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 (Pet) To modify the enviroment to permit accomplishment of the task despite limitations in ability or skills example: use of systems, devices To provide an agent or assisting person with task requirements or perform them entirely example: momchild diad

2.

3.

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 Mdicine (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

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

Management

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.
ITB

general
SDR

reversible
orthoses
BTX-A

irreversible

Orthopedic surgery

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 logos woman human

roof

parent

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