Angela BM Tulaar

FILOSOPHY OF PHYSICAL MEDICINE

& REHABILITATION (PMR)
To improve the functional ability of a person in
accordance with his potentials to maintain or increase
the quality of life through optimal prevention or
minimizing impairment, disability, and handicap
Meningkatkan kemampuan fungsional seseorang
sesuai dengan potensi yang dimiliki untuk
mempertahankan dan/atau meningkatkan kualitas
hidup dengan cara mencegah / mengurangi hendaya
disabilitas dan kecacatan seoptimal mungkin
White Book KFR, hal.15
 Interaction between ICF components
HEALTH CONDITION
( disorders of disease )

Body Functions Activities Participation

and Structures

Environmental Personal Factors

Factors
Indonesian PM&R White Book, pp 20
 Components of Effective
Interventions to Improve Function

INDIVIDUAL

FUNCTION

TASKS ENVIRONMENT
• Bones

• Muscles

• Tendons

• Ligaments

• Joints
• Body has over 600 muscles
• Muscles are the only tissues which contract and
relax; --they cause all body movements.
• Injuries to the brain, spinal cord, or other nerves
may affect muscle control.
• Inability to control muscle is -Paralysis
• The skeleton is composed of over 200 bones
• Two or more bones come together to form JOINTS
• Bones have a rich supply of BLOOD and NERVES
i.e. (they hurt and bleed when damaged).
• Acute Compartment Syndrome • Clubfoot
• Ankylosing Spondylitis • Coccydynia
• Baker's Cyst • Coccyx Fracture
• Boutonniere Deformity Of Finger • Colles' Fracture
• Bunion • Contractures
• Bursitis • Costochondritis
• Calcific Tendonitis Of The Shoulder • Degenerative Disk Disease
• Carpal Tunnel Syndrome • Dermatomyositis
• Cauda Equina Syndrome • Dupuytren's Contracture
• Chondromalacia Patella • Elbow Fracture
• Chronic Fatigue Syndrome • Femoral Fracture
• Chronic Neck Pain • Fibromyalgia
• Clavicle Fracture • Finger Dislocation
• Finger Extensor Tendon Injury •
• Finger Flexor Tendon Injury •
• Finger Fracture
• Flat Foot
• Floating Shoulder
• Foot Fracture
• Foot Pain
• Forearm Fracture
• Fracture
• Frozen Shoulder
• Ganglion Cyst
• Gout
• Hammer Toe
Herniated Disc
Hip Dislocation
• Hip Fracture
• Hip Labral Tears
• Juvenile Rheumatoid Arthritis
• Kyphosis
• Legg-Calve-Perthes Disease
• Lordosis
• Low Back Pain
• Morton's Neuroma
• Neck Fracture
• Osgood-Schlatter Disease
• Osteoarthritis
• Pelvic Fracture • Shoulder Tendinopathy
• Pes Cavus • Skull and Facial Fracture
• Plantar Fasciitis • Spinal Stenosis
• Polymyalgia Rheumatica • Spondylolisthesis
• Polymyositis • Spondylolysis
• Psoriasis • Temporomandibular Disorder
• Reiter's Syndrome • Tendinopathy
• Rhabdomyolysis • Toe Fracture
• Rheumatoid Arthritis • Torticollis
• Rotator Cuff Injury • Trauma
• Sacroiliac Joint Pain • Trigger Finger
• Sciatica • Vertebral Fracture
• Scoliosis • Whiplash
• Sesamoid Fracture • Wrist Fracture
• FRACTURE - a break or disruption in bone
– open - the skin is pierced by broken bone fragments
– closed - the broken bones do not penetrate the skin
• SUBLUXATION / DISLOCATION - displacement or
separation of a bone from its normal position at the joint.
• SPRAIN - partial or complete tearing of LIGAMENTS and
tissues at the joint.
• STRAIN - An extreme stretching or tearing of MUSCLE
&/OR TENDON.
• RUPTURE of MUSCLE, LIGAMENT, &/OR TENDON
• Pain
• Swelling
• Deformity
• Discoloration of the skin (bruising)
• Inability to use the affected part
normally
• Loss of sensation in the affected part.
• Significant deformity
• Moderate or severe swelling and
discoloration
• Inability to move or use the affected part.
• Bone fragments protruding from the wound
• Bones grating or a pop or snap heard by the
victim
• Loss of circulation in an extremity.
• A cause of injury that suggests the injury may
be severe.
• The goal of Physical Medicine
and Rehabilitation in Fracture :
1) early mobilization to
prevent complications
of prolonged immobilization;
2) to prevent disabilities;
3) to return patient to his/her
pre-morbid fungsional
level/capacity before the
fracture.
Consider Fracture Healing Process
This phase extends throughout the period of
immobilization following the fracture :
1. Control of inflammation and its symptoms like :
Pain
Edema and
Lack of circulation
2. Checking the immobilization (cast/splint)
3. Proper positioning of the fractured limb
4. Improve circulation to the fracture site by repeated
strong movements to the parts of the limb which
are free of immobilization
• Main goal : prevent complications of prolonged
immobilization
– Pain management
– Positioning ; Elevation of the extremity (distal higher
than proximal)
– Isometric exercises of the Quadriceps, Hamstrings, and
Gluteal muscles
– Active exercises to the uninvolved extremities and the
“crutch walking muscles”
– General body mobilization should be started soon after
the acute inflammatory phase recedes..
 Most important phase of vigorous effort to
regain the pre-fracture state.
 It involves :
1. The fractured site should be inspected for
any signs of non-union or infection
2. The joint which were earlier immobilized
should now be mobilized by concentrated
effort and specialized techniques
3. Re-education of the correct pattern of
movements. Increase in the strength and
endurance of the related muscle groups
by using specialized therapeutic
techniques
• Heat Therapy, for pain, muscle spasm (sedation),
increase circulation and decrease soft tissue
contraction;
• Upper and Lower Extremities Exercises: passive, active
assistive and active, followed by resistive exercise ;
• Bed Mobilization Exercises;
• Mobilization Exercises using mobility aids (crutches or
walker ) at week 6-12, and further assistance during
change from crutches to cane (week 12-24);
• Assistance during change from non-weight bearing to
partial weight bearing mobilization (week 6-12);
• Functional Training according to evaluation
Rehabilitation Protocol for Femoral Shaft Fracture
treated with the plate and screw Fixations

