Rehabilitation

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Rehabilitation and physical medicine in the
treatment of rheumatic diseases

• As. PhDr. Kamila Rasová, Ph.D.
• Department of rehabilitation
• Third Faculty of Medicine, Charles University in
  Prague

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Rheumatic diseases
Rheumatic diseases (rheumatism) are painful
conditions usually caused by inflammation,
swelling, and pain in the joints or muscles. Some
rheumatic diseases like osteoarthritis are the
result of "wear and tear" to the joints. Other
rheumatic diseases, such as rheumatoid arthritis,
happen when the immune system becomes
hyperactive the immune system attacks the
linings of joints, causing joint pain, swelling,
and destruction. Almost any joint can be affected
in rheumatic disease. There are more than 100
rheumatic diseases.
Rheumatoid arthritis
Ankylosing spondylitis
Reactive arthritis and psoriatic arthritis
Systemic lupus erythematosus
Systemic sclerosis
Idiopathic inflammatory myopathies
Juvenile idiopathic arthritis
Sjögren syndrome
Gout (Gouty arthritis)
Osteoarthritis
Soft tissue rheumatism
Lyme disease (Lyme arthritis)
Septic arthritis
http//www.webmd.com/rheumatoid-arthritis/an-overv
iew-of-rheumatic-diseases
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Sign, symptoms and problems accompaining revmatic
diseases

• Pain in joint, joint swelling, joint may be warm
  to touch, joint stiffness, muscle weakness and
  joint instability
• Other organ involvement, fever
• People are physical deconditioned, fatiguing,
  depressed, hopeless, anxious, frustrated and
  fearful of doing even normal activities.
• It is restricted a persons ability to work,
  participate in daily and recreational activities
  and may affect their relationships with family or
  friends.

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System model a basis for comprehensive
rehabilitation
Umphred D.A., El-Din D. Neurological
Rehabilitaton, 2001
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Clinical practice, including rehabilitation,
should be based on the ICF model. This model
facilitates the structuring, organization and
documentation of the whole rehabilitation
process. It enables all professionals involved in
patient care to coordinate their actions to
achieve the maximum participation in life even
with impairments resulting from the disease.

• Increased political attention towards
  high-quality rehabilitation for

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Comprehensive rehabilitation

• The promotion of a persons functioning depends
  upon a full assessment of persons medical,
  psychological and social issues that cannot be
  addressed by a single practitioner but require a
  team of health professionals. Such teamwork
  should lead to interventions that improve
  maintenance of functioning and minimize
  disability.

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Teamwork

• Multidisciplinary - efforts of different team
  members are parallel and discipline oriented. The
  result will be the sum of the efforts of all team
  members.
• Interdisciplinary - working together for the same
  goal. Team members are required to have the
  skills of their discipline as well as the ability
  to contribute to a group effort on behalf of the
  patient. The treatment programme is synergistic,
  producing more than each discipline could achieve
  individually. This synergistic approach is
  obtained formally by a team conference.

