MEDICAL REHABILITATION IN THE DERMATOMUSCULO SKELETAL SYSTEM

SUSANTI DHARMMIKA,Physical Medicine & Rehabilitation DepartmentFaculty of MedicineBandung Islamic University -2012

CSG OF DMS SYSTEM1. DERMATOSIS (INFECTION, NEOPLASM)2. BURN 3. DENTAL PROBLEMS4. CONGENITAL MALFORMATIONS5. TRAUMA OF THE MUSCULOSKELETAL SYSTEM

(FRACTURE, DISLOCATION)6. SPINAL PROBLEMS7. JOINT PROBLEMS

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

MEDICAL DIAGNOSIS(IMPAIRMENT, DISEASE)

FUNCTIONAL DIAGNOSIS(DYSFUNCTION, DISABILITY)

FUNCTIONAL PROBLEM LIST

ASSESSMENT BY ALLIED HEALTH PROFESSIONS

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

FUNCTIONAL PROBLEM LIST1. COMMUNICATION2. MOBILIZATION3. ACTIVITIES OF DAILY LIVING4. VOCATIONAL & A-VOCATIONAL

ACTIVITIES5. PSYCHO-SOCIAL6. EDUCATION7. ETC: PAIN

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

LEARNING OBJECTIVES FOR THE STUDENTS1. UNDERSTAND THE SCOPE OF

IMPAIRMENTS, DISABILITIES AND HANDICAPS

2. UNDERSTAND THE DIFFERENCE BETWEEN MEDICAL CARE & REHABILITATION CARE

3. UNDERSTAND THE ROLE OF THE FAMILY & THE COMMUNITY

4. UNDERSTAND THE AFTER-CARE (HOME-CARE) OF DISABLING DISEASES

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

COMPETENCE OF THE GENERAL PRACTITIONER

1. PREVENTION OF DISABILITIES & HANDICAPS

2. AFTER CARE OF IMPAIRMENTS & DISABILITIES

3. PREVENTING OF 2ND DISABILITIES AND HANDICAPS

4. PROMOTING INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

5. PROMOTING INTEGRATION IN THE COMMUNITYDr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of

Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

REHABILITATION APPROACHES

IMPAIRMENT

DISABILITY

HANDICAP

FUNCTIONAL REHABILITATI

ON

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

SCOPE OF PHYSICAL MEDICINE AND REHABILITATION

(MEDICAL REHABILITATION)

1. PROMOTIVE SERVICES :

- EDUCATION of HEALTHY LIVING

- EDUCATION IN PREVENTING AND AVOIDING DISABILITES

- INCREASING OVERALL CONDITION

2. PREVENTIVE REHABILITATION

- PREVENTION OF SECONDARY AND TERTIER DISABILITIES

3. CURATIVE SERVICES

- MEDICAMENTOSA

- REHABILITATIVE NURSING

- PHYSIOTHERAPY

- SPEECH THERAPY

- OCCUPATIONAL / VOCATIONAL THERAPY

- ORTHOTICS and PROSTHETICSDr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

PROBLEM LIST

BURN

IMMOBILIZATION

MUSCULOSKELETAL TRAUMA

PAIN

WOUND HEALING STIFFNESS & CONTRACTURES

SPINAL PROBLEM(DEFORMITIES,

INFECTION, TRAUMA

PARA/TETRAPLEGIA

MUSCLE IMBALANCE,

SPASM & PAIN

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

PROBLEM LIST

JOINT PROBLEM

IMMOBILIZATION

MUSCULOSKELETAL CONGENITAL

MALFORMATIONS (CLEFT PALATE)

AFTERCARE

Dr.Marina A.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., Hasan Sadikin Hospital

CASUISTIC IN THE DMS SYSTEM

BURN INJURY REHABILITATION

BURN INJURY IS NECROSIS AND DAMAGE OF TISSUE SECONDARY

TO EXPOSURE TO AN EXTERNAL AGENT SUCH FLAME, RADIATION, OR OTHER AGENTS OF EXTREME TEMPERATURE

CAUSE COMPLEX LOCAL & SYSTEMIC RESPONSES INVOLVING THE CARDIOVASCULAR AND PULMONARY SYSTEMS, MICROCIRCULATION, METABOLISM, NUTRITION, ENDOCRINOLOGY, AND IMMUNOLOGY

