principles of rehabilitation of orthopedic patients
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Introduction to Introduction to Rehabilitation MedicineRehabilitation Medicine
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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
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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
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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.
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Components of RehabilitationComponents of Rehabilitation
Medical RehabilitationMedical Rehabilitation
Social Rehabilitation
Vocational Rehabilitation
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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.
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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
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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
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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
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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
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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
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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
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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.
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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.
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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
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Other team membersOther team members
Vocational CounselorVocational Counselor Recreation therapistRecreation therapist Spiritual counselorSpiritual counselor Rehabilitation Rehabilitation
EngineerEngineer
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The Team ApproachThe Team Approach
Physiatrist
P. T. O.T.
Psych.
S.&L. T.Ortho./Prosthe.
Nurse SocialWork
patient
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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
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•The Physiatric ApproachThe Physiatric Approach
Past Medical HistoryPast Medical History Review of SystemsReview of Systems Functional Functional
ExaminationExamination Musculoskeletal Musculoskeletal
ExaminationExamination Neurological Neurological
ExaminationExamination
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•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
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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
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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
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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
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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
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Instrumental Activities of Daily Instrumental Activities of Daily LivingLiving
Environmental Environmental HardwareHardware Vacuum cleanerVacuum cleaner Stove/ovenStove/oven RefrigeratorRefrigerator Microwave ovensMicrowave ovens
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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
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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
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CRYOTHERAPYCRYOTHERAPY
Cold
DecreasedTissue Temp.
Increased Blood Viscosity
AndVasoconstriction
Decreased Metabolism
DecreasedBleeding
DecreasedRemoval ofBy Products
DecreasedProduction of Metabolites
DecreasedLeucocyte Phagocyte
Activity
Retard Healing
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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
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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
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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
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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
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Why Rehabilitate?Why Rehabilitate?
From Rehabilitation to PrehabilitationFrom Rehabilitation to PrehabilitationPrevent reinjuryPrevent reinjury Improve proprioceptionImprove proprioceptionPrevent Immobility due to apprehensionPrevent Immobility due to apprehension
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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
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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
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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
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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
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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
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Acute StageAcute Stage
Criteria for Criteria for advancementadvancementPain controlPain controlAdequate tissue Adequate tissue
healinghealingNear normal ROMNear normal ROMTolerance for Tolerance for
strengtheningstrengthening
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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
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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
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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
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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
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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.