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psychotherapy
physiotherapy
occupational therapy
uro - rehabilitation
art therapy
patient
speech therapy
cognitive rehabilitation
hippotherapy
muzikoterapie
Patients family and friends
Social service
dance therapy
sports therapy
canisterapie
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Process of rehabilitation
Boissonnault W.G., Umphred D.A. Neurological
Rehabilitaton, 2001
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A visual analogue scale (VAS) a psychometric
response scale for subjective characteristics or
attitudes that cannot be directly measured.
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Wong Baker Faces Pain Scale - a Pain Assessment
Tool Used by People in Pain - combines pictures
and numbers to allow pain to be rated by the
user. The faces range from a smiling face to a
sad, crying face. A numerical rating is assigned
to each face, of which there are 6 total.
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Excerise tolerance  Never heard of it I know it but not use in my patiens Used in my patients
Heart rate        
Rate of perceived exertion(RPE)        
Oxygen consumption, intake, uptake per kg
NYHA Functional Classification        
Spiroergometry
Gait pattern functions   Never heard of it Have heard of it or seen it Know how to do it
Spatio-temporal parameters, e.g. stride length, cadence and walk ratio      
Timed tandem gait      
Fatigue  Never heard of it Have heard of it or seen it Know how to do it
(Modified) Fatigue Impact Scale      
Fatigue Severity Scale      
Rating scales, e.g. Visual analogue scale, Verbal rating scale      
Fatigue Scale for motor and cognitive function FSMC
 Mental and psychological functions Never heard of it Have heard of it or seen it Know how to do it
Mini-Mental State Examination      
Paced Auditory Serial Additions Test (PASAT)      
Symbol digit modality test      
Beck Depression Inventory      
Hospital Anxiety and Depression Scale      
Mental Health Inventory (MHI)
Muscle power function  Never heard of it Have heard of it or seen it Know how to do it
Medical research council scale (MRC)      
Repetitive muscle activity testing      
Motoricity index      
Motor club assessment      
Testing of Muscle Function      
Dynamometry
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 Changing and maintaining body position Never heard of it Have heard of it or seen it Know how to do it
Berg balance scale (BBS)      
ABC Self Confidence Scale      
Dynamic gait index (DGI)      
Dizziness handicap inventory      
Number of falls      
Tinetti Balance Assessment tool      
Trunk impairment scale      
Postural stabilometric platform      
Walking, mobility  Never heard of it Have heard of it or seen it Know how to do it
10 m gait maximal speed      
10 m gait normal speed      
Timed 25-Foot Walk      
6 minute walk test      
2 minute walk test      
Ambulatory Index      
Timed up and go test (TUG)
Rivermead motor assessment      
Rivermead Mobility Index
Hauser Ambulation Index      
FSQ mobility questions      
Functional Ambulation Categories      
Using arms and hands  Never heard of it Have heard of it or seen it Know how to do it
Nine hole peg test      
Box and Blocks test      
Purdue Pegboard      
Action Research Arm Test      
TEMPA      
Disabilities of the arm, shoulder and hand (DASH)      
Wolf Motor Function Test      
Brunnstrom-Fugl-Meyer test
International Cooperative Ataxia Rating Scale (ICARS)
Scale for the assessment and rating of ataxia (SARA)
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Health related quality of life instruments   Never heard of it Have heard of it or seen it Know how to do it
Sickness Impact Profile      
Short-Form(SF-12, SF-36)      
 Work and leisure
Functional Status Questionnaire            
Frenchay Activities Index            
Modified Social Support Survey (MSSS)
Environment Status Scale Environment Status Scale          
 Self care Never heard of it Have heard of it or seen it Know how to do it
Barthel Index      
Incapacity Status Scale      
Functional Independence Measure (FIM)      
Multiple Sclerosis self efficacy scale (MS - SES)      
FSQ self care questionnaire      
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Psychosocial state of a person with chronic pain
- three classes of chronic pain patient

• dysfunctional people who perceived the severity
  of their pain to be high, reported that pain
  interfered with much of their lives, reported a
  higher degree of psychological distress caused by
  pain, and reported low levels of activity
• interpersonally distressed people with a common
  perception that significant others were not very
  supportive of their pain problems
• adaptive coopers patients who reported high
  levels of social support, relatively low levels
  of pain and perceived interference, and
  relatively high levels of activity.

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Rehabilitation goals in RD

• reducing and controlling pain
• improving mood
• enhancing physical function
• Improve quality of life

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Rehabilitation treatment

• Education and self-management
• Exercise, rest, and energy conservation
• Manual and mechanical therapies
• Physical modalities

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Education and self-management

• Information on the nature and prognosis of
  arthritis efficacy and side effects of arthritis
  medications and exercise, pacing, and other
  rehabilitation interventions.

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General recommendation Move to Help Prevent
Joint Pain

• Keep joints healthy by keeping them moving. The
  more you move, the less stiffness you'll have.
  Whether you're reading, working, or watching TV,
  change positions often. Take breaks from your
  desk or your chair and move around.

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General recommendation Protect Your Body and
Your Joints

• Injury can damage joints. So protecting your
  joints your whole life is important. Wear
  protective gear like elbow and knee pads when
  taking part in high-risk activities like skating.
  If your joints are already aching, consider
  wearing braces when playing tennis or golf.

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General recommendation Healthy Weight for
Healthy Joints

• Even a little weight loss can help. Every pound
  you lose takes four pounds of pressure off your
  knees and decreses the risk of cartilage
  breakdown.
• Consider your joints when lifting and carrying.
  Carry bags on your arms instead of with your
  hands to let your bigger muscles and joints
  support the weight.

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General recommendation Low-Impact Exercise for
Joints

• To protect your joints, your best choices are
  low-impact options like walking, bicycling and
  swimming. That's because high-impact, pounding,
  and jarring exercise can increase your risk of
  joint injuries and may slowly cause cartilage
  damage. Light weight-lifting exercises should
  also be included, but you have to consult it with
  expert.

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General recommendation Strengthen Muscles Around
Joints

• Stronger muscles around joints mean less stress
  on those joints. Research shows that having weak
  thigh muscles increases your risk of knee
  osteoarthritis, for example. Even small increases
  in muscle strength can reduce that risk.
• Avoid rapid and repetitive motions of affected
  joints.

