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MEDICAL REHABILITATION, ITS FORMS

June 21, 2024

MEDICAL REHABILITATION, ITS FORMS. INDIVIDUAL PLAN OF MEDICAL REHABILITATION.

Board of WHO (1980) gave a definition of medical rehabilitation: rehabilitation – is an active process, whose goal is to achieve full recovery of damaged due to disease or injury, functions, or if it is unreal – the optimal implementation of the physical, mental and social potential of the disabled, the most adequate integration of its in society.

Thus, medical rehabilitation includes measures to prevent disability during the period of the disease and help the individual to achieve maximum physical, mental, social, vocational and economic usefulness, which he will be able within the existing of disease. Among other medical disciplines rehabilitation has a special place, as regards not only the state of organs and body systems, but also features a man in his daily life after discharge from the facility.
According to international classification of WHO, adopted in Geneva in 1980, there are the following levels of medical and biological and psycho-social consequences of illness and injury, which should accounted during rehabilitation: damage (impaiment Eng.) – Any anomaly or anatomical loss, fisiological , psychological structures or functions; of disability (disability Eng.) – arising from damage to the loss or limitation of opportunities to carry out daily activities in a manner or within the limits considered normal for human societies, social restrictions (handicap Eng.) – arising from damage and disturbance of life and loss obstacle to the fulfillment of social roles considered normal for that individual.
In recent years, the rehabilitation is connected with term of “quality of life, connected with health” (healthrelated quality of life, Eng.). In this case, it is the quality of life is considered as an integral characteristic, which should be guided in evaluating the effectiveness of rehabilitation of patients and people with disabilities.
Proper understanding of the impact of the disease is crucial for understanding the essence of medical rehabilitation and the focus of rehabilitation actions.

Prosthetic-rehabilitation-institutions.
Type and kind of rehabilitation institutions should be determined by its accreditation and licensing, which is part of the state program .

This institution must have equipment in accordance with the standard of organizational medical and technological requirements, meet the sanitary standards, have a post-credit performance models of end results, be completed by qualified personnel.
Qualification characteristics of staff should confirm valid certificate- document that gives the right to perform certain services, operations and procedures.
Experts who are involved in the medical and social rehabilitation: doctors of therapeutic profile, traumatologist, neurologists, neurosurgeons and other specialists (depending on the character of diseases of individuals who are the subject of rehabilitation), nurses, physiotherapists, specialists in physical therapy and sports, psychotherapeutists, labor therapy specialists and experts from labor, teachers, psyhologists, sociologists, lawyers, representatives of social security organizations, representatives of enterprises, trade unions.

Rehabilitation and treatment (prevention and treatment) institutions.

Stages of rehabilitation.

In the state are treatment facilities which have the next phases of rehabilitation:
-Stationary
-Half-polyclinic(day-care)
-Polyclinic.
Such institutions should have adequate infrastructure.
With a view to provide medical help distinguish the following rehabilitation and medical

institutions:
– Special (cardiac, neurological and others)
– Poly-profile(common-type)
According to the administrative-territorial levels emit: regional, inter – regional, local, sectoral rehabilitation and medical institutions.

At the regional level rehabilitation treatment gives rehabilitation hospital. The hospital of rehabilitation profile has increased (compared with general hospitals) number of nurses from massage, labor therapy, practitioners of the healing of physical education, etc.

General contraindications for referral of patients to rehabilitation hospital treatment:
– All patients in acute form of a disease;
– All the chronic diseases that require special treatment;
– Infectious diseases of children transferred to the end of isolation;
– Bacillus-carrying;
– All infectious diseases of eyes, skin, malignant anemia, neoplasmas
cachexia, amyloidosis of internal organs, active tuberculosis of
lungs and other organs;
– Patients with diseases of the cardio-vascular system in insufficiency-form
Blood circulation problems
– Epileptic patients with psychoneurosis, psychopathy, mental disorders
Patients that requires individual care and treatment;
– Concomitant diseases, contraindications for sanatorium
treatment.
In the regional centers and cities of regional subordination the treatment and prevention institutions and hospitals have specialized offices (centers) of rehabilitation, working closely with specialized units of different profile. Depending on where the institutions are organized (this can be fixed, as sanatorium or rehabilitation centers), they must have employed qualified doctors and nurses who have been trained and knows the basics of rehabilitation features and rehabilitation of patients with different disease profiles .

Structure Centers (branches) of rehabilitation:
– Diagnostic department: clinical diagnostic laboratory, office of functional testing, X-ray room, etc.;
– Physiotherapy department: phototherapy, electrotherapy, hydrotherapy, mud therapy, inhalation therapy, massage;
– Physical therapy department: specialized rooms, classrooms of
physiotherapy, pool, sports fields, outdoor yards;
– Department of social and occupational rehabilitation: Room of home
rehabilitation, employment workshops;
– Department of social and psychological rehabilitation: cabinet of psycho ¬
therapeutist, sociologist, lawyer, a speech therapist.

Stationary-replacement medical care.

In conditions of implementation method of economic management in health care created new forms of organization of stationary-replacement medical care: day stationary in polyclinics, hospital stationaries (departments, rooms) of day staing, home hospitals.
Work of day care stationary in polyclinics and hospitals is accented at treatment and rehabilitation of patients, improving quality of care, ensure its availability, increase its efficiency, reduction terms of treatment, carrying out some diagnostic tests and more. This facilitates decreasing quantity of hospital beds and increasing the effectiveness of rehabilitation measures.

Home hospital( stationary) is organized for patients with acute and chronic diseases , who for health reasons do not require   hospitalization or   if it   is not possible. This form of medical care requires the patient to ensure a qualified doctors and nurse care,   necessary investigations, appropriate methods of   treatment, social support, and correction of nutrition.
In the huge industrial enterprises restorative treatment conducts in health units, which may be on stationary or daily base at   departments of industrial rehabilitation which are the parts of   large enterprises.
Purpose:
– Preserving the profession of   sick or disabled person;
– Acquiring a new profession in the case of loss of earlier.
Means used for Treatment and Training impact:
– Special industrial machinery and instruments;
– Special attachments for machine tools and instruments;
– Special equipment to create the jobs place.
Rehabilitation commissions of   treatment-prophylactic   institutions.
In health care (rehabilitation-treatment ) institutions should be created rehabilitation commission (council).

Structure of Rehabilitation Commission

– Permanent members: the head office, the doctor-patient account specialist, physiotherapeuist, doctor of physical therapy, doctor of functional testing, instructor of occupational therapy, a lawyer;
– Non-permanent members: if needed, other specialists are invited
(related specialties, psychotherapeutist, etc.).

