
CONSTANT time
The international review of the Literature seemsto show the best possible stimulus is the
STRENGTH OF MUSCLE TRANSMITTED BY TENDONS TOBONE TISSUE DURING CONTRACTION
isometric, isotonic exercise with no load or lightweights, gradually progressive resistance
REHABILITATION PROJECT
Subjects with osteoporotic fractures yet
EXERCISE
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The rehabilitationIN THE GYM
can be integrated
and completed
THE EXERCISE IN WATERthat amplifies possibilitiesand
spatialities operational
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THERE IS NO EVIDENCE OF EFFICACY
ON THE BONE MASS
USEFUL IN PATIENTS WITH STRONG PAINAND WITH RECENT FRACTURE
BETTER - AEROBIC CAPACITY
-FLEXIBILITY
-EXTENSION OF MOVEMENT
REDUCE THE PAIN
ANTICIPATE THE LOAD
HYDROKINESIOTHERAPY
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HYDRATION cartilage covering
TURNOVER of synovial fluid
improvement TRADE METABOLICjoint environment
HYPOXIA with the stagnation of
circulating fluidsRECRUITMENT and OVERRIDE
OSTEOCLASTS
bone resorption
microporotic cavity formation
loss of vertical trabeculae
in the vertebral bodies
MOVEMENT
Early in water
Prof.ssa G.L.MauroOrtopedia News suppl Anno XVI N 1-3 2010
SETTING
A NEW FRACTURE
IN THE VERTEBRAL
BODIES
PHYSICAL INACTIVITYin elderly fractured patience
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CINE BALNEOTERAPY
Especially
in thermal wateris an important tool in the treatment of patients
after osteoporotic vertebral fracture
the therapeutic effectslinked to the physical
characteristicsof water
specific effectsof thermal water
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EXCLUSION CRITERIA
The contraindications to thermal rehabilitation arescarce and frequently relative
M. De Fabritis, S.Masiero, S. Mariotti, G. Gigante, EUR MED PHYS 2009; 45 (SUPPL. 1 TO NO.3)
ABSOLUTE
Heart failureArrhythmias high riskIschemic heart diseaseUncontrolled hypertensionPhlebitisActive infectionsFecal incontinenceFeverNeoplasms in placePrevious interventions for cancerImmunodeficiencyInsufficiency renal
RELATED
EpilepsyUrinary incontinenceSwallowing disorders
TEMPORARY
Skin lesionsDermatopatia
ConjunctivitisTimpani openInfectious DiseasesShameFear of water
TREATMENT PROGRAM
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THERAPEUTIC EXERCISE
IN THERMAL POOL
- Daily sessions
- Duration of sessions: 40 '
- Sulphate-calcium-magnesium, carbon
- Salinity '2949 mg / l
- Temperature: 35 -36 c
DAILY EXERCISES
IN THE GYM
DURATION OF PROGRAM:
2 WEEKSTREATMENT PROGRAM
IN SPAS
PHYSICAL THERAPYalways considering
any contraindicationsfor each case
MUD
action anti-inflammatory
analgesic
muscle relaxant
eutrophic
stimulating action on
metabolic processes
effects on general
kinaesthesia
Tens, Magnetoterapy, Laserterapy
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4. Increased power of immune defenses
1. Intense hyperemia of the skin and deep tissues periarticular
2. Riducing muscle hypertonicity
3. Remodeling connective fundamental component
- vascular neoformation- neosynthesis glycosaminoglycans- cellularisation, etc
5. Riduction of infiammatory process
6. Neuro-endocrine reactions (stimulates productions of ACTH, FSH, LH)
MECHANISMS OF ACTION THERMAL THERAPY
THERMAL STRESS
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THERMAL STRESSNeuro-endocrine reactions
GH: STIMULUS TO CHONDROGENESIS and
OSTEOGENESIS
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Relaxation exercisesStretching exercisesExercises of global mobility
REHABILITATION PROTOCOLIN WATER
1- RELAXATION EXERCISES
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IN FLOATING IN PRONE
FLOATING IN SUPINO
FLOATING IN
VERTICAL
1 RELAXATION EXERCISES
"slow" passive and active mobilization
progressively greater amplitude
respecting pain threshold
2- STRETCHING EXERCISES
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2- STRETCHING EXERCISES
To remedy any tensions and correct the posture of the
spine compromised by muscular retractions
3- EXERCISES OF GLOBAL MOBILITY
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3- EXERCISES OF GLOBAL MOBILITY
upper limbslower limbs
To recovery the normal joint range
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Reduction of loads and support action (buoyant force)
Muscle relaxant effectto decreased muscle tone (heat)
Analgesic effectto increase the pain threshold (PI and viscosity)-> stimulation of baroreceptors joint (g.c.s.)
Increase stimuli esterocettori (PI and viscosity) -> amplification ofmotor patterns and better perception position of the body segments
Increased proprioceptive stimulation (resistance and motions ofturbulence)
-> Continuous postural control and intense muscle work
CRENOBALNEOTHERAPY
1. ALLOWS ACTIVE AND PASSIVE MOBILIZATIONEXERCISES IN MAXIMUM SECURITY
2. PREPARE THE PATIENCE TO "DRY REHABILITATION
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strengthening of the extensor muscles of the spineipercifosi correction and overall postureexercises for balance and proprioceptionmotor coordination (truncated upper limbs, trunk, lower limbs)respiratory coordinationnatural load exercises
The criteria for the CHOICE of exercises
The EXCLUSION criteria exercisesprevent flexion of the trunkexercises involving posture monopodaliche, kneeling or quadrupedicheuse of weights or other loads that are not naturalexercising in place unsafe and too expensive in terms of energy
REHABILITATION IN THE GYM
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CONCLUSIONS
The rehabilitation therapy in thermal water
is an important resourcefor the care and delicate process
recovery ofADL of elderly patients
In VERTEBRAL OSTEOPOROTIC FRACTURESthe hydrokinesiotherapy
allowing you to anticipate the loadhas proved a valuable tool
in the early recovery
- MOVEMENT- FEATURES AND JOINT- MUSCLE TROPHISM
IN THE ABSENCE OF PAIN
CONCLUSIONS
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CONCLUSIONS
PATIENT
First actor ofits recovery
Explain to the patient what is osteoporosisRecommend rules adequate lifestyle etc.
Stay in a spa can become an opportunity to develop
useful strategies education and awareness
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Thanks