Physical Medicine medium

Physical Medicine and Rehabilitation

• ICF: International Classification of Functioning; impairment = deviation/loss of body structure or function.
• Therapeutic Exercises:
  • Vasodilation in exercising muscles, vasoconstriction in non-exercising areas.
  • Vascular resistance in muscles to meet demand; ↑ BP in isometric exercises.
  • ↑ cardiovascular effects in isotonic/isometric exercises; if exercise continues, heart rate and BP stabilize.
  • Post pituitary hormones and androgens affect TG, LDL, HDL, and HDL in endurance exercises.
  • Endurance: low resistance, high repetition exercises, type 1 fibers; ventricular cavity enlarges.
  • Strength: high resistance, low repetition exercises, both type 1 & 2 fibers; ventricular cavity normal, wall thickness increased.
• Contraindications to ROM Exercises: tears, unhealed fractures, surgery, deep vein thrombosis, active heterotopic ossification, cardiovascular instability, myocardial infarction.
• Stretching Exercises:
  • Pathology: fibrous or osseous contracture; with slight force, some elongation of collagen fibers; prolonged stretching—CT undergoes plastic deformation and cannot return to original size even without force.

Complications of Stretching

• Tissue damage in painful conditions lasting more than 1 hour.
• Subluxation (misalignment/partial dislocation) - result of inappropriate stretching/pressure overload.
• static/dynamic exercises.

Muscle Strength Exercises

• Isometric: resistance, static; muscle contracts w/o movement.
• Isotonic: same tonus, muscle lengthens and shortens within ROM (dumbbells).
• Isokinetic: dynamic speed of muscle contraction; controlled by mechanical device, constant velocity; eccentric contractions: muscle tightening when it is long.

Physical Activity

• Aerobic activity: continuous movement using big muscle groups (walking, swimming, soccer); causes heart, lungs, & vascular system to work harder.
• Strength training: muscles work against resistance (free weights, body weight).
• Flexibility training: ability to move a joint through its range of motion (yoga, pilates).

Inflammatory Conditions

• Inflammatory pain pattern (at least one of three symptoms): maximal morning pain, waking up night pain, morning stiffness greater than 1 hour.
• Inflammatory Arthritis: group of diseases caused by overactive immune systems; joint pain and stiffness; joint may feel warm, swollen, and tender; systemic diseases include RF, CRP, ESR elevated.
• Rheumatoid Arthritis: most common inflammatory arthritis; multiple small joints of hands and feet, symmetrical inflamed synovium; warmth, pain, stiffness, RF, anti-CCP, antibodies (+).
• Psoriatic Arthritis: Spondylarthropathy—combination of psoriasis; pain, swelling, large/small joints, sometimes spine; can cause complete swelling of fingers/toes (dactylitis).
• Juvenile Idiopathic Arthritis: inflammation in joints, sometimes spine & ligaments; lasting > 6 weeks; swelling or mobility problems (limp if leg is affected); some types—eye inflammation without symptoms.
• Ankylosing Spondylitis: most common inflammatory spondylarthritis; primarily affects spine, hip, sternum, and large joints; over time, noticeably reduced motion in the spine; presence of HLA-B27 gene can help confirm.
• Gout: Elevated uric acid crystals; risk of kidney stones, commonly in the big toe.
• Pseudogout: Calcium pyrophosphate dehydrate deposition disease; affects wrist and knees.
• Sjogren’s Syndrome & Lupus: Can cause inflammatory arthritis as a symptom.

Treatments

• NSAIDs (ibuprofen), corticosteroids, disease-modifying antirheumatic drugs (DMARDs) (methotrexate, biologic DMARDs).

Osteoarthritis

• Degenerative disease of synovial joints; characterized by breakdown of articular cartilage; pathology: fibrillation, eburnation(polished surface due to cartilage loss), osteophytes (bone spurs), subchondral cysts; primary OA (idiopathic).

• Secondary OA: due to some other disease.

• Risk factors: older age, female, obesity, genetic factors (COL2A1 gene), trauma.

• Symptoms: joint pain (degenerative), stiffness (after inactivity); Limited ROM, deformity (restriction of ADLs); radiological findings: narrow joint space, osteophytes (bone spurs), subchondral sclerosis, bone cysts.

• Gonarthrosis (OA of knee): joint stiffness <30 minutes; pain on pressure, crepitus; lab. within normal limits.

• genu varum: bowed legs; genu valgum: knock knees.

• Coxarthrosis (OA of hip): Pain of hip, gluteal area, radiating to knee; limited walking, antalgic limping, & ROM, Trendelenburg test (+); lab. within normal limits.

Osteoporosis

• Primary osteoporosis: type 1 (post-menopausal, trabecular bone loss) and type 2 (senile, cortical bone loss).
• Secondary osteoporosis: caused by medications (steroids, methotrexate), cancer treatments, anti-cancer medications (antacids), immobilization.
• Diagnostic tools: blood tests (vit D, serum Ca, P, PTH, FSH), gold standard is DEXA (dual-energy X-ray absorptiometry)—bone mineral density; scores compared to healthy young adults; osteopenia (-2.5 to -1 SD); osteoporosis (< -2.5 SD); severe osteoporosis plus fractures; silent bone disease unless fractures; loss of height, postural abnormalities (vertebral fractures)
• Treatment: –– Medications to stop bone resorption; biphosphonates (first choice), teriparatide (analog to PTH). –– Anabolic medications (teriparatide): safe during pregnancy; Denosumab (RANK inhibitor); Calcium and vitamin D supplementation.
• Other conditions — Osteomalacia low vitamin D, abnormal bone structure, X-ray and labs confirm; treatment :vit D & calcium replacement. — Paget Disease osteitis deformans—deformed bone; symptoms: pain, tenderness, nerve entrapment; diagnostic test: alkaline phosphatase in blood; treatment calcitonin

Other conditions

• Sprains: soft-tissue injury from overstretching/tearing of ligaments around a joint; swelling and pain.
• Strains: stretch or tear of muscle or tendon fibers.
• Tendintis: inflammation of tendons; pain, swelling redness, and sensitivity around the tendons.
• Synovitis: inflammation of synovial membrane inside the joint capsule; swelling, pain, and restricted ROM.
• Synarthrotic Joints: fixed joints (e.g., skull).
• Amphiarthrotic Joints: partially moveable joints (e.g., ribs, sternum, vertebrae).
• Diarthrotic Joints: freely moveable joints (e.g., most limbs).
• Special Joints: hyoid bone + eyeball.
• Muscular Dystrophy: genetic diseases that cause muscles to weaken progressively.
• Myopathy: disease characterized by muscle weakness and pain due to abnormal muscle structure.

Electrotherapy

• Electrical stimulation for muscle strengthening, pain relief, functional improvement.
• TENS: pain control, modulation of pain uses gate control theory
• Contraindications: cardiac pacemaker, unstable angina, carotid sinus application, thrombosis.