Phase 1 Begin isometrics and upper extremity

0 – 6 weeks conditioning
Begin quadriceps sets, gluteal sets,
hamstring sets, ankle pumps
Perform straight leg raising in all
planes, supine and standing
Perform knee active ROM exercise
Use stationary bicycle for ROM and
strengthening
Instruct and observe crutch walking
technique
Rehabilitation Protocol for Femoral Shaft Fracture
treated with the plate and screw Fixations

Phase 2 Ambulate with 20 kg weight bearing

6 weeks – 3 until evidence of bridging callus on two
months radiographics views
Begin open and closed chain exercise
Perform ROM exercise for knee in
cast brace
Phase 3 Ambulate with crutches until achieving
3 – 6 months full weight bearing in single leg stance
Progress open and closed chain
exercise
Stress active ROM and active assised
ROM of the knee after cast removal.
• Pressure sore (decubitus);
• Joint stiffness contracture;
• Muscle Atrofi:
• Myositis Ossificans
• Complex regional pain
syndrome (CRPS), or Reflex
Sympathetic Dystrophy,
Sudeck’s acute post-
traumatic bone atrophy,
shoulder-hand syndrome and
causalgia
• Volkmann’s Contracture
distal to the fracture
• (1)delayed union, (2) non
union, (3) malunion.Non-
union
• Osteomyelitis
• Suppurative Arthritis
• sprain, partial or totalrupture
• Vascular Injury
• Nerve injury or compression
 PMR Management
• ACUTE PHASE
- Cold application
(Ice compress, etc)
- Elevation
(if not contraindicated)
- TENS (Transcutaneous
Electrical Nerve Stimulation)
for pain
Contraindications !
 PMR Management
• SUB-ACUTE PHASE
- Heat application Contraindications ! :
(If not contraindicated) - Metal implant
- Vascular & sensory
problem, etc
- Exercises
(if not contraindicated) Rene Caillet,
Knee Pain, 1981

- TENS
(If there is still pain)
 muscle spindle activity
to stretch HEAT THERAPY
vasodilatation
counter-irritant effect

