principles of rehabilitation of orthopedic patients

Introduction to Introduction to Rehabilitation MedicineRehabilitation Medicine

What is Rehabilitation?What is Rehabilitation? The process of helping a The process of helping a

person to reach the fullest person to reach the fullest physical, psychological, physical, psychological, social, vocational, social, vocational, avocational and educational avocational and educational potential consistent with his potential consistent with his or her physiologic or or her physiologic or anatomic impairment, anatomic impairment, environmental limitations environmental limitations and desires and life plansand desires and life plans

Definitions:Definitions: PathologyPathology is a disease or trauma that causes changes in is a disease or trauma that causes changes in

structure or function of a specific body tissue or organstructure or function of a specific body tissue or organ ImpairmentImpairment

Occurs at the organ system level & is defined as a loss or Occurs at the organ system level & is defined as a loss or abnormality of psychological, physiologic or anatomic abnormality of psychological, physiologic or anatomic structure or function resulting from pathologystructure or function resulting from pathology

DisabilityDisability Occurs at the personal level & is defined as any restriction or Occurs at the personal level & is defined as any restriction or

lack (resulting from an impairment) of ability to perform an lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal activity in the manner or within the range considered normal for a human beingfor a human being

Definitions Definitions HandicapHandicap 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

ActivityActivity The nature and extent of functioning at the level The nature and extent of functioning at the level

of the person.of the person. ParticipationParticipation

The nature and extent of a personThe nature and extent of a person’’s involvement s involvement in life situations in relationship to impairments, in life situations in relationship to impairments, activities, health conditions and contextual activities, health conditions and contextual factors.factors.

Components of RehabilitationComponents of Rehabilitation

Medical RehabilitationMedical Rehabilitation

Social Rehabilitation

Vocational Rehabilitation

What is Rehabilitation What is Rehabilitation Medicine?Medicine?

Branch of medical science concerned with the Branch of medical science concerned with the comprehensive evaluation and management of comprehensive evaluation and management of patients with impairment and disability arising patients with impairment and disability arising from neuromuscular, musculoskeletal, from neuromuscular, musculoskeletal, cardiovascular and pulmonary disorders; also cardiovascular and pulmonary disorders; also concerned with the medical, social, vocational concerned with the medical, social, vocational and psychological aspects arising from them.and psychological aspects arising from them.

Medical Rehabilitation TeamMedical Rehabilitation Team

Composed mainly of:Composed mainly of: PhysiatristPhysiatrist Physical TherapistPhysical Therapist Occupational TherapistOccupational Therapist Rehabilitation NurseRehabilitation Nurse PsychologistPsychologist Speech and language therapistSpeech and language therapist Orthotist/prosthetistOrthotist/prosthetist Social workerSocial worker PatientPatient

PhysiatristPhysiatrist

Team leaderTeam leader Coordinates the various Coordinates the various

members to achieve the members to achieve the goal set.goal set.

Manages the medical Manages the medical aspects and medical aspects and medical complications that arise complications that arise during rehabilitationduring rehabilitation

Occupational TherapistOccupational Therapist

Evaluate and train patients in Evaluate and train patients in ADLADL’’s and IADLs and IADL’’ss

Explore vocational and Explore vocational and avocational interestsavocational interests

EvaluatesEvaluates the patientthe patient’’s skill s skill within the community within the community

Train patients in use of modified Train patients in use of modified environment, assistive devices environment, assistive devices and UE prosthesesand UE prostheses

Educate the patientEducate the patient’’s family to s family to maintain independencemaintain independence

Physical TherapistPhysical Therapist

Use of physical Use of physical agents for treatmentagents for treatment

Assist patient in Assist patient in functional restoration functional restoration especially for gross especially for gross motor functionsmotor functions

Train use of LE Train use of LE prosthesesprostheses

PsychologistPsychologist

Helps the patient and Helps the patient and significant others to significant others to prepare psychologically prepare psychologically for full participationfor full participation

Testing for intelligence, Testing for intelligence, personality, psychological personality, psychological statusstatus

counselingcounseling

Rehabilitation NurseRehabilitation Nurse Direct personal care of Direct personal care of

patientspatients Addresses the ADLAddresses the ADL’’ss Assist in medication Assist in medication

managementmanagement Educate families on the Educate families on the

related disabilitiesrelated disabilities Assist in use of adaptive Assist in use of adaptive

devicesdevices

Speech and Language Speech and Language TherapistTherapist

Evaluates and treats patients Evaluates and treats patients with neurogenic disorders with neurogenic disorders such as aphasia, dysarthria, such as aphasia, dysarthria, apraxia, cognitive-apraxia, cognitive-communication impairments, communication impairments, dysphagiadysphagia

Educates patients/families on Educates patients/families on care of tracheostomy tubes, care of tracheostomy tubes, dysphagia, alternative dysphagia, alternative communication.communication.