CLASSIFICATION ETIOLOGY DEPTH OF INJURY

ACUTE BURN REHABILITATIONGOALS: PROMOTE WOUND HEALING PROMOTE COMPLICATIONS OF JOINT

CONTRACTURE, WEAKNESS, IMPAIRED ENDURANCE AND LOSS OF FUNCTIONAL ABILITY

INDIVIDUALIZED BY BURN LOCATION, DEPTH OF INJURY, PERCENT OF BODY SURFACE INJURED, ASSOCIATED INJURIES AND COMPLICATIONS

PATIENT AGE AS WELL AS PREVIOUS FUNCTIONAL LEVEL AND HEALTH ARE SIGNIFICANT

ACUTE BURN REHABILITATIONPROPER POSITIONING IS FUNDAMENTAL TO PREVENT

DEVELOPMENT OF CONTRACTURES AND AVOID COMPRESSION NEUROPATHIES

TYPICALLY POSITIONS OF EXTENSION AND ABDUCTION SHOULDE BE CHOSEN INDIVIDUALIZED ACCORDING TO SPECIFIC INJURY

The most common contractures are essentially identical to the most common position abnormalities produced with inadequate motion: Flexion: elbows, wrists, neck,

interphalangeal joints Adduction: shoulder Extension: feet, metacarpophalangeal

joints  

ACUTE BURN REHABILITATIONSPLINTING IS USED TO PREVENT JOINT CONTRACTURES,

MAINTAIN PROPER POSITIONING, AND PROTECT NEW SKIN GRAFTS

ADD COST TO PATIENTS CARE UST BE USER FRIENDLY FOR PATIENTS AND

NURSES NONBURN AREA MAY REQUIRE SPLINTING

TO PREVENT ANKLE CONTRACTURES DUE TO PROLONGED BED REST

RESTING HAND SPLINT

WRIST EXTENSION 60-800 METACARPOPHALANGEAL

FLEXION FULL INTERPHALANGEAL

EXTENSION THUMB ABDUCTION

Ideal for post-op and burn patients. Helps prevent foot-drop and assists in positioning foot. Splint is for bed use.

ACUTE BURN REHABILITATIONEXERCISE REQUIRES UNDERSTANDING OF LOCATION, DEPTH, AND

EXTENT OF BURN ACCORDING TO PRE-EXISTING CONDITION INITIAL GOALS:

ACTIVE AND ACTIVE ASSISTED EXERCISE FOR ALLERT PATIENTS SLOW PASSIVE EXERCISE FOR OBTUNDED/ CRITICALLY ILL ROM EXERCISE CAN BE PERFORMED UNDER ANESTHESIA

(BECAUSE INTOLERATE TO PAIN) IF NORMAL ROM IS LOSS STRETCHING STRENGTHENING BEGIN AS TOLERATED (PROGRESSIVE-

RESISTIVE EXERCISE) ENDURANCE TRAINING MONITORING OF CP RESPONSE

ACUTE BURN REHABILITATIONEARLY AMBULATION MAINTAIN INDEPENDENCE, BALANCE, AND LOWER

EXTREMITY ROM, DECREASES RISK OF DEEP VENOUS TROMBOSIS

BEGIN WITH DANGLING OF LOWER EXTREMIIES AMBULATION

CHECK STATUS OF THE GRAFT: 5-7 DAYS AFTER GRAFTING (STABLE CIRCULATION TO GRAFT)

ELASTIC WRAPS AVOID VENOUS POOLING MONITOR GAIT DEVIATIONS (DUE TO PAIN,

WEAKNESS, CONTRACTURES, HYPESTHESIA, ETC)

POST ACUTE BURN REHABILITATIONWOUND AND SKIN CARE ONCE WOUND CARE IS NO LONGER MAJORITY

PRIORITY ; PRIMARY FOCUS SHIFTS TO MAXIMIZING PATIENT’S POTENTIAL FOR INDEPENDENCE IN WORK AND COMMUNITY LIVING

EDUCATION : WOUND CARE & DRESSINGS HEALED BURN SKIN IS FRAGILE, EASILY ABRADED,

SENSITIVE TO SUN & CHEMICALS SUN BLOCK, APPROPRIATE CLOTHING, LUBRICATIONS

SCARING ( 3 MONTHS AFTER DEEP PARTIAL THICKNESS AND FULL THICKNESS INJURY)

POST ACUTE BURN REHABILITATIONSCARING SCARING ( 3 MONTHS AFTER DEEP

PARTIAL THICKNESS AND FULL THICKNESS INJURY)

SCAR SUPRESSION CONTINOUS PRESSURE FACILITATES A PARALLEL ARRANGEMENT OF COLLAGEN DURING MATURATION CUSTOM FITTED ELASTIC GARMENT (25 MMhG, 23HOURS/DAY)

POST ACUTE BURN REHABILITATIONSCARING SCARING ( 3 MONTHS AFTER DEEP

PARTIAL THICKNESS AND FULL THICKNESS INJURY)

SCAR SUPRESSION CONTINOUS PRESSURE FACILITATES A PARALLEL ARRANGEMENT OF COLLAGEN DURING MATURATION CUSTOM FITTED ELASTIC GARMENT (25 mmHg, 23HOURS/DAY)

POST ACUTE BURN REHABILITATIONJOINT FUNCTION IMMOBILITY AND SCARRING LEAD TO JOINT

CONTRACTURES ACTIVE EXERCISE PROPER POSITIONING SPLINTING

EXERCISE: 3-4 TIMES/DAY PATIENTS AND FAMILY TEACHING IS IMPORTANT TO REINFORCE JOINT EXERCISE

JOINT CONTRACTURE THAT FAILS NON SURGICAL TREATMENT CONSIDER TO SURGERY

POST ACUTE BURN REHABILITATION EXERCISE SHOULD CONTINUE GOALS:

ACHIEVING AND MAINTAINING JOINT ROM, NORMAL STRENGTH, NORMAL CARDIOPULMONARY FUNCTION,AND ENDURANCE

GAIT AND MOBILITY FOCUS ON INDEPENDENCE ON ALL SURFACES, PROGRESSING TO GAIT WITHOUT ASSISTIVE DEVICE

POST ACUTE BURN REHABILITATION PSYCHOLOGICAL ADJUSTMENT

PSYCHOLOGICAL HEALTH AFTER INJURY COSMESIS AND APPREARANCE SPECIAL

MAKEUP, PLASTIC SURGERY RETURN TO SCHOOL AND WORK OUTPATIENTS REHABILITATION DISCHARGE

PLANNING IF INDEPENDENT IN ALL ASPECTS OF CARE OR HAVE APPROPRIATE HOME OR COMMUNITY SERVICES IN PLACE --. FOLLOW UP MEDICAL CARE

FRACTURE REHABILITATION

THE GOAL OF REHABILITATION OF FRACTURES IS TO RESTORE FUNCTIONAL ABILITIES OF THE INDIVIDUAL (SALTER).

THE DURATION AND TYPE OF REHABILITATION TREATMENT REQUIRED FOLLOWING A FRACTURE ARE RELATED TO THE ASSOCIATED SOFT TISSUE INVOLVEMENT, AS WELL AS THE LOCATION AND TYPE OF FRACTURE AND THE METHOD OF STABILIZATION (CHAPMAN).

PROTOCOLS FOR REHABILITATION MUST BE BASED UPON STABILITY OF THE FRACTURE AND FRACTURE MANAGEMENT (OPERATIVE, NONOPERATIVE).

REHABILITATION EMPHASIZES RESTORING FULL RANGE OF MOTION, STRENGTH, PROPRIOCEPTION, AND ENDURANCE, WHILE MAINTAINING INDEPENDENCE IN ALL ACTIVITIES OF DAILY LIVING (BUCHOLZ).

COLD AND OTHER MODALITIES MAY BE USED IN CONTROLLING PAIN AND EDEMA (SALTER).

THE INDIVIDUAL SHOULD BE ENCOURAGED TO CONTINUE FUNCTIONAL ACTIVITIES TO PREVENT COMPLICATIONS OF INACTIVITY AND BED REST. DEPENDING ON THE STABILITY OF THE FRACTURE, RANGE OF MOTION EXERCISES OF THE ADJACENT JOINTS MAY BE STARTED IMMEDIATELY AND PROGRESSED TO STRENGTHENING EXERCISES AS INDICATED (CHAPMAN).

• BONE HEALING MAY OCCUR WITHIN 6 TO 20 WEEKS; HOWEVER THE BONE STRENGTH AND THE ABILITY OF THE BONE TO SUSTAIN A HEAVY LOAD MAY TAKE UP TO SEVERAL YEARS (CHAPMAN).

• ONCE HEALING HAS OCCURRED, THE INDIVIDUAL MAY RESUME FULL ACTIVITIES OF DAILY LIVING. RESUMPTION OF PRE-INJURY STATUS IS THE GOAL, WITH CONSIDERATION OF ANY RESIDUAL DEFICIT.

• THE TREATING PHYSICIAN SHOULD GUIDE THE RESUMPTION OF HEAVY WORK AND SPORTS; IT IS IMPORTANT TO INSTRUCT THE INDIVIDUAL NOT TO OVERLOAD THE FRACTURE SITE UNTIL THE BONE HAS REGAINED ITS FULL STRENGTH.

THERAPEUTIC EXERCISE AND RANGE OF MOTION THE ULTIMATE PURPOSE OF AN

EXERCISE PROGRAM IS TO RESTORE: FUNCTION PERFORMANCE MUSCLE STRENGTH ENDURANCETO PRETRAUMA LEVEL

RANGE OF MOTION FULL RANGE OF MOTION FUNCTIONAL RANGE OF MOTION ROM EXERCISE:

ACTIVE ROM ACTIVE-ASSISTIVE ROM PASSIVE ROM

MUSCLE STRENGTH UNCOMPLICATED FRACTURES DO NOT

PRESENT NEUROLOGIC PROBLEMS MUSCLE SURROUNDING THE SITE OF FRACTURE ARE WEAKER, USUALLY SECONDARY TO DIRECT TRAUMA, IMMOBILIZATION, OR REFLEX INHIBITION

STRENGTHENING EXERCISE

STRENGTHENING EXERCISE INCREASE THE AMOUNT OF FORCE THAT A MUSCLE CAN GENERATE

BASIC STRENGTHENING EXERCISE: ISOMETRIC ISOTONIC ISOKINETIC

HIGH PERFORMANCE STRENGTHENING EXERCISE CLOSED-CHAIN EXERCISE OPEN CHAIN EXERCISE

FUNCTIONAL/TASK SPECIFIC EXERCISE

MODALITIES USED THERAPEUTIC HEAT THERAPEUTIC COLD HYDROTHERAPY ELECTRICAL MODALITIES SPRAY AND STRETCH

GAIT ALTER GAIT PATTERN AFTER FRACTURE ASSISTIVE DEVICES

ADAPTIVE EQUIPMENT

THE REHABILITATION OF CLEFT PALATESPEECH

THE REHABILITATION OF CLEFT PALATE SPEECH IDEALLY REQUIRES AN INTEGRATED, TEAM APPROACH INCORPORATING THE PROFESSIONAL EFFORTS OF:• PLASTIC AND RECONSTRUCTIVE SURGERY• SPEECH AND LANGUAGE PATHOLOGY• DENTISTRY AND ORTHODONTIA THE IMPACT A CLEFT PALATE HAS UPON SPEECH

PRODUCTION CANNOT BE OVERSTATED. A NUMBER OF THE MAJOR ORGANS OF SPEECH

HAVE INTERRUPTED FUNCTION DUE TO THIS DEFORMITY.

EVEN WITH SURGICAL CORRECTION, SPEECH MAY NOT PROCEED NORMALLY WITHOUT THERAPEUTIC HELP.

OTHER PROBLEM : FEEDING : SUCKING, CHEWING&

SWALLOWING

If surgical correction of the cleft lip and/or palate is done before 1 year of age, there

is a good likelihood that speech development will be normal. However, if such correction occurs after 1 year of age or the age of speech onset, a significant

number of children may still require speech therapy in order to overcome their incorrect method of sound production. Even with children who have had cleft lip and

palate repair before the onset of speech, as many as 25% of them may have the need

for some speech therapy Historically, such correction has been problematic in developing nations. There

are many reasons for this: economic, geographical and availability of speech

therapy services. The conventional methods of speech therapy require that an individual

be

PAIN

DEFINITIONS OF PAIN THE INTERNATIONAL ASSOCIATION FOR THE

STUDY OF PAIN "AN UNPLEASANT, SUBJECTIVE, SENSORY AND

EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE OR DESCRIBED IN TERMS OF SUCH DAMAGE

" PAIN, HOWEVER, IS MUCH MORE THAN A PHYSICAL SENSATION CAUSED BY A SPECIFIC STIMULUS. IT IS A COMPLEX MECHANISM WITH PHYSICAL, EMOTIONAL, AND COGNITIVE COMPONENTS. IT IS SUBJECTIVE, AND HIGHLY INDIVIDUAL.

PAINMANAGEMENT OF PAIN

MEDICATION (NSAID ETC) PHYSICAL MODALITIES HEAT, COLD,

WATER, MASSAGE, ELECTRICAL MOVEMENT & MOBILIZATION EXERCISES ROM EXC, STRETCHING EXC