Responsibilities of rehabilitation commission:
– Selection of patients who need rehabilitation, creating plan of rehabilitation
according to the functional diagnosis of individual
features of an organism of the patient, disease and ensure
their implementation;
– Development technologies of realization of “Individual Rehabilitation Program”
(IRP) and transmission in a certain sequence of rehabilitation program
its structural and functional units for execution;
– Clarification of the functional diagnosis during rehabilitation
and prediction of prognosed rehabilitation;
– Correction, if necessary, methods of IRP;
– Manage the execution of IRP through regulation and interaction
succession in the rehabilitation of structural and functional
units;
– Accounting treatment effectiveness: a comparison of the results of
treatment with programmed;
– Analysis of rehabilitation activity, quality and efficiency of
individual programs and identify measures for their optimization;
– Address issues of efficiency (efficient without limitation, ready for labour activity
with restrictions in volume, time or nature of productive activities,
is temporarily unable to work, requires referral to medical and social
expert commission (MSEC) to continue
the sick-list.
– Rehabilitation of disabled – information of MSEK about conducted reconstructive treatment, feedback.

– The long-term disability – clearance for MSEC;
– Preparation of documents to the Fund of Social Protection of Disabled devoted
for buing medicines needed for a course of conservative
or surgical treatment;
– Providing treatment and rehabilitation departments of prophylactic
and medical institutions with necessary equipment, remedies ¬
qualified personal, etc.
– Development of main directions of development and improvement of
rehabilitation service in their health care settings.

These include:
– Resorts (trade unions, departmental, regional submission);
– Preventive health center.
Sanatorium treatment based on using natural healing natural factors.

They provide high efficiency of rehabilitation therapy, rehabilitation, prevention, provide an opportunity to reduce the amount of medication in the treatment of patients.
Resort – A place with the presence of natural therapeutic factors (mineral springs, therapeutic mud, favorable climate) and spa, hydro-engineering and medical institutions.
Depending on the benefits of a natural physical healing factor, allocate resorts: climatic, balneological, mud, mixed. Used climate of deserts, steppe, steppe-wood, mountain, sea, climate of the salt mines.

To use a medical factors in the resort, are created special units – spas, resorts, spa polyclinics.
Health – specialized residential institutions created in the system of sanatorium-resort treatment uses a complex of medical factors – climate therapy, balneotherapy, mud therapy. Motels provide comfortable accommodation for patients: medical buildings, beaches, mineral waters, inhalyatories, saunas, cabins of physiotherapy, water, mud-treatment, sports facilities, classrooms for physical treatment, massage, reflexology, psychotherapy. All of this is equipped with facilities for living and recreation, nutrition, music-, aroma, vocals & dance-therapy, routes for terrenkur, tourism, hiking, beautiful nature, well- trained highly-qualified, attentive service personnel, all this creates conditions for a minimum using of remedies, has positive results of treatment and rehabilitation of patients.

Profiles of sanatoriums for treatment:
– Diseases of the circulatory system;
– Diseases of the digestive system;
– A respiratory diseases (non-tuberculous origin);
– Diseases of female genitals;
– Diseases of the musculo-skeletal system;
– With skin diseases;
– With kidney disease and urinary tract;
– With metabolic disorders.
There are also health centers for children, adolescents, for treaing tuberculosis of internal organs, spastic paralysis and more.

According to the rules, the medical screening of patients for the sanatorium treatment holds a doctor who leads a patient or head doctor of
department or the chief physician of hospital, clinic, etc.

Established a mandatory list of studies and consultations, the necessity of which is needed for a spa treatment: clinical analysis of blood, urine, chest X-ray examination, a gynaecologist investigation – for women. To clarify the indications conducted additional observations : ECG – at heart diseases or for those, aged over thirty years, the psychiatrist conclusion if is the presence in a history of neuro-psychiatric disorders and more. After the survey determine the indications for sanatorium treatment and types of resorts, which are best to the patient.

Indications for referral to the spa treatment. Referral to resorts in view of their specific subject suffering from various chronic diseases in the stage of stable remission without the expressed dysfunctions relevant authorities (eg, without significant coronary, respiratory, pulmonary insufficiencis, etc.) without spread inflammatory process (L.M . Klyachkin, M. Vinogradov, 1995).
Contraindications to the spa treatment:
– Acute illness;
– Diseases of internal organs in the presence of pronounced organ and system failure;
– Infectious diseases, including sexually transmitted;
– Mental disorders, alcoholism, drug addiction;
– The second half of pregnancy, all period of pathological pregnancy, status of abortion (the first menstruation), lactation;
– Prone to bleeding;
– Cancer;
– Acute progressive forms of pulmonary tuberculosis and tuberculosis in the chronic period of dissemination and a tendency to bleeding;
– Lack of patient ability to self-service.

In some cases after treatment of malignant new formations, in satisfactory general condition, the patient can be directed to local health centers for a general treatment.
After a spa treatment for the patient is given san-kurortnaya book, which indicate that the treatment was conducted in the sanatorium, and with what results patient graduated from.

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It is optimal to eliminate or full compensate damaged function through rehabilitation. However, this is not always possible, and in these cases it is desirable to organize the patient vital functions so as to exclude the effect on him existing anatomical and physiological defects. If this former activity is impossible or negatively affect the health, it is necessary to switch the patient to such kinds of social activity that most degrees, will help to meet all his needs.

, the full legislative support of the disabled in education, health, social services and employment.

The ideology of medical rehabilitation in recent years has undergone a significant evolution. If the 40-ies of the policy framework for the chronically ill and disabled have been their protection and care for them, with the 50-ies started to develop the concept of integration of patients and people with disabilities in regular society, with special emphasis step of their learning, their technical subsidiary funds. In the 70’s – 80 years, born the idea of maximum adaptation of the environment to the needs of patients and the disabled

In this regard, it becomes apparent that the system of medical rehabilitation is very much dependent on the economic development of society.
Despite significant differences in systems of medical rehabilitation in different countries are increasingly developing international cooperation in this sphere, all frequently raised the issue of the need for international planning and development of a coordinated program of rehabilitation of physically handicapped persons. Thus, from 1983 to 1992 was declared by UN the International Decade of Disabled. In 1993 the UN General Assembly adopted the Standard Rules on the equalization of persons with disabilities “that should be considered in the United States point of reference in the field of disability rights. Apparently, the inevitable further transformation of ideas and scientific and practical problems of medical rehabilitation related to gradually take place in a society of social economic change.
General indications for medical rehabilitation in the report of the WHO Expert Committee on the Prevention of disability Rehabilitation (1983). These relative:
“Significant reduction in functional abilities;
“Reduced ability to learn;
“Special susceptibility to environmental effects;
“Violations of social relations;
“Violations of labor relations.
General contraindications to the use of rehabilitation measures include the accompanying acute inflammatory and infectious diseases, decompensated somatic and cancer, expressed frustration intellectually-mnestic sphere and the mental illnesses that impede communication and the possibility of involvement of the patient in the rehabilitation process.

