Principles of rehabilitation of orthopedic patients
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Principles of rehabilitation of orthopedic patients






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Principles of rehabilitation of orthopedic patients Principles of rehabilitation of orthopedic patients Presentation Transcript

  • Introduction to Rehabilitation Medicine
  • What is Rehabilitation?
    • The process of helping a person to reach the fullest physical, psychological, social, vocational, avocational and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations and desires and life plans
  • Definitions:
    • Pathology
    • is a disease or trauma that causes changes in structure or function of a specific body tissue or organ
    • Impairment
      • Occurs at the organ system level & is defined as a loss or abnormality of psychological, physiologic or anatomic structure or function resulting from pathology
    • Disability
      • Occurs at the personal level & is defined as any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being
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  • Definitions
    • Handicap
    • occurs at the societal level & is defined as a disadvantage for a given individual that limits or prevents fulfillment of a role that is normal (depending on age, gender, social, cultural factors) for that individual
    • Activity
      • The nature and extent of functioning at the level of the person.
    • Participation
      • The nature and extent of a person ’ s involvement in life situations in relationship to impairments, activities, health conditions and contextual factors.
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  • Components of Rehabilitation
    • Medical Rehabilitation
    Social Rehabilitation Vocational Rehabilitation
  • What is Rehabilitation Medicine?
    • Branch of medical science concerned with the comprehensive evaluation and management of patients with impairment and disability arising from neuromuscular, musculoskeletal, cardiovascular and pulmonary disorders; also concerned with the medical, social, vocational and psychological aspects arising from them.
  • Medical Rehabilitation Team
    • Composed mainly of:
    • Physiatrist
    • Physical Therapist
    • Occupational Therapist
    • Rehabilitation Nurse
    • Psychologist
    • Speech and language therapist
    • Orthotist/prosthetist
    • Social worker
    • Patient
  • Physiatrist
    • Team leader
    • Coordinates the various members to achieve the goal set.
    • Manages the medical aspects and medical complications that arise during rehabilitation
  • Occupational Therapist
    • Evaluate and train patients in ADL ’ s and IADL ’ s
    • Explore vocational and avocational interests
    • Evaluates the patient ’ s skill within the community
    • Train patients in use of modified environment, assistive devices and UE prostheses
    • Educate the patient ’ s family to maintain independence
  • Physical Therapist
    • Use of physical agents for treatment
    • Assist patient in functional restoration especially for gross motor functions
    • Train use of LE prostheses
  • Psychologist
    • Helps the patient and significant others to prepare psychologically for full participation
    • Testing for intelligence, personality, psychological status
    • counseling
  • Rehabilitation Nurse
    • Direct personal care of patients
    • Addresses the ADL ’ s
    • Assist in medication management
    • Educate families on the related disabilities
    • Assist in use of adaptive devices
  • Speech and Language Therapist
    • Evaluates and treats patients with neurogenic disorders such as aphasia, dysarthria, apraxia, cognitive-communication impairments, dysphagia
    • Educates patients/families on care of tracheostomy tubes, dysphagia, alternative communication.
  • Social Worker
    • Evaluates the patient ’ s total living condition, including:
      • Lifestyle
      • Finances
      • Employment history
      • Community resources
    • Assess the impact of disability with the above mentioned factors
    • Facilitate assistance to cope with such impact.
  • Orthotist/Prosthetist
    • Evaluates, designs and fabricates orthoses and/or prostheses.
    • Follow up and educate users of care and maintenance of such devices
  • Other team members
    • Vocational Counselor
    • Recreation therapist
    • Spiritual counselor
    • Rehabilitation Engineer
  • The Team Approach Physiatrist P. T. O.T. Psych. S.&L. T. Ortho./ Prosthe. Nurse Social Work patient
  • The Physiatric Approach
    • Physiatric History
      • Chief complaint
      • HPI
      • Fxnal Hx
        • ADL
        • Community activities
        • Vocational activities
        • Functional Goals
      • Psychosocial Hx
    • The Physiatric Approach
    • Past Medical History
    • Review of Systems
    • Functional Examination
    • Musculoskeletal Examination
    • Neurological Examination
  • Musculoskeletal examination
    • 0 – no contractions
    • 1 – palpable contractions noted
    • 2- full range of motion with gravity eliminated
    • 3 – full range of motion with gravity
    • 4 – full range of motion with gravity and slight resistance
    • 5 – full range of motion with gravity and full resistance
  • Modified Ashworth scale for Spasticity
    • 0 – no increase in tone
    • 1 – slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part is moved in flexion or extension
    • 1+ - slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout the remainder (less than half) of the range of motion
    • 2 - more marked increase in muscle tone through most of the ROM but affected parts easily moved
    • 3 – Considerable increase in muscle tone, passive movement difficult
    • 4 – affected parts rigid in flexion or extension
    • Activities of Daily Living
    • Mobility
      • Bed mobility
      • Wheelchair mobility
      • Transfers
      • Ambulation
    • Self Care
      • Dressing
      • Self feeding
      • Bathing
      • grooming
  • Activities of Daily Living
    • Communication
      • Writing
      • Typing/computer use
      • Telephone use
      • Use of special communication devices
    • Environmental Hardware
      • Keys
      • Faucets
      • Light switches
      • Use of windows and doors
  • Instrumental Activities of Daily Living
    • Home Management
      • Shopping
      • Meal planning
      • Meal preparation
      • Cleaning
      • Laundry
      • Child care
      • recycling
  • Instrumental Activities of Daily Living
    • Community Living Skills
      • Money/financial mgt
      • Use of public transport
      • Driving
      • Shopping
      • Access to recreational activities
  • Instrumental Activities of Daily Living
    • Health Mgt.