Social WorkerSocial Worker Evaluates the patientEvaluates the patient’’s total s total

living condition, including:living condition, including: LifestyleLifestyle FinancesFinances Employment historyEmployment history Community resourcesCommunity resources

Assess the impact of disability Assess the impact of disability with the above mentioned with the above mentioned factorsfactors

Facilitate assistance to cope Facilitate assistance to cope with such impact.with such impact.

Orthotist/ProsthetistOrthotist/Prosthetist

Evaluates, designs Evaluates, designs and fabricates and fabricates orthoses and/or orthoses and/or prostheses.prostheses.

Follow up and Follow up and educate users of care educate users of care and maintenance of and maintenance of such devicessuch devices

Other team membersOther team members

Vocational CounselorVocational Counselor Recreation therapistRecreation therapist Spiritual counselorSpiritual counselor Rehabilitation Rehabilitation

EngineerEngineer

The Team ApproachThe Team Approach

Physiatrist

P. T. O.T.

Psych.

S.&L. T.Ortho./Prosthe.

Nurse SocialWork

patient

The Physiatric ApproachThe Physiatric Approach

Physiatric HistoryPhysiatric History Chief complaintChief complaint HPIHPI Fxnal HxFxnal Hx

ADLADL Community activitiesCommunity activities Vocational activitiesVocational activities Functional GoalsFunctional Goals

Psychosocial HxPsychosocial Hx

•The Physiatric ApproachThe Physiatric Approach

Past Medical HistoryPast Medical History Review of SystemsReview of Systems Functional Functional

ExaminationExamination Musculoskeletal Musculoskeletal

ExaminationExamination Neurological Neurological

ExaminationExamination

•Activities of Daily LivingActivities of Daily Living MobilityMobility

Bed mobilityBed mobility Wheelchair mobilityWheelchair mobility TransfersTransfers AmbulationAmbulation

Self CareSelf Care DressingDressing Self feedingSelf feeding BathingBathing groominggrooming

Activities of Daily LivingActivities of Daily Living CommunicationCommunication

WritingWriting Typing/computer useTyping/computer use Telephone useTelephone use Use of special communication Use of special communication

devicesdevices Environmental HardwareEnvironmental Hardware

KeysKeys FaucetsFaucets Light switchesLight switches Use of windows and doorsUse of windows and doors

Instrumental Activities of Daily Instrumental Activities of Daily LivingLiving

Home ManagementHome Management ShoppingShopping Meal planningMeal planning Meal preparationMeal preparation CleaningCleaning LaundryLaundry Child careChild care recyclingrecycling

Instrumental Activities of Daily Instrumental Activities of Daily LivingLiving

Community Living Community Living SkillsSkills Money/financial mgtMoney/financial mgt Use of public transportUse of public transport DrivingDriving ShoppingShopping Access to recreational Access to recreational

activitiesactivities

Instrumental Activities of Daily Instrumental Activities of Daily LivingLiving

Health Mgt.Health Mgt. Handling medicationHandling medication Knowing health risksKnowing health risks Making medical Making medical

appointmentsappointments Safety MgtSafety Mgt

Fire safety awarenessFire safety awareness Response to dangerous Response to dangerous

situationssituations Response to alarmsResponse to alarms

Instrumental Activities of Daily Instrumental Activities of Daily LivingLiving

Environmental Environmental HardwareHardware Vacuum cleanerVacuum cleaner Stove/ovenStove/oven RefrigeratorRefrigerator Microwave ovensMicrowave ovens

Considerations in RehabilitationConsiderations in Rehabilitation

Goal settingGoal setting Understanding the Understanding the

functions of the team functions of the team membersmembers

Autonomy of each Autonomy of each membermember

Understanding the Understanding the needs of the patientneeds of the patient

Physiologic response to HeatPhysiologic response to HeatHeatHeat

Decreased Blood viscosity

Decreased Blood viscosity

Increased tissue tempIncreased

tissue tempIncreased

Local sweatingIncreased

Local sweating

IncreasedPhagocytosisIncreased

PhagocytosisArteriolarDilatationArteriolarDilatation

IncreasedCapillary Flow

IncreasedCapillary Flow

IncreasedCapillary Pressure

IncreasedCapillary Pressure

IncreasedCapillary

Permeability

IncreasedCapillary

Permeability

Increased Clearingof

Metabolic waste

Increased Clearingof

Metabolic waste

Increased Supply of nutrients

Increased Supply of nutrients

CRYOTHERAPYCRYOTHERAPY

Cold

DecreasedTissue Temp.

Increased Blood Viscosity

AndVasoconstriction

Decreased Metabolism

DecreasedBleeding

DecreasedRemoval ofBy Products

DecreasedProduction of Metabolites

DecreasedLeucocyte Phagocyte

Activity

Retard Healing

Rehabilitation of Orthopedic Rehabilitation of Orthopedic PatientsPatients

Why rehabilitate?Why rehabilitate?Resolve the clinical symptomsResolve the clinical symptomsReturn to activity Return to activity General fitnessGeneral fitnessFrom rehabilitation to prehabilitationFrom rehabilitation to prehabilitation

Decreases the chance of injuryDecreases the chance of injury

Why rehabilitate?Why rehabilitate?

