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MEDICAL REHABILITATION IN THE DERMATOMUSCULO SKELETAL SYSTEM

MEDICAL REHABILITATION IN THE DERMATOMUSCULO SKELETAL SYSTEM. SUSANTI DHARMMIKA, Physical Medicine & Rehabilitation Department Faculty of Medicine Bandung Islamic University -2012. CSG OF DMS SYSTEM. DERMATOSIS (INFECTION, NEOPLASM) BURN DENTAL PROBLEMS CONGENITAL MALFORMATIONS

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MEDICAL REHABILITATION IN THE DERMATOMUSCULO SKELETAL SYSTEM

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  1. MEDICAL REHABILITATION IN THE DERMATOMUSCULO SKELETAL SYSTEM SUSANTI DHARMMIKA, Physical Medicine & Rehabilitation Department Faculty of Medicine Bandung Islamic University -2012

  2. CSG OF DMS SYSTEM • DERMATOSIS (INFECTION, NEOPLASM) • BURN • DENTAL PROBLEMS • CONGENITAL MALFORMATIONS • TRAUMA OF THE MUSCULOSKELETAL SYSTEM (FRACTURE, DISLOCATION) • SPINAL PROBLEMS • JOINT PROBLEMS Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  3. Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  4. FUNCTIONAL PROBLEM LIST • COMMUNICATION • MOBILIZATION • ACTIVITIES OF DAILY LIVING • VOCATIONAL & A-VOCATIONAL ACTIVITIES • PSYCHO-SOCIAL • EDUCATION • ETC: PAIN Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  5. LEARNING OBJECTIVES FOR THE STUDENTS • UNDERSTAND THE SCOPE OF IMPAIRMENTS, DISABILITIES AND HANDICAPS • UNDERSTAND THE DIFFERENCE BETWEEN MEDICAL CARE & REHABILITATION CARE • UNDERSTAND THE ROLE OF THE FAMILY & THE COMMUNITY • UNDERSTAND THE AFTER-CARE (HOME-CARE) OF DISABLING DISEASES Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  6. COMPETENCE OF THE GENERAL PRACTITIONER • PREVENTION OF DISABILITIES & HANDICAPS • AFTER CARE OF IMPAIRMENTS & DISABILITIES • PREVENTING OF 2ND DISABILITIES AND HANDICAPS • PROMOTING INDEPENDENCE IN ACTIVITIES OF DAILY LIVING • PROMOTING INTEGRATION IN THE COMMUNITY Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  7. REHABILITATION APPROACHES • FUNCTIONAL REHABILITATION Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  8. 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 PROSTHETICS Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  9. PROBLEM LIST Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  10. PROBLEM LIST Dr.MarinaA.Moeliono, SpRM et.al., Dept. of Physical Medicine and Rehabilitation, Faculty of Medicine-Padjadjaran Univ., HasanSadikin Hospital

  11. CASUISTIC IN THE DMS SYSTEM

  12. BURN INJURY REHABILITATION

  13. 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

  14. ACUTE BURN REHABILITATION GOALS: • 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

  15. ACUTE BURN REHABILITATION PROPER 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

  16. 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  

  17. ACUTE BURN REHABILITATION SPLINTING • 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

  18. RESTING HAND SPLINT • WRIST EXTENSION • 60-800 METACARPOPHALANGEAL FLEXION • FULL INTERPHALANGEAL EXTENSION • THUMB ABDUCTION

  19. ACUTE BURN REHABILITATION EXERCISE • 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

  20. ACUTE BURN REHABILITATION EARLY 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)

  21. POST ACUTE BURN REHABILITATION WOUND 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)

  22. POST ACUTE BURN REHABILITATION SCARING • 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)

  23. POST ACUTE BURN REHABILITATION SCARING • 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)

  24. POST ACUTE BURN REHABILITATION JOINT 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

  25. 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

  26. 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

  27. FRACTURE REHABILITATION

  28. 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).

  29. 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).

  30. THERAPEUTIC EXERCISE AND RANGE OF MOTION • THE ULTIMATE PURPOSE OF AN EXERCISE PROGRAM IS TO RESTORE: • FUNCTION • PERFORMANCE • MUSCLE STRENGTH • ENDURANCE TO PRETRAUMA LEVEL

  31. RANGE OF MOTION • FULL RANGE OF MOTION • FUNCTIONAL RANGE OF MOTION • ROM EXERCISE: • ACTIVE ROM • ACTIVE-ASSISTIVE ROM • PASSIVE ROM

  32. 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

  33. 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

  34. MODALITIES USED • THERAPEUTIC HEAT • THERAPEUTIC COLD • HYDROTHERAPY • ELECTRICAL MODALITIES • SPRAY AND STRETCH

  35. GAIT • ALTER GAIT PATTERN AFTER FRACTURE • ASSISTIVE DEVICES

  36. ADAPTIVE EQUIPMENT

  37. THE REHABILITATION OF CLEFT PALATESPEECH

  38. 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. • ANUMBER 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

  39. 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

  40. PAIN

  41. 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.

  42. PAIN MANAGEMENT OF PAIN • MEDICATION (NSAID ETC) • PHYSICAL MODALITIES  HEAT, COLD, WATER, MASSAGE, ELECTRICAL • MOVEMENT & MOBILIZATION • EXERCISES ROM EXC, STRETCHING EXC

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