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General recommendation Full Range of Motion is
Key

• Move joints through their full range of motion to
  reduce stiffness and keep them flexible. Range of
  motion refers to the normal extent joints can be
  moved in certain directions.

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Post Isometric Relaxation (PIR)

• The post-isometric relaxation technique begins by
  placing the muscle in a stretched position. Then
  an isometric contraction is exerted against
  minimal resistance. Relaxation and then gentle
  stretch follow as the muscle releases. This
  technique was applied to tight, tender muscles
  that are commonly associated with musculoskeletal
  pain

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Manual and mechanical therapies

• manual therapy is defined as a clinical approach
  utilizing skilled, specific hands-on techniques,
  including but not limited to manipulation/mobiliza
  tion, used by the physical therapist

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General recommendation Know Your Joints' Limits

• It's normal to have some aching muscles after
  exercising.
• But if your pain lasts longer than 48 hours, you
  may have overstressed your joints. Don't exercise
  so hard next time. Working through the pain may
  lead to injury or damage.

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General recommendation Protect Joints With Good
Posture

• Stand and sit up straight. Good posture protects
  your joints all the way from your neck down to
  your knees.

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Pain treatment

• "Pain can be treated not only by trying to cut
  down the sensory input, but also by influencing
  the motivational-affective and cognitive factors
  as well."

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Pain receptors

• These are bare sensory nerve endings that network
  throughout all organs and tissues of the body
  (except the brain)
• They respond to many types of stimuli eg extremes
  of temperature, lacerations, or anything that is
  potentially damaging to the tissue.
• When actual injury occurs, Bradykinin (the most
  potent pain producing chemical/enzyme known) is
  released from the damaged cells.
• This bradykinin attaches to the pain receptors
  (free nerve endings) causing them to transmit
  pain impulses.

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Neural Pathways in Pain

• These painful impulses travel to the central
  nervous system through two different fibres
• 1. The fibres that transmit impulses quickly are
  called A-delta fibres. The types of sensations
  they carry are localised, sharp, pricking, brief
  sensations.
• 2. The fibres that transmit impulses more slowly
  are called C fibres. The types of sensations they
  carry are dull, burning, aching, longer lasting
  sensations.

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• Both these fibres send impulses by releasing a
  transmission agent called Substance P. Both
  fibres (A-delta and C) follow a similar pathway
  up the spinal cord until they reach the Brain.
• C fibres end in the lower regions of the
  forebrain whereas A-delta fibres go straight onto
  the motor and sensory areas of the cortex.
• The lower regions of the forebrain do not assess
  the pain signals as dramatically as the motor and
  sensory areas of the cortex.
• The cortex provides immediate attention for the
  sharp localised pain signals, whereas the C
  fibres carrying dull aching pain signals are
  assessed more from an emotional/motivational
  perspective in the forebrain.

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• There are two types of pain, transmitted by two
  separate sets of pain-signaling pathways in the
  central nervous system.
• Sudden, short-term pain, such as the pain of
  cutting a finger, is transmitted by a group of
  pathways that Melzack calls the "lateral" system,
  because they pass through the brain stem on one
  side of its central core.
• Prolonged pain, on the other hand, such as
  chronic back pain, is transmitted by the "medial"
  system, whose neurons pass through the central
  core of the brain stem.

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Role of pain

• Pain is part of the body's defense system,
  producing a reflexive retraction from the painful
  stimulus, and tendencies to protect the affected
  body part while it heals, and avoid that harmful
  situation in the future.
• People with congenital insensitivity to pain have
  reduced life expectancy.

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Pain behaviours

• facial grimacing and guarding
• increase or decrease in vocalizations
• changes in routine behavior patterns and mental
  status changes (withdrawn social behavior and
  possibly experience a decreased appetite and
  decreased nutritional intake, moaning with
  movement or when manipulating a body part, and
  limited range of motion are also potential pain
  indicators.

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Gate Control Theory, Patrick Wall and Ronald
Melzack, 1965

• This theory states that pain is a function of the
  balance between the information traveling into
  the spinal cord through large nerve fibers (carry
  non-nociceptive information) and information
  traveling into the spinal cord through small
  nerve fibers(carry nociceptive information). If
  the relative amount of activity is greater in
  large nerve fibers, there should be little or no
  pain. However, if there is more activity in small
  nerve fibers, then there will be pain.

