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
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