Transcript Možnosti fyzioterapie u nemocných s roztroušenou sklerózou

Rehabilitation and physical
medicine in the treatment
of rheumatic diseases
As. PhDr. Kamila Řasová, Ph.D.
Department of rehabilitation
Third Faculty of Medicine, Charles University in
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-overview-ofrheumatic-diseases
Sign, symptoms and problems accompaining
revmatic diseases
• Pain in joint, joint swelling, joint may be warm
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•
•
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 person’s ability to work,
participate in daily and recreational activities and
may affect their relationships with family or
friends.
System model –
a basis for comprehensive rehabilitation
Umphred D.A., El-Din D. Neurological Rehabilitaton, 2001
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.
International Classification of Functioning, Disability and Health (ICF)
• Increased political attention towards high-quality rehabilitation for
Neurological Rehabilitaton,
2001
Comprehensive rehabilitation
• The promotion of a person’s functioning
depends upon a full assessment of
person’s 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.
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.
psychotherapy
physiotherapy
occupational
therapy
uro art therapy
patient
rehabilitation
speech
cognitive rehabilitation
therapy
hippotherapy
Patient´s family muzikoterapie
Social service
and friends
dance therapy
sports therapy
canisterapie
Process of rehabilitation
Boissonnault W.G., Umphred D.A. Neurological Rehabilitaton, 2001
A visual analogue scale (VAS)
a psychometric response scale for subjective characteristics or attitudes that cannot be
directly measured.
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.
Excerise
tolerance
Never heard of
it
I know it but
not use in my
patiens
Used in my
patients
Gait pattern
functions
Heart rate
Spatio-temporal
parameters, e.g. stride
length, cadence and
walk ratio
Timed tandem gait
Rate of perceived
exertion(RPE)*
Oxygen consumption,
intake, uptake per kg
NYHA** Functional
Classification
Spiroergometry
Fatigue
Mental and
psychological
functions
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)
Never heard of Ha
it
Never heard of Have heard of it Know how to do
it
or seen it
it
Never heard of Have heard of it Know how to do
it
or seen it
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
Muscle power
function
Medical research
council scale (MRC)
Repetitive muscle
activity testing
Motoricity index
Motor club
assessment
Testing of
Muscle Function
Dynamometry
Never heard of Have heard of it Know how
it
or seen it
it
Changing
and
maintainin
g body
position
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
Never heard of Have heard of it Know how to do
it
or seen it
it
Walking,
mobility
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
Never heard of
it
Have heard of
it or seen it
Know how to
do it
Using
arms and
hands
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-FuglMeyer test
International
Cooperative Ataxia
Rating Scale
(ICARS)
Scale for the
assessment and rating
of ataxia (SARA)
N
Health –
related
quality of life
instruments
Work and leisure
Functional Status Questionnaire
Frenchay Activities Index
Modified Social Support Survey
(MSSS)
Sickness Impact Profile
Environment Status Scale
Short-Form(SF-12, SF-36)
Self care
Barthel Index
Incapacity Status
Scale
Functional
Independence
Measure (FIM)
Multiple Sclerosis –
self efficacy scale (MS
- SES)
FSQ self care
questionnaire
Never heard of Have heard of it Know how to do
it
or seen it
it
Never Have heard of it Know how t
heard of
or seen it
it
it
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.
Rehabilitation goals in RD
• reducing and
controlling pain
• improving mood
• enhancing physical
function
• Improve quality of life
Rehabilitation treatment
• Education and self-management
• Exercise, rest, and energy
conservation
• Manual and mechanical therapies
• Physical modalities
Education and selfmanagement
• Information on the nature and prognosis
of arthritis; efficacy and side effects
of arthritis medications; and exercise,
pacing, and other
rehabilitation interventions.
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.
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.
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.
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.
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.
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.
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
Manual and mechanical
therapies
• manual therapy is defined as a clinical
approach utilizing skilled, specific handson techniques, including but not limited to
manipulation/mobilization, used by the
physical therapist
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.
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.
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."
Pain receptors
• These are bare sensory nerve endings that
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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.
Neural Pathways in Pain
• These painful impulses travel to the central
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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.
• Both these fibres send impulses by releasing a
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•
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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.
• There are two types of pain, transmitted by
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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.
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.
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.
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.
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!!
• From the spinal cord, the messages go directly
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•
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.
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.
Possibilities how to reduce pain
1) Spinal level: Close the gate
2) Subcortical level: activation of limbic
system and hypothalamus-pituitaryadrenal axis
3) Cortical level: cognitive training,
afirmative training
„Sedare dolorem divinum est.“
Cicero
Conditions that open or
close the gate
Conditions that
open the gate
Physical
conditions
Extent of the injury Medication
Inappropriate
activity level
Emotional
Conditions
Anxiety or worry
Tension
Depression
Mental conditions
Conditions that
close the gate
Focusing on the
pain
Boredom
Counterstimulation,
eg massage
Positive emotions –
afirmative training
Relaxation
Rest
Intense
concentration or
distraction
Involvement and
interest in life
activities
Other pain reduce pain –
creating of define
nociceptive afference
inhibit other painfull
aference
„derivative therapy“
vacutherapy
Acupuncture
1.Stimulation of large
diameter nerve fibers that
inhibit pain ("close the
gate").
2.Could be placebo effect.
Causes release of
endorphins ("the body's own
morphine-like substances„,
Reduces anxiety.
3.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)
Transcutaneous Electrical
Nerve Stimulation (TENS)
1.Stimulation of large
diameter nerve fibers which
"close the gate" and reduce
pain.
2.Could be placebo effect.
TENS involves the passage of lowvoltage electrical current to electrodes
pasted on the skin.
STRES/
BOLEST
RAPHE
HIPOKAMPUS
Deliberace HPA
LC
NA
CRH
Sympatická
ggl
HYPOTHALAMUS
CRH
HYPOFÝZA
ACTH
glukokortikoidy
thymocyty
NADLEDVINA
astrocyty
katecholaminy
Stress
(aerobic training)
1.Activation of endogenous
opiate system (endorphins)
2.Activation of non-opiate
pain inhibitory system
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
Automatické programy aktivující terapie
Motorické programy aktivující terapie
Physical modalities that
reduce pain and stiffness
• Thermotherapy – heat therapy, cryotherapy
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•
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– 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
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.