Physical Medicine And Rehabilitation PDF

# 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 d...

# 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 - If exercise continues heart rate, BP stabilizes - Post pituitary hormones & androgens ↑ - ↑ TG, ↓ LDL, ↑ HDL in endurance exercises - Endurance: low resistance, high repetition → Type Ⅰ fibers. - ↑ Ventricular cavity enlarges - Strength: high resistance, low repetition → both Type Ⅰ & Ⅱ fibers. - Ventricular cavity normal, wall thickness increased ### Contraindications to ROM Exercises - Tears, unhealed fractures, surgery - Deep vein thrombosis (DVT) - Active heterotopic ossification - Cardiovascular instability - Myocardial infarction ## Stretching Exercises - The type of pathology: if 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, it is the first diagnosis to be considered - Subluxation: misalignment, partial dislocation, result of inappropriate stretching, static exercises → pressure overload, dynamic exercises → volume overload ## Muscle Strength Exercises - Isometric resistance: static, muscle contracts w/o movement - Isotonic exercise: same tonus. Muscle lengthens and shortens within ROM. Dumbbell - Isokinetic exercise: dynamic speed of muscle contraction controlled by mechanical device, constant velocity. - Eccentric contractions: kind of isotonic. Muscle tightening when it is long. ## Physical Activity - Duration, intensity, frequency - **Aerobic Activity:** continuous movement using big muscle groups, causes heart, lung & vascular system to work harder. Walking, swimming, soccer, etc. - **Strength Training:** muscles work against resistance. Free weights (dumbbells), body weight (push-ups) - **Flexibility Training:** ability to move a joint through its range of motion. Yoga, pilates etc. ## Inflammation - Redness (rubor), heat (calor), swelling (tumor), pain/hypersensitivity (dolor), loss of function (functio laesa) ## Non-Inflammatory Joint Pain: Mostly Osteoarthritis - **Osteoarthritis:** ↓ th of morning stiffness & pain aggravated by activities improving to rest. (-) to biomarkers. ## Inflammatory Pain Pattern (at least one of the 3): - Maximal pain on morning, waking up at night because of pain, morning stiffness longer than 1h. ## Inflammatory Arthritis - Group of disease caused by overactive immune system. Joint pain & stiffness. Joint may feel warm, swollen, tender. Systemic disease RF, CRP, ESR elevated ## Rheumatoid Arthritis - Most common inflammatory arthritis. - Multiple small joints of hand & 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 finger/toe → dactylitis ## Juvenile Idiopathic Arthritis - <16yr - Inflam. in joints, sometimes spine & ligaments. - Last > 6 weeks - Swelling or mobility problems, limp if leg is affected. - Some types → eye inflammation without symptoms. ## Ankylosing Spondylitis - Most common inflammatory spondylarthritis - Primarily spine, hip, sternum, large joints - Over time noticeably reduced motion in spine. - HLA-B27 gene presence can help confirm. ## Gout - Elevated uric acid crystals - Big toe → risk of kidney stones. ## Pseudo Gout - Calcium pyrophosphate dehydrate deposition disease. - CPDD - Wrist, knee - Sjögren Syndrome & Lupus can cause inflammatory arthritis as a symptom. ## Treatment: - NSAIDs, (ibuprofen), corticosteroids, disease-modifying antirheumatic drugs (DMARDs) (methotrexate), biologic DMARDs ## Osteoarthritis - Degenerative disease of synovial joints. - Characterized by breakdown of articular cartilage and proliferative changes - Pathology: fibrillation, eburnation (polished surface due to cartilage loss), osteophytes, subchondral cysts. - **Primary OA:** idiopathic. Proximal interphalangeal (Heberden nodules) and 2 in carpometacarpal joints of thumb (Bouchard nodules) in women, hip, knee, distal interphalangeal joints - **Secondary OA:** due to some other disease. - **Most important cause of disability in old age → OA** ### Risk Factors: - Age, female, obesity, Col2A1 gene, trauma. ### Clinic: - Joint pain (degenerative), stiffness (after inactivity) limited ROM (later stage), deformity (restriction of ADL) ### Radiology: - Narrow joint space, osteophytes, subchondral sclerosis, bone cysts. ## Gonarthrosis - **OA of knee joint.