USD
PHONOPHORESIS :
ion transfer process using
Ultrasound diathermy; active agent
is pushed in; decrease
inflammation & pain; promote bone
healing
CRYOTHERAPY TENS
(Transcutaneus Electrical
- compress; immerse; Nerve Stimulation)
- ice massage ;
- vapocoolant spray  opioid endogen
(metenkephaline,Subs.P,
beta-endorphine)
 ISOMETRIC EXERCISE
Quadriceps / Knee joint

 Quadriceps contraction
without joint movement
 knee in full extension
 pad under the knee :
press the knee on the pad
and hold for 5 seconds -
minimal joint movement
 apply weight / resistance
gradually Rene Caillet,
Knee Pain, 1981
 ISOMETRIC EXERCISE
Cervical / Neck
 without neck movement
 resistance on every
direction of movement :
- flexion:resistance on forehead
- extension:resistance at the
back of the head -
- lateral flexion (left & right):resistance at sides
- rotation:resistance at the sides during head
turning to left and right
 ISOTONIC EXERCISE

 Muscle contraction with joint

movement
 gradual weight applied
 light resistance / weight high
repetition  endurance
 weight increase(%)  strength

Rene Caillet,
Knee Pain, 1981

Quadriceps Isotonic Exercise Hamstrings Isotonic Exercise

 ISOTONIC
EXERCISE
Hamstring

 hamstrings muscle contraction with knee joint motion

 gradual weight applied at the ankle
 light resistance/weight, increased gradually starting from
0.5 - 1 kg to 1.5 – 2 kg
 repetition of 10-20 times unless muscle fatique / soreness
occurs of the hamstrings
 ISOKINETIC EXERCISE
Knee joint

 motion controlled through

complete range with constant
angular velocity (degrees per
second); muscle shortening
or lengthening; weight / force
varies
i.e Cybex
 RANGE OF MOTION EXERCISE :
Neck
Neck moved to several directions slowly :

- flexion : look downward

- extension : look upward
- lateral flexion (right & left):
move head to right and left
-Rotation : turn head to right
and left
 JOINT STIFFNESS / LIMITED
JOINT RANGE OF MOTION

Lorig K.Arthritis
Helpbook, 1984

ROM exercise using

Active ROM exercise
Continuous Passive
self applied
Movement machine
 Exercises
for Crutch-
walking
muscles
www.wikihow.com
 Types of Crutches & Energy expenditure

The energy cost (oxygen consumption) VO2.wt-1 (ml.min-1.kg-1) of ambulating with underarm
crutches compared to normal walking was approximately twice as great. Fisher SV, Patterson RP.
Arch Phys Med Rehabil. 1981 Jun;62(6):250-6.
 www.slideshare.net

Axillary Crutches
- When non-weight
bearing gait is required
Hickman J. Mountain Orthopedics
LLC. 2014 Possible Gait pattern:
1. Two point gait :
a. swing to
b. swing through
2. Three point gait
3. Four point gait
GAIT PATTERNS
Body Mechanics and Positioning
(Client Care) (Nursing) Part 4.
http://executive-education.nus.edu/
 Aquatic
Exercise)

• (-) Gravitation
• (+) Buoyancy
• (-) Pressure on joints
• non-weight bearing
 ORTHOSES &
ASSISTIVE DEVICE

OSTEOPOROSIS /
- reduce pressure on the spine; FRACTURE

- support the spine / compensate

- prevent kyphosis
  Age
 Health
 Fitness  Disease
 Environment  llness
 Task / Job  Trauma
 Psycho-Socio- Human Functioning
Cultural -Spiritual
Baby until Elderly
Activity of Daily Living
• Musculoskeletal (ADL) • Functional impairment
• Neuromuscular Productivity  Activity limitation
• Cardiorespiration Leisure Activities//  limitation of Participatory
Hobby and role
• Sensory-perception
• Cognition Physical Medicine
• Skill & Rehabilitation
Social
• Communication Kompetensi medis
Patologi Penyakit
Proses Pemulihan Therapiy:
Plastisitas Otak • Medical
Biomolekuler • Physical
Biomekanika
• Remedial
Kinesiologi
Proses pembelajaran • Psycho-
Fisiologi aktivitas behavior
Energy expenditure  Orthotic-
gerakan prosthetic
 Alat bantu
Holistic Approach of Human Functioning in Physical Recovery
Medicine and Rehabilitation Management Human Functioning
(Tulaar ABM, 2010).