In our country, based on the All-Union Institute of Social Hygiene and Public Health Organization in honour of N.A. Semashko (1980), the total number of hospitalizations in the offices of therapeutic profile in the rehabilitative treatment need 8.37 per 10 000 population, in the surgical departments – 20.91 per 10 000, neurological – 21.65 per 10 000 population and in general follow-up care to be 20 to 30% depending on the basic profile of the department, which requires 6.16 beds per 10,000 population. In-patient rehabilitation, According to N.A. Shestakova et al. (1980), require 14 – 15% of those who applied in the clinic, with about 80% of the bottom are people with the consequences of damage to the musculoskeletal system.

Basic principles of medical rehabilitation of the most complete exposition of one of its founders K. Renker (1980):
1. Rehabilitation should be exercising, starting with the occurrence of illness or injury and until the complete return of man in society (the continuity and solidity).
2. The problem of rehabilitation must be addressed comprehensively, taking into account all its aspects (complexity).
3. Rehabilitation should be available to all who need it (availability).
4. Rehabilitation should adapt to the constantly changing structure of diseases, as well as to take into account technological advances and changing social structures (flexibility)

.
Given the continuity of the isolated stationary, ambulatory, and in some countries (Poland, Russia) – sometimes even a sanatorium stage of medical rehabilitation.
As one of the leading principles of rehabilitation is complex action, rehabilitation may be called only those institutions that are providing complex medical-social and vocational educational activities. Identify the following aspects of these activities (Smith, M.A. 1982):
1. Medical aspect – involves questions of medical, therapeutic and diagnostic and therapeutic and preventive plan.
2. The physical aspect – covers all issues related to the application of physical factors (physical therapy, exercise therapy, mechano-and occupational therapy), with an increase in physical performance.
3. The psychological aspect – the acceleration of the process of psychological adaptation to change as a result of the disease situation in life, prevention and treatment of developing pathological mental changes.
4. Professional – a working population – prevention of possible reduction or disability; for disabled people – to the extent possible, rehabilitation, these include questions of definition of disability, employment, occupational health, physiology and psychology, labor retraining courses.
5. Social aspect – covers the influence of social factors on the development and course of illness, social security and employment pension legislation, the relationship of patient and family, society and production.
6. Economic aspect – the study of the economic costs and the expected economic effect according to different types of restorative treatment, forms and methods of rehabilitation for the planning of health and social-economic activities.

To carry out all directions of important logistical and staffing supplying of rehabilitation facilities. Structure and equipment of individual offices and departments is determined by the capacity of institutions and the composition of patients undergoing rehabilitation.

The most common structural units are: the department of physical pherapy, which includes the offices of physiotherapy, gymnastics halls and mechanotherapy, cabinets of manual therapy, therapeutic massage, acupuncture, branch or office therapy, the implementation of vocational rehabilitation – a complex of different workshops: Office (offices) of functional therapy; Office (cabinet) of psychodiagnostic and psychotherapy: if is possibile (in the major centers) – a complex of laboratories for clinical and biochemical studies, X-ray department.
The main specialists outside the team are- specialists in rehabilitation and physical therapy, clinical psychologist, therapist, social worker, if necessary – speech therapist. A brigade is headed by physician in rehabilitation.

Rehabilitation of sick and disabled people is currently one of the priority areas of medicine in our country and abroad. The primary challenges faced by rehabilitation specialists are: improvement of medical rehabilitation, development of criteria for effectiveness of medical rehabilitation for different groups of patients, improving data collection relating to sick and disabled, with the subsequent creation of databases on the local, national and international levels. In our country, in addition, it is important to strengthen the legislative framework related to the field of medical rehabilitation, as well as improved training system of rehabilitators at graduate and postgraduate levels.

Treatment by physical exercises (LFC) is one of the most important and effective methods of medical rehabilitation, which is widely used in diseases of the nervous system of various etiology with diverse clinical syndromes in neurological and neurosurgical practice (Kurella M. in 1962; Kaptelin A.F., 1969; Moshkov V.N., 1972, 1982; Naydin V.L., 1972, Semenova K.A. et all 1972; Shterengerts A.E., 1972, Markov D.A., 1973; Tykochinskaya E.J. and others.1973, White N.A., 1974; etc.) is determined, on the one hand the breadth of the impact of therapeutic exercise in the various functional systems of the body – cardio-vascular, respiratory, musculo-skeletal, nervous, endocrine, and on the other hand, training and and restorative effect of these exercises at defficiency or failure of various body functions.

Modern theoretical and practical aspects of physical therapy allow us to formulate the most general principles of this method of medical rehabilitation in different fields of medicine.

1. Targeting techniques of LFC, determined the specific functional deficits in motor, sensitive, vegetative-trophic area, in the cardio-vascular, respiratory activity.
2. Differentiation techniques of LFC, depending on the type of functional deficits, as well as its degree.
3. Adequacy of load exercise therapy individually dynamic capabilities of the patient, as assessed by the general state of the cardio-vascular and respiratory systems and backup capabilities of the functional deficit of the system at this particular stage of the disease (in this occupation LFC) in order to achieve the training effect for optimum load.
4. Timeliness of application techniques of gymnastics at the early stages of the disease … in order to maximize the use of safe functions to restore the damaged, as well as the most effective and rapid development of devices for which the complete restoration of functional deficits.
5. Sequential activation of therapeutic effects of physical fitness through the expansion of methodological arsenal and the volume of exercise therapy, increasing training loads and coaching effects on certain functions and for the whole body of the patient.

6. Functionally acquited combination of various means of LFC – physiotherapy, massage, postural exercise – depending on the period of the disease, functional deficits, Degree of its severity, prognosis of recovery of functions and associated complications, as well as the phase of rehabilitation of the patient.
7. Complexity of procedures in medical rehabilitation exercise therapy with other methods – drug therapy, physio-balneo-therapy, acupuncture, hyperbaric oxygenation, apparat-treatment, orthopedic interventions, etc.
Using these principles of exercise therapy is mandatory as in the construction of a medical complex on the specific session and the course, and in formulating rehabilitation program for a separate patient or group of patients with the same type of a disease..