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1) Without any stimulation, both large and small
nerve fibers are quiet and the inhibitory
interneuron (I) blocks the signal in the
projection neuron (P) that connects to the brain.
The "gate is closed" and therefore NO PAIN. 2)
With non-painful stimulation, large nerve fibers
are activated primarily. This activates the
projection neuron (P), BUT it ALSO activates the
inhibitory interneuron (I) which then BLOCKS the
signal in the projection neuron (P) that connects
to the brain. The "gate is closed" and therefore
NO PAIN. 3) With pain stimulation, small nerve
fibers become active. They activate the
projection neurons (P) and BLOCK the inhibitory
interneuron (I). Because activity of the
inhibitory interneuron is blocked, it CANNOT
block the output of the projection neuron that
connects with the brain. The "gate is open",
therefore, PAIN!!
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• From the spinal cord, the messages go directly to
  several places in the brain including the
  thalamus, midbrain and reticular formation.
• Some brain regions that receive nociceptive
  information are involved in perception and
  emotion. Also, some areas of the brain connect
  back to the spinal cord - these connections can
  change or modify information that is coming into
  the brain. In fact, this is one way that the
  brain can REDUCE pain.
• Two areas of the brain that are involved in
  reducing pain are the periaqueductal gray and the
  nucleus raphe magnus.

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Nociception lead to active change of standard
movement pattern with aim to not irritate damged
palce and activate functional restitution. Pain
- nocicepton interpreted at the concious level
lead to concious tonic muscle reaciton in sense
of spasm often accompained by reflex inhibition
of antagonists (e.g. Tightness of m. iliopspas
lead to inhibition of m. gluteus maximus) rarely
by clonus.
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Possibilities how to reduce pain

1. Spinal level Close the gate
2. Subcortical level activation of limbic system
   and hypothalamus-pituitary-adrenal axis
3. Cortical level cognitive training, afirmative
   training

Sedare dolorem divinum est. Cicero
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Conditions that open or close the gate
  Conditions that open the gate Conditions that close the gate
Physical conditions Extent of the injury Medication
  Inappropriate activity level Counterstimulation, eg massage
Emotional Conditions Anxiety or worry Positive emotions afirmative training
  Tension Relaxation
  Depression Rest
Mental conditions Focusing on the pain Intense concentration or distraction
  Boredom Involvement and interest in life activities
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Other pain reduce pain creating of define
nociceptive afference inhibit other painfull
aference derivative therapy
Acupuncture Stimulation of large diameter nerve fibers that inhibit pain ("close the gate"). Could be placebo effect. Causes release of endorphins ("the body's own morphine-like substances, Reduces anxiety. Some types of acupuncture may stimulate small diameter nerve fibers and inhibit spinal cord pain mechanisms (this would not agree with the gate control theory)
vacutherapy
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Transcutaneous ElectricalNerve Stimulation (TENS) Stimulation of large diameter nerve fibers which "close the gate" and reduce pain. Could be placebo effect.
TENS involves the passage of low-voltage
electrical current to electrodes pasted on the
skin.
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STRES/ BOLEST
RAPHE
HIPOKAMPUS
Deliberace HPA
NO
LC
NA
HYPOTHALAMUS
CRH
Sympatická ggl
CRH
HYPOFÝZA
ACTH
glukokortikoidy
thymocyty
NADLEDVINA
ON
astrocyty
katecholaminy
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Stress (aerobic training) Activation of endogenous opiate system (endorphins) Activation of non-opiate pain inhibitory system
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Physiotherapy based on neurophysiological
prinicples - an activation of the cerebellum
and consequently via hypothalamus
paleocerebellum and the neocerebellum limbic
system part of a limbic system is hypothalamus
that owing to the hypothalamus-pituitary-adrenal
axiscan
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Automatické programy aktivující terapie
Motorické programy aktivující terapie
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Physical modalities that reduce pain and stiffness

• Thermotherapy heat therapy, cryotherapy
• Heat can increase the inflammatory response and
  possibly increase joint damage, but this has not
  been supported empirically contraindications
  in inflamation.
• Electromagnetic fields
• Low-power laser
• Transcutaneous electrical nerve stimulation
• Ultrasound

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Conclusion

• Rehabilitation improves range of motion,
  strength, and functional activities and must be
  individualized according to the disease activity,
  accumulated joint damage, and the patient's goals
  and interests.
• High-impact exercises such as jumping,
  basketball, etc. should be avoided.with
  significant rheumatic disease.
• Medium-impact exercises such as walking, jogging,
  bicycling, and swimming are appropriate, unless
  there is severe joint inflammation.Severely
  inflamed joints should only be subjected
  to gentle mobilization and stretching within the
  available range of movement.