      • Handling medication
      • Knowing health risks
      • Making medical appointments
    • Safety Mgt
      • Fire safety awareness
      • Response to dangerous situations
      • Response to alarms
  • Instrumental Activities of Daily Living
    • Environmental Hardware
      • Vacuum cleaner
      • Stove/oven
      • Refrigerator
      • Microwave ovens
  • Gait Analysis
    • Important physiatric tool
    • May help show functional weakness
    • Divided into 2 major phases:
      • Stance phase
      • Swing phase
  • Swing Phase
    • Covers 40 % of the gait cycle
    • Initial swing (acceleration)
    • Midswing
    • Terminal swing (deceleration)
  • Stance phase
    • Covers 60 % of the gait cycle
    • Loading response (heel strike)
    • Midstance (foot flat)
    • Terminal stance (heel off)
    • Preswing (toe off)
  • Six determinants of Gait
    • Pelvic rotation in the horizontal plane
    • Pelvic tilt in the frontal plane
    • early Knee flexion
    • Weight transfer from heel to foot flat
    • Late knee flexion
    • Pelvic lateral displacement
  • Considerations in Rehabilitation
    • Goal setting
    • Understanding the functions of the team members
    • Autonomy of each member
    • Understanding the needs of the patient
  • Physiologic response to Heat Heat Decreased Blood viscosity Increased tissue temp Increased Local sweating Increased Phagocytosis Arteriolar Dilatation Increased Capillary Flow Increased Capillary Pressure Increased Capillary Permeability Increased Clearingof Metabolic waste Increased Supply of nutrients
  • CRYOTHERAPY Cold Decreased Tissue Temp. Increased Blood Viscosity And Vasoconstriction Decreased Metabolism Decreased Bleeding Decreased Removal of By Products Decreased Production of Metabolites Decreased Leucocyte Phagocyte Activity Retard Healing
  • Rehabilitation of Orthopedic Patients
    • Why rehabilitate?
      • Resolve the clinical symptoms
      • Return to activity
      • General fitness
      • From rehabilitation to prehabilitation
        • Decreases the chance of injury
  • Why rehabilitate?
    • Resolve clinical symptoms
      • Use of modalities
      • Use of appropriate medications
      • Protect, Relative Rest, Icing, Compression and Elevation (PRICE)
      • Surgical Indications
  • Why Rehabilitate?
    • Return to Activity-Restoration of Function
      • Retard muscle decline in strength and mass
      • Deter complications brought about by immobility
      • Maintain or improve flexibility
  • Why Rehabilitate?
    • General Fitness
      • Improve Cardiovascular fitness
      • Overall strength is improved
      • Improve tolerance and endurance
  • Why Rehabilitate?
    • From Rehabilitation to Prehabilitation
      • Prevent reinjury
      • Improve proprioception
      • Prevent Immobility due to apprehension
  • What is being Rehabilitated?
    • Discovering the type of injury
      • Microtrauma
        • Chronic cases
        • Due to repetitive disruption of the structures
      • Macrotrauma
        • Often acute cases
        • Due to specific events
  • What is being Rehabilitated?
    • Method of injury presentation
      • Injury classified as
        • Acute
          • Episode usually easily recalled
        • Chronic
          • Gradual onset of symptoms
        • An acute exacerbation of a chronic injury
        • Subclinical adaptations of activity
          • May be asymptomatic
  • What is being Rehabilitated?
    • Accurate Diagnosis of the injury:
      • Identifies areas that are in need for Rehabilitation
      • Evaluates the effects of injury to:
        • Function and physiology
        • Adaptation
        • anatomy
  • Principles of Rehabilitation In Orthopedic patients
    • Treatment Planning
      • Based on 3 stages of rehabilitation
        • Acute
        • Recovery stage
        • Functional stage
  • Acute stage
    • Focus of treatment
      • Clinical symptom
      • Tissue injury
    • Tools for rehabilitation
      • Rest and/or immobilization
      • Physical modalities
      • Medications
      • Manual therapy
      • Initial exercise
      • surgery
  • Acute Stage
    • Criteria for advancement
      • Pain control
      • Adequate tissue healing
      • Near normal ROM
      • Tolerance for strengthening
  • Recovery stage
    • Focus of treatment;
      • Tissue overload complex
      • Functional biomechanical deficit complex
    • Tools:
      • Manual therapy
      • Flexibility
      • Proprioception /neuromuscular control
      • Specific exercise
  • Recovery Stage
    • Criteria for advancement:
      • No pain
      • Complete tissue healing
      • Essentially pain free ROM
      • Good flexibility
      • 75 to 80 % strength
  • Functional Stage
    • Focus of treatment
      • Functional biomechanical deficit complex
      • Subclinical adaptation complex
    • Tools
      • Exercises
      • Technique/skills instructions
      • Specific functional program
  • Functional Stage
    • Criteria for return to play or function
      • No pain
      • Full pain free ROM
      • Normal strength and balance
      • Good general fitness
      • Normal mechanics
  • Conclusion
    • Rehabilitation of patients rests on accurate diagnosis, proper identification of roles, cooperation among the different disciplines and a potent but practical goal setting.
    • The patient is always the focus of treatment, and should have a quality of life that is deemed most acceptable.