Massage is one of the oldest methods of physical influence on the patient’s body. Many manuals and monographs, which describe techniques, tactics and characteristics of various types of massage are devoted to this method (Fedorov A., 1971, White N.A., 1974; Kunichev L.A., 1979; Glaser O. et al., 1962; Danube and others, 1988 ; Vasichkin V.I., 1990 – 1995).

Important tasks that are solved with the help of massage are:
1. Tonic effect – by increasing blood and lymph circulation, as well as non-specific stimulation of exteroceptive and proprioceptive sensitivity (classical, segmental, acupressure);
2. Regionally-tonic effect on muscles with paresis – is achieved by using different ways of classic massage in a large volume, with sufficient force, as well as a special type of massage reeduction (Pokorny F. Malkova N. 1955) with eksteroretseptivnym relieved by rubbing and kneading the longitudinal abdominal muscles in various it states (relaxation or varying degrees of stress) and subsequent shaking, point vibrations and short-term to pain sensation of pressing muscles;
3. Relaxing effect on spastic, locally-constricted muscles, carried out using common relaxation techniques of classical massage (rubbing, shaking, small vibrations), performed at a slow pace with the mandatory pauses between meals, as well as using a point and segmental massage of certain points and zones;

4. Analgesic effect is achieved by reflex influence of a point (acupressure), segmental, oriental and classical (in a relaxed form) massage.
All massage techniques should combined with various methods of physiotherapy. Only in special cases when the general condition of the patient does not allow for therapeutic exercises classes, a massage is becoming independent, strategic method.

Massage – a combination of techniques of mechanical action due to friction, pressure, vibration, carried out directly on the surface of the human body by hands, or special apparattus through the air, water, or another environment. Massage can be general and local. Depending on the tasks distinguish the following types of massage: the hygienic, medical, sports, self-massage.

Hygienic massage – active means of preventing disease, maintaining health.
Therapeutic massage – is an effective treatment of injuries and illnesses.There are following its variants:
“Classical – applies without regard to the reflex action and is held close to the damaged area of the body or directly on it.
“Reflexological – is conducted to the reflex effects on the functional state of internal organs and systems, tissues, and the use of special methods of acting on certain areas – dermatomes.
“Connective tissue – in this type of massage affect mainly on the connective tissue, subcutaneous tissue, the basic techniques of connective tissue massage is carried out taking into account the direction of the lines of Beningofa.

“Periosteal – in this form of massage by exposure to a certain point cause reflex changes in the periosteum.
” Pointed – a kind of massage therapy, when locally affect either relaxing or stimulating way to biologically active points (zones) according to indications for the disease or disorder of the function, or pain, localized in certain parts of the body.
“Hardware massage – carried out by means of vibration, pneumo-vibration, vacuum, ultra-sound, ionizing devices, etc.
“Medical self-massage – is carried by the patient, may be recommended by the attending physician, nurse, specialist of massage, exercise therapy. Choose most effective techniques to influence on the area of the body.
Sports massage – developed and systematized by prof. A. M. Sarkizovym- Serazini.

Accordingly, there are the following objectives of its varieties: hygiene, training, recovery, tentative. In medical rehabilitation is not used separately, only in conjunction with the medical gymnastics.

Physiotherapy.

The comprehensive rehabilitation of patients used different types of physiotherapy. All they solve some practical problems: reduction of inflammatory activity, activation of reparative processes, reduce pain, improve blood and lymph circulation, increased trophic of the tissues, prevention and elimination of contractures, the restoration of important immune-adaptive system.

Principles of physical therapy is the timely use of physical factors, the correct combination, the continuity of treatment. There are several groups of artificially produced and natural healing physical factors.
We give a characteristics of the most common of them, used in lesions of the musculo-skeletal system. This low currents (galvanization, medicament electrophoresis, pulsed current and alternating currents) of high voltage.
Galvanisation and medicinal electrophoresis are based on the using of continuous direct current produced with wall units AGN-1, AGN-2 portable PRT-3, AGP-33 and the apparatus “Potok-1”. Galvanic current, influencing the functional state of the major body systems, is a stimulant of its biological and physical functions. Under his influence in the tissues located in the interelectrode space, and even throughout the body increases blood circulation and lymph flow, increased resorption ability of tissues, stimulates the exchange-trophic processes, increased secretory function of gland, shown an analgesic effect.
When galvanizing and medicinal electrophoresis by the galvanic current is selected in the range from 0,01 to 0,2 mA / sq.sm., and the duration of the procedure is within 10-20 minutes. The maximum current density in the treatment of children aged 1 year – 0.03 mA / sq. sm., in teens, it reaches 0.08 mA / sq. sm., the duration of the procedure 10-15 min. On the course -8-12 procedures. Electrophoresis, both the first and second method can be arranged longitudinally (along the muscle, nerve trunk) and transversely (the affected joint, bone-forming callus, etc.).

Features of electrophoresis are not only at a slow and prolonged entry of drug from the skin depot in tissues and organs, but also that it enters it into at electrically active state. The advantage of this method is the possibility of introducing a small amount of drug that gives the weakening side effect of many medicines, as well as the relevant testimony to focus the drug in a limited area of the body and at a predetermined depth of tissue.
Impulse currents of low frequency is the current coming in the form of individual pulses of different shape, duration and frequency. They are divided into pulses of DC and AC lines. The duration of each pulse is measured in milliseconds, frequency in hertz, the current in milliamps, voltage – volts, repeatedly – in fractions of seconds. Used in pulsed currents operating frequency range from 1 to 150 Hz, voltage – tens to hundreds of volts, the amperage from one to several tens of milliamperes, the duration – from 0,01 to 100 msec. As a source of pulsed current used vehicles of the type “Amplipuls”, “Sneem-1”, “Model-17”, “Tonus-1”, “Tone-2”, “Diadynamic (Poland),” Bipulsator (Bulgaria). In recent years, electro-produced vehicles “Stimulus-1 ‘,’ Stimulus-2 ‘. In the application of pulse currents usually have the same electrodes as in electroplating, the “active” electrode is an area of 1 to 16 square santimetres. see, and the second (indiferentny) – up to 100-200 square santimetres.

Selected to stimulate and shape the currents and their parameters, which are at the lowest current strength and the least unpleasant feeling would give the most pronounced effect. Muscle stimulation is carried out by the impact of pulse current on the motor nerve, and if it is not available for immediate impact, current is applied to the muscle. In both cases, the active electrode to be connected normally to the cathode, is placed on the motor point (which is close to the site adjoins the nerve). The second electrode, attached to the anode, have in the gate area of the nerve roots in paraspinal area. Duration of treatment from 1-2 to 10-15 minutes.
As a result, there is a passive electro-muscle contraction, which leads to a gradual recovery of contractile function, improve blood supply and trophic of a muscle. Distinguish between passive and passive-active electrostimulation. Passive conduct in case of impossibility of muscle contraction, passive and active – with a weak muscle contraction with a view to gain. Electrical stimulation is shown in diseases and effects of injuries of the locomotor apparatus, accompanied by atrophy and hypotrophy of muscles, peripheral nerve injuries, cerebral palsy. Contraindication for electrical stimulation include acute inflammation, bleeding and susceptibility to them, unjoint bone fractures, cancer, epileptic or convulsive readiness, intolerance of the current.
Under electrodiagnostics understand method of determining the functional state of the organ or system in response to dosage effects of electric shock. It is used not only for diagnosis, including differential, but also for the production forecast, determination of optimal parameters of pulsed current for electrical stimulation.
Electrodiagnostics uses devices AFM-3, OUEN-1, CED-5, etc. In classical electrodiagnostics determine the response of muscles when exposed to it or its innervating nerve and tetanizing intermittent galvanic currents. To this end, one electrode of diameter 10 mm. mounted on the motor points of the corresponding nerve or muscle, the second area – 150 square santi- meters.

See the midline of the body, often in the spine, and passing a current estimate response and required for its detection threshold amperage.
If it affects the motor nerve, the absence of motor response to tetanizing current (pulse duration of 1-2ms, 100 Hz), slow and lingering decline in the opening and closing the galvanic current, raising the threshold of galvanic excitability at the anode.
Quantitative changes electroexitability – is raising or lowering the threshold current.
Increasing electroexitability fashionable watch with spazmofilia and tetany, a decrease – if myopathy, muscle atrophy, poliomyelitis. Myotonic reaction may be a significant increase electroexitability both types of current, but the contraction of muscles in this sluggish and slow.
When you do not receive tetanic contraction of the muscles under the influence of tetanizing current , check the excitability of the action of the exponential current. Starting with the study of short pulses, their duration increased to as long as do not receive tetanic contraction, the duration of which is recorded in the protocol and apply it in the future when practice an electrical stimulation.
For high-voltage currents is darsonvalization in which, as sources of high-frequency pulse current, used vehicles “Iskra-1”, “Iskra-2”. Constant electric field of high voltage (franklinization) is achieved by using devices AF-2, AF-3. With a total franklinization apply the so-called “static shower”: the alternating magnetic field of low frequency (sound) is produced by use of the device Polyus-1 “; the magnetic field of high frequency (short-wave therapy), where the generators used vehicles DHQ-2 or SCR- 4, the electric field of ultra-high frequency (UHF), for which the approach used for UHF 30, UHF 66, “Screen-1”, “Screen-2”; electromagnetic field of ultrahigh frequency (UHF) for centimeter and decimeter (MWSS and UHF therapy), where the generators are used vehicles, “Luch-58”, “Luch-2”, “Wave-2.

.
Private methods of application of these types of electrotherapy are detailed in handbooks and textbooks on physiotherapy.

Mechano-therapy is a system of functional treatment with different devices and projectiles used in conjunction with other tools and methods of modern medical rehabilitation of patients. The efficiency of mechano-therapy devices can be divided into the following groups:
1. “Diagnostic” devices that help to take into account to accurately assess the effect of locomotor recovery;
2. Supporting, fixing machines – to help highlight some phases of voluntary movements;
3. Training aids to help batch mechanical stress during movement;
4. Combined machines (they consists of the first three groups machines).

Currently, the practice of restorative treatment is widely used following groups of machines in mechano-therapy:
1. Devices based on the principle of the block (functional mechano-therapeutical table. Block plant stationary type, portable bloc installation) designed to strengthen the dosage of different muscle groups of upper and lower extremities);
2. Devices based on the principle of the pendulum, to restore mobility and increase range of motion in various joints of the upper and lower limbs and devices to improve the overall efficiency (simulations). Pendulum devices are reliable. Racks allow for height adjustment retention device. At the reception, consisting of a base rigidly connected by four guiding columns with top cover, we can simultaneously strengthen by apparatus of mechano-therapy. On the columns are two plates that are installed devices. Availability of contra-weight enables the device is easily attached using the locking device at the desired height.

Conclusion.
Thus, rehabilitation and compensation of motor functions ieurosurgical patients (patients with traumatic brain injury), being one of the main terms of the overall process of rehabilitation can be effective only with careful clinical and physiological studies and taking into account the specifics of neurosurgery.
Clinical definition of syndrome of motor disorders, combinations thereof and the prevalence in each case to determine the degree of motor disorder and its dependence on the nature of surgical intervention, assessment of the dynamics of recovery and various times after surgery – everything is falling on the basis of a clinical study of individual restorative, compensatory treatment. Physiological analysis of motor defect, identification of specific components of motor failure and their classification with subsequent consideration in terms of a complex hierarchy of levels and movement possibilities of restoring or replacing damaged motions, ie use of the plasticity of the nervous system, – make up the theoretical basis of directed rehabilitation process. Stressing the role of the target effects on one of the main factors of regulation of motor act – proprioception, which violation, regardless of their depth, lead to some disorders of motor function of the patient, which consists mainly of a mismatch interarticular interaction force, spatial and temporary values. Dynamic and varied use of clinical and physiological data allow to develop a comprehensive, multifaceted plan for rehabilitative treatment, and aim to ensure its effective implementation.
Efficiency of treatment is determined by the complexity of the various mandatory rehabilitation measures, such as physiotherapy, drug therapy, physical therapy, orthotics and prosthetics, as well as occupational therapy, aimed at social adaptation of patients. Only a varied combination of these methods, flexible and very depending on the current problems some restorative phase of treatment – all this allows for optimal rehabilitation of neurosurgical patients, restoring their motor functions.

Long-term medical practice has shown that the most appropriate and effective way of reducing the treatment is physical exercises, and above all, its main part of – gymnastics, with which the treatment is made by movements.

Moreover, the crucial role played by the special instructional techniques of therapeutic exercises, aimed at the reconstruction or replacement of damaged motor functions. Increased strength and decreased muscle tone increased, recovery of the ability to fine-dose stress and mastery of the optimal speed of the establishment of an effective muscle balance and re-creation of targeted combined action at all levels of the motor circuit – the whole range of activities readaptional subservient to, mainly, the special motor training, embodies thesis of treating by movement.

A variety of instructional techniques special gymnastics – from active muscle relaxation exercises to complex coordinatory acquires an even greater role when they are aimed at restoring or creating a vast arsenal of applied skills that allow a patient in a short time to move to full self-service motor, and subsequently – to return to the labor processes, which ultimately determine the completeness of the social rehabilitation of the patient.
Naturally, all the special exercises are closely combined with the bracing exercises, massage, medication status, without which there is the strengthening of vital systems: cardio-vascular, respiratory and others to ensure the wellfare of the somatic status Very important factor in treatment is a comprehensive assessment of neurosurgical specifics – of and localizing the tactics and the nature of surgical intervention, the state of the vascular net in the area of operation, the dynamics of brain and local symptoms, etc. All these data largely determine the starting date, activity and choice of methods for restoration-compensatory treatment, the sequence of their application, the tactics of rehabilitation.
In some cases the same part of the available clinical and physiological data, and constructed on the basis of their treatment program can significantly recover critical patient movement capabilities, even when the spontaneous processes of rehabilitation are missing or have been completed. This last point is particularly important to the quality of rehabilitation therapy, because advances in rehabilitation medicine ranks the most relevant and active medical specialties.
FACILITIES WHICH ARE USED IN RESTORATION TREATMENT. SANATORNO-RESORTS STAGE OF REHABILITATION.

Thus, medical rehabilitation includes measures to prevent disability during the period of the disease and help the individual to achieve maximum physical, mental, social, vocational and economic usefulness, which he will be able within the existing of disease. Among other medical disciplines rehabilitation has a special place, as regards not only the state of organs and body systems, but also features a man in his daily life after discharge from the facility.
According to international classification of WHO, adopted in Geneva in 1980, there are the following levels of medical and biological and psycho-social consequences of illness and injury, which should accounted during rehabilitation: damage (impaiment Eng.) – Any anomaly or anatomical loss, fisiological , psychological structures or functions; of disability (disability Eng.) – arising from damage to the loss or limitation of opportunities to carry out daily activities in a manner or within the limits considered normal for human societies, social restrictions (handicap Eng.) – arising from damage and disturbance of life and loss obstacle to the fulfillment of social roles considered normal for that individual.
In recent years, the rehabilitation is connected with term of “quality of life, connected with health”. In this case, it is the quality of life is considered as an integral characteristic, which should be guided in evaluating the effectiveness of rehabilitation of patients and people with disabilities.
Proper understanding of the impact of the disease is crucial for understanding the essence of medical rehabilitation and the focus of rehabilitation actions.

In total, the program “Health Rights for 2002-2011years” attracted more than 160 agencies, organizations and institutions.
The main executors of rehabilitation programs in the first place, are:
Rehabilitation – treatment organizations
Prosthetic-rehabilitation-institutions.
Type and kind of rehabilitation institutions should be determined by its accreditation and licensing, which is part of the state program .

Rehabilitation and treatment (prevention and treatment) institutions.

Stages of rehabilitation.

institutions:
– Special (cardiac, neurological and others)
– Poly-profile (common-type)
According to the administrative-territorial levels emit: regional, inter – regional, local, sectoral rehabilitation and medical institutions.

Rehabilitation and health institutions
After rehabilitation in medical unit sick or disabled person is transferred for rehabilitation in rehabilitation (treatment-prophylactic) institutions for sanatorium stage of rehabilitation.
These include:
– Resorts (trade unions, departmental, regional submission);
– Preventive health center.
Sanatorium treatment based on using natural healing natural factors.

Physiatry, also known as physical medicine and rehabilitation, is a medical specialty focused on prevention, diagnosis, and nonsurgical treatment of disorders associated with disability. Specialists also care for patients with musculoskeletal disorders, with acute and chronic pain, and ieed of rehabilitation services. Physiatry has been aptly branded the “quality of life medical specialty” because its goal is to restore optimal patient function in all spheres of life, including the medical, social, emotional, and vocational dimensions.

A team-oriented medical specialty, PM&R strives to promote a person’s quality of life and functional outcomes. By blending the best of the traditional medical approach (“adding years to life”) with the functional model (“adding life to years”), PM&R accomplishes its noble mission.

The official name of the field reflects the two important parts of the specialty:

Physical medicine—Diagnosis and treatment of musculoskeletal disorders with the use of medications, modalities, procedures, and exercise.

Rehabilitation—The process of making the person with a disability “maximally able” again, through the application of rehabilitation principles and techniques.

While many physiatrists view themselves as primary care physicians for people with disabilities (and therefore offer comprehensive care for persons with diverse medical conditions), growing number of physiatry specialists have elected to focus on specific rehabilitation areas. Common conditions treated by physiatrists include amputations, arthritis, brain injuries, burns, cancer, cardiac disorders, fibromyalgia, industrial injuries, multiple sclerosis, neuromuscular diseases, neuropathies, orthopaedic injuries, pain disorders, pediatric disorders, pulmonary disorders, spinal cord injuries, stroke, and trauma.

Physiatrists treat patients with acute and chronic pain and neuromusculoskeletal disorders. They often practice in major rehabilitation centers, hospitals, and private settings as either a primary caregiver or a specialist. Often, a physiatrist coordinates a team of doctors and other health care professionals. A comprehensive rehabilitation program may include physical therapists, speech therapists, occupational therapists, recreational therapists, nurses, psychologists, social workers, and specialists in allied medical specialties.

Diagnostic tools include those used by other physicians (medical history, physical examinations, x-rays, and laboratory tests), as well as special techniques in electrodiagnostic medicine such as electromyography (EMG), nerve conduction studies, and somatosensory and motor evoked potentials. EMG examinations and nerve conduction studies are the most common procedures used.

Treatment options include the use of medications; modalities such as hot packs, cold packs, ultrasound, and electrotherapy; assistive devices, such as a brace or artificial limb; massage; biofeedback; traction; and therapeutic exercise. Surgery is not used. Physiatrists, with added training, also perform interventional procedures, including spinal blocks, botulinum toxin injections, and acupuncture.

Health is the optimum condition of a person’s physical, mental, and social well-being. Health is not merely the absence of disease or infirmity. An illness is the patient’s unique subjective experience of “unwellness,” distress, or failed function. Illness not only is a biologic state but also can be an existential transformation that affects trust in the body and reliance on the future. Illness determines the psychological response of the patient and his or her perception of the functional capacity of the body. The illness experience contributes to the psychological state, which influences the perception of the body’s ability to function in the present and future. A disease is a medical construct that diagnoses a disorder as characterized by a set of symptoms, signs, and pathology and attributable to infection, diet, heredity, or environment.

Define disability and activity.

A task is a purposeful activity that requires engagement of the whole person. A disability is any restriction or lack (resulting from an impairment) of a person’s ability to perform a task or activity within the range considered normal for a human of a particular age. An example is an inability to perform activities of daily living, such as dressing, driving, shopping, or cooking. Disabilities reflect the consequences of impairment on activities of the individual. Activities are performance of personal-level tasks or activities undertaken by the person.

Handicap results from the interaction of the person (including impairments and disabilities) with the environment. The environment is all that surrounds the patient and therefore has a profound impact on his or her self-perception and function. Specifically, the characteristics of the environment that need to be considered are physical, psychological, social, and political. The physical environment provides the conduit for travel through obstructive barriers that may limit access. Adaptations are modifications to the built or natural environment that enable the person with disabilities to fully participate in life activities. The psychological environment is all the stimuli uniquely experienced by the person living with disablement, including communicated attitudes and expectations of the person. The social environment includes the predominant cultural role with expectations for acceptance in family, work, and leisure acitivities.

In contrast to classic medical therapeutics, which emphasizes diagnosis and treatment directed against the pathologic process, rehabilitation produces multiple simultaneous interventions addressing both the cause and secondary effects of injury and illness (biopsychosocial model). Traditionally, medical science has directed treatment at the cause of disease (biomedica) model), neglecting the secondary effects of illness. The very nature of rehabilitation includes assessment of the individual’s personal capacities, role performance, and life aspirations.

Rehabilitation has been defined as the development of a person to his or her fullest physical, psychological, social, vocational, avocational, and educational potential, consistent with his or her physiology or anatomic impairment and environmental limitations. Comprehensive rehabilitation can be further considered to require five necessary and sufficient subcomponents:

1. Unique, patient-centered plan formulated by the patient and rehabilitation team

2. Goals derived and prioritized through an interdisciplinary process

3. Patient participation required to achieve the goals

4. Results in improvement in the patient’s personal potential

5. Outcomes demonstrate reduction in impairments, disabilities, and handicaps

It is a process of interaction and intervention that requires knowledge of the patient as a whole person, derivation of goals specifically to meet the patient’s life plan, and interventions that maximize all of the patient’s capabilities and potential. The process has six interactive components:

1. Exploration of both the illness experience and the disease

2. Understanding of the whole person

3. Defining common ground in team treatment planning and patient compliance

4. Incorporating prevention and health promotion

5. Enhancing the treatment relationships between the interdisciplinary team and the patient

6. Taking a realistic and practical perspective

Conditions maximize the success of interdisciplinary rehabilitation teams:

1. Allegiance to a mission statement (i.e., person-centered rehab in the least restrictive setting)

2. Specifically delineated roles for each discipline

3. Balance of participation by each professional

4. Agreement on and implementation of ground rules for interaction

5. Clear and effective communication and documentationPerson-Centered Rehabilitation

6. Scientific approach to patient problems

7. Clearly defined, measurable goals

8. Working knowledge of group process

9. Expedient procedures for coming to consensus and decision-making

Describe the phases in the rehabilitation process.

Phase I (evaluation) requires knowledge of the patient’s personal life tasks, roles, and aspirations. The individual effects of disablement (impairment, disability, and handicap) of the person are quantified. The person’s unique characteristics—mediators that allow for adaptive capacity—limiting disablement severity are identified and targeted as foci for therapy.

Phase II emphasizes treatment to arrest the pathophysiologic processes causing tissue injury.

Phase III (therapeutic exercise) focuses on enhancement of organ performance.

Phase IV (task reacquisition) emphasizes total person adaptive techniques.

Phase V (environmental modification) directs efforts toward environmental enhancement (physical, psychological, social, and political) to reduce handicap.

These phases approximate the emphasis of the team’s interventions during a continuum that guides the patient out of acute treatment to reintegrate with the community. The rehabilitation problem list is a sequence of diagnoses, impairments, disabilities, and handicaps that guide goal setting. Members of the rehabilitation team derive goals from their encounters with the patient as a whole person. The patient drives the process by demonstrating his or her particular predicament with disablement. Adaptation is achieved by enhancing the patient’s personal characteristics that mediate or limit the disablement. The overall goal is the fullest personal enablement and action toward fulfillment of life roles.

MEDICAL REHABILITATION AT DISEASES OF BREATHING SYSTEM

Diseases of the respiratory system are a major cause of illness world-wide and are increasingly important as a cause of mortality and morbidity (Rimington et al. 2001). In the United Kingdom they are the most common reason for consulting a general practitioner, and result in more days lost from work than any other type of illness.

Respiratory diseases can be broadly divided into obstructive and restrictive types.

1 Obstructive diseases include conditions in which there is a resistance to airflow either through reversible factors such as bronchospasm or inflammation, or through irreversible factors such as airway fibrosis or loss of elastic recoil owing to damage to the airways and the alveoli.

2 Restrictive disorders are characterised by reduced lung compliance leading to the loss of lung volume which may be caused by disease affecting the lungs, pleura, chest wall or neuromuscular mechanisms. These diseases are therefore different from the obstructive diseases in their pure form, although mixed restrictive and obstructive conditions can occur.

Obstructive diseases are by far the most common and are secondary only to heart disease as a major cause of disability. Therefore their pathophysiology and treatment will be discussed initially in some detail. They are:

• chronic bronchitis

• emphysema

• chronic bronchitis and emphysema together

• asthma

• bronchiectasis

• cystic fibrosis.

Secondly, as the changing pattern of respiratory disease has resulted in opportunistic pneumonias which are a common presentation in patients with acquired immune deficiency syndrome (AIDS), the restrictive disorders and their management will then be considered. They are:

• pneumonia

• pleurisy

• pleural effusion

• pneumothorax

• acute respiratory distress syndrome (ARDS)

• fibrosing alveolitis.

Finally, there are other lung disorders that fit into neither of the first two categories but need to be included owing to their prevalence within the community or hospital environment. They are:

• lung abscess

• pulmonary tuberculosis

• bronchial and lung tumours

• respiratory failure.

Chronic obstructive pulmonary disease (COPD) is an ill-defined term that is often applied to patients who have a combination of chronic bronchitis and emphysema which frequently occur together (and may also include asthma). In the majority of cases, chronic bronchitis is the major cause of obstruction, but in some cases emphysema is predominant. There are many patients who report shortness of breath increasing in severity over several years and, on examination, are found to have a chronic cough, an overinflated chest and poor exercise tolerance. It is often difficult to assess clinically to what extent these patients have chronic bronchitis or emphysema or a mixture of both.