** Joint stiffness < 30 min. - Pain on pressure + ROM, crepitus (gıcırdana) > 50yr. - Lab within normal limits - Genua varum: Bowed legs - Genua valgum: Knock knees. ## Coxarthrosis - OA of hip joint. Males > 70yr. - Pain of hip, gluteal & groin areas radiating to knee. - Limited walking, antalgic limping, &ROM, Trendelenburg test (+). - Lab within normal limits ## Treatment: - Symptomatic, structure modifying, surgical. - **Oral systemic meds**: analgesics (acetaminophen), NSAID, opioids. - **Intraarticular**: hyaluronan, glucocorticoids, PRP, stem cells. - **Topical agents.** - **Prevention:** exercise, weight control, no trauma. ## Osteoporosis - Loss of bone density & damage in microstructure. ### Primary Osteoporosis - **Type 1:** post menopausal due to estrogen (trabecular) - **Type 2:** senile (+70yr) → vit D. ### Secondary Osteoporosis - Caused by meds; like steroid, methotrexate, anticancer, Gl (antacids), immobilization. ### Diagnostic Tools: - Blood test: vitD, serum Ca., P, PTH, FSH - **Gold standard:** DEXA (dual energy X-Ray absorbiometry) - **DEXA (bone mineral density)** - T score: standard dev. pt. comp. to young & healthy - Z score: standard dev. pt. comp to same age - (-2.5) - (-1) → osteopenia - < (-1) - (-2.5) → osteoporosis - < (-2.5) + fractures → severe osteoporosis - Silent bone disease unless fractures - Loss of height + postural abnormality → vertebral fracture ### Treatment: - Meds to stop bone resorption: biphosphonates. 1st choice. Not in severe renal failure. Side effect: mandible aseptic necrosis. Not allowed for dental procedures.* - Anabolizing agents: Teriparatide (PTH analog) - Denozumab: RANK inhibitor. Safe in pregnancy. - In osteopenic phase: calcium & vit D usage, Ca rich diet, no alcohol caffeine, smoking. ## Osteomalacia - Vit D abnormality, defective resorbtion of bone, DEXA, blood tests, Ca, Vit D. - Treatment: Vit D & Ca replacement - X-Ray: looser zones → pseudofracture → pelvic area ## Paget Disease - Osteitis deformans. Defective bone, mostly asymptomatic, hearing loss. Pain, tenderness, nerve entrapment. - Alkaline phosphate. - Cortical thickening, bowing of legs. - Treatment: calcitonin. ## Neuronal Plasticity: - Brain & nervous system's ability to modify & reorganize their activities, enables reconstruction and gain function of damaged nerve cells. - **Short term:** within secs/mins. Changes in synaptic communication & excitability. - **Medium term:** hr/days. Reshaping & strengthening of synaptic connections. - **Long term:** wks/months. Changes in gene expression, morphological alterations of neurons. ## Orthotics: - External devices that support, align or protect part of body. ## Prosthetics: - Artificial devices that imitate and perform the functions of amputated limb/organ. ## Sprain: - Soft tissue injury caused by overstretching, tearing of ligaments around a joint, symptoms are swelling, &ROM, pain, bruising. ## Strain: - Result from stretch or tear in muscle or tendon fibers. ## Tendinitis: - Inflammation of tendon. Pain, swelling, redness, sensitivity, &ROM. ## Synovitis: - Inflammation of synovial membrane in the joint capsule - swelling, pain, &ROM. ## In acute phase soft tissue injuries: - **RICE method** - Rest - Ice - Compression - Elevation - **Pain relief** - **Immobilization** ## Synarthrotic Joints: <- Fixed joints - skull, pelvic bones ## Amphiarthrotic Joints: - Partially moveable - vertebra, ribs, sternum ## Diarthrotic Joints: - Freely moveable - have joint capsule ## Special Joints: - Hyoid bone + eyeball ## Muscular Dystrophy: - Genetic disease that causes the muscles to gradually weaken. ## Myopathy: - Disease characterized by muscle weakness and pain due to abnormal muscle structure. ## Electrotherapy: - Electrical stimulation for muscle strengthening, pain relief, functional improvement. - **STENS:** pain control, modulation of pain, uses gate control theory. - **Contraindications:** cardiac pacemaker, unstable angina, carotid sinus application, thrombosis.