Resolve clinical symptomsResolve clinical symptomsUse of modalitiesUse of modalitiesUse of appropriate medicationsUse of appropriate medicationsProtect, Relative Rest, Icing, Compression Protect, Relative Rest, Icing, Compression

and Elevation (PRICE)and Elevation (PRICE)Surgical IndicationsSurgical Indications

Why Rehabilitate?Why Rehabilitate?

Return to Activity-Restoration of FunctionReturn to Activity-Restoration of FunctionRetard muscle decline in strength and massRetard muscle decline in strength and massDeter complications brought about by Deter complications brought about by

immobilityimmobilityMaintain or improve flexibilityMaintain or improve flexibility

Why Rehabilitate?Why Rehabilitate?

General FitnessGeneral Fitness Improve Cardiovascular fitnessImprove Cardiovascular fitnessOverall strength is improvedOverall strength is improved Improve tolerance and enduranceImprove tolerance and endurance

Why Rehabilitate?Why Rehabilitate?

From Rehabilitation to PrehabilitationFrom Rehabilitation to PrehabilitationPrevent reinjuryPrevent reinjury Improve proprioceptionImprove proprioceptionPrevent Immobility due to apprehensionPrevent Immobility due to apprehension

What is being Rehabilitated?What is being Rehabilitated?

Discovering the type of Discovering the type of injuryinjuryMicrotraumaMicrotrauma

Chronic casesChronic casesDue to repetitive Due to repetitive

disruption of the disruption of the structuresstructures

MacrotraumaMacrotraumaOften acute casesOften acute casesDue to specific eventsDue to specific events

What is being Rehabilitated?What is being Rehabilitated?

Method of injury Method of injury presentationpresentation Injury classified asInjury classified as

AcuteAcute Episode usually easily Episode usually easily

recalledrecalled ChronicChronic

Gradual onset of Gradual onset of symptomssymptoms

An acute exacerbation An acute exacerbation of a chronic injuryof a chronic injury

Subclinical adaptations Subclinical adaptations of activityof activity

May be asymptomaticMay be asymptomatic

What is being Rehabilitated?What is being Rehabilitated?

Accurate Diagnosis of the Accurate Diagnosis of the injury:injury: Identifies areas that are in Identifies areas that are in

need for Rehabilitationneed for Rehabilitation Evaluates the effects of Evaluates the effects of

injury to:injury to: Function and physiologyFunction and physiology AdaptationAdaptation anatomyanatomy

Principles of Rehabilitation In Principles of Rehabilitation In Orthopedic patientsOrthopedic patients

Treatment PlanningTreatment PlanningBased on 3 stages of rehabilitationBased on 3 stages of rehabilitation

AcuteAcuteRecovery stageRecovery stageFunctional stageFunctional stage

Acute stageAcute stage Focus of treatment Focus of treatment

Clinical symptomClinical symptom Tissue injuryTissue injury

Tools for rehabilitationTools for rehabilitation Rest and/or Rest and/or

immobilizationimmobilization Physical modalitiesPhysical modalities MedicationsMedications Manual therapyManual therapy Initial exerciseInitial exercise surgerysurgery

Acute StageAcute Stage

Criteria for Criteria for advancementadvancementPain controlPain controlAdequate tissue Adequate tissue

healinghealingNear normal ROMNear normal ROMTolerance for Tolerance for

strengtheningstrengthening

Recovery stageRecovery stage

Focus of treatment;Focus of treatment; Tissue overload complexTissue overload complex Functional biomechanical Functional biomechanical

deficit complexdeficit complex

•Tools:Tools:Manual therapyManual therapyFlexibilityFlexibilityProprioception Proprioception /neuromuscular /neuromuscular controlcontrolSpecific exerciseSpecific exercise

Recovery StageRecovery Stage

Criteria for Criteria for advancement:advancement:No painNo painComplete tissue healingComplete tissue healingEssentially pain free Essentially pain free

ROMROMGood flexibilityGood flexibility75 to 80 % strength75 to 80 % strength

Functional StageFunctional Stage

Focus of treatmentFocus of treatment Functional biomechanical Functional biomechanical

deficit complexdeficit complex Subclinical adaptation Subclinical adaptation

complexcomplex ToolsTools

ExercisesExercises Technique/skills Technique/skills

instructionsinstructions Specific functional programSpecific functional program

Functional StageFunctional Stage

Criteria for return to Criteria for return to play or functionplay or functionNo painNo painFull pain free ROMFull pain free ROMNormal strength and Normal strength and

balancebalanceGood general fitnessGood general fitnessNormal mechanicsNormal mechanics

ConclusionConclusion

Rehabilitation of patients rests on accurate Rehabilitation of patients rests on accurate diagnosis, proper identification of roles, diagnosis, proper identification of roles, cooperation among the different cooperation among the different disciplines and a potent but practical goal disciplines and a potent but practical goal setting.setting.

The patient is always the focus of The patient is always the focus of treatment, and should have a quality of life treatment, and should have a quality of life that is deemed most acceptable.that is deemed most acceptable.