Patients may also present with a more episodic form of disease, which is a characteristic of an asthmatic component. Therefore,’chronic obstructive pulmonary disease’ is a convenient term which encompasses one or all of these pathological components.

Chronic bronchitis and emphysema often coexist in COPD, the disease is progressive and is characterised by acute exacerbations. It is not usually diagnosed until irreversible damage has occurred.

It is difficult to determine the exact prevalence of COPD. However, figures from general practice suggest that 5% of men and 2% of women will be diagnosed as suffering from COPD, although in the population as a whole it is estimated that 11 % of men and 8% of women have evidence of obstructed airways when specifically tested by spirometry (Joint Health Surveys Unit 1996). COPD is projected to be the fifth major cause of death worldwide by 2010 (Office for National Statistics 1997).

The survival rate for COPD varies between 5 and 30 years, but eventually cardiac and ventilatory failure will occur. Avoidance of the precipitating factors listed below will tend to improve the prognosis:

• stopping smoking

• control of atmospheric pollution

• prompt treatment of all acute infections

• maintenance of good general health.Since COPD is characterized by obstruction, the greater the obstruction the lower the chance of survival (Pearson and Calverley 1995). As obstruction to flow is measured by FEV_; which stands for forced expiratory volume in one second. Together with age, FEVj is the most important determinant of survival

CHRONIC BRONCHITIS

The relationship between age, FEV and survival.

Definition

Chronic bronchitis is a chronic or recurrent increase in the volume of mucus secretion sufficient to cause expectoration when this is not due to localized bronchopulmonary disease. In the definition of this disease, chronic/recurrent is further defined as a daily cough with sputum for at least 3 months of the year for at least two consecutive years and airways obstruction which does not change markedly over periods of several months (West 1995). Chronic bronchitis is a clinical diagnosis (unlike the definition of emphysema).

Aetiology of Chronic Bronchitis

This is more common in middle to late adult life and in men more than women (Clarke 1991). Cigarette smoking is the chief culprit, and although in the UK over 20% of the adult population continue to smoke (Department of Health 1997) only 15-20% of smokers develop COPD. The reason for this is probably genetic although the number of cigarettes smoked does have an effect on the progression of the disease.

Exposure to risk: pack-years

Rather than simply recording a patient’s current smoking habits, a much better ‘ indicator of any potential deterioratio lung function is an assessment of pack-years, which is the number of packs (20 per pack) smoked daily multiplied by the number of years of smoking. For example, someone aged 60 years who has smoked five cigarettes per day (0.25 of a pack) since the age of 15 has a lifetime exposure equal to 0.25 x 45 = 11 pack-years. Another person of the same age who smoked 30 cigarettes per day (1.5 packs) between the ages of 15 and 25 (gave up till age 40, since then has smoked one pack per day) has a lifetime exposure of (1.5 x 10) + (1 x 20) = 35 pack-years.

Atmospheric pollution (e.g. industrial smoke, smog and coal dust) will also predispose to the development

Age

FEV.

3-year survival probability

<60 >50% of expected 90%

>60 >50% of expected 80%

>60 40-50% of expected 75%

>60 30-40% of expected 60%

of the disease, which is therefore more common in urban than in rural areas. It is more prevalent in socio-economic groups 4 and 5 and is costly in terms of working days lost annually in Britain.

Pathology of Chronic Bronchitis

The hallmark is hypertrophy of, and an increase iumber of, mucous glands in the large bronchi and evidence of inflammatory changes in the small airways (Thurlbeck 1976). Some irritative substance stimulates overactivity of the mucus-secreting glands and the goblet cells in the bronchi and in the bronchioles which causes secretion of excess mucus. This mucus coats the walls of the airways and tends to clog the bronchioles, which is functionally more important. The cells increase in size and their ducts become dilated and may occupy as much as two-thirds of the wall thickness (West 1995). The airways become narrowed and show inflammatory changes, which results in mucosal oedema thus further decreasing the diameter of the airways. The ciliary action is also inhibited.

This narrowing of the lumen of the airways is further emphasised during expiration by the normal shortening and narrowing of the airways. Consequently the airways obstruction is enhanced during expiration, with resulting trapping of air in the alveoli. The lungs gradually lose their elasticity as the disease progresses. They will gradually become distended permanently, which eventually may cause extensive rupture of the alveolar walls. After repeated exacerbations due to infection there is widespread damage to the bronchioles and the alveoli with fibrosis and kinking occurring as well as compensatory overdistension of the surviving alveoli. This is closely allied to and contributory to the development of emphysema.

Clinical Features of Chronic Bronchitis

The most important clinical features are cough, sputum, wheeze and dyspnoea.

Cough

The patient will complain of a cough for many years, initially intermittent and gradually becoming continuous. Fog, damp or infection increases it. The patient may also complain of bouts of coughing occasionally on lying down or in the morning. The cough and sputum production are not associated with either mortality or disability, and are reversible in most smokers once they stop smoking. The cough is caused by either irritation of airway nerve receptors due to the release of compounds from inflammatory cells or from the presence of increased mucous production.

Sputum

This is mucoid and tenacious, usually becoming mucopurulent during an infective exacerbation.

Wheeze

Wheezing is a symptom described by as many as 80% of patients with COPD. Wheezing is a characteristic feature of COPD, although it is also reported in many other acute and chronic respiratory diseases. Wheezing is caused by the sound generated by turbulent airflow through the narrowed conducting airways and may be worse in the mornings or may be related to weather changes.

Dyspnoea or shortness of breath

This occurs in patients with COPD and, together with the energy-requiring consequences of chronic infection and inflammation, leads to increased work of breathing (Donahoe et al. 1989). The patient becomes progressively more short of breath as the disease progresses.

Other signs and symptoms

Exercise intolerance

Owing to abnormalities of respiratory function, patients with COPD ventilate excessively and ineffectively at all work levels compared with subjects with normal lung function. This limits exercise performance. Limitation of exercise tolerance is, however, determined not only by pulmonary function but also by many other factors – including motivation, muscle mass and nutritional status. Of equal importance is the impact these symptoms have on the patient’s quality of life, activities of daily living and recreational activities. Patients should also be assessed for the impact that these symptoms have on:

• ability to work

• psychological well-being

• sexual function.

Deformity

These patients often develop a barrel chest due to hyperinflation and use of accessory muscles of respiration. The thoracic movements are gradually diminished and paradoxical indrawing in the intercostal spaces may develop.

Cyanosis

This is a blue coloration of the skin caused by the presence of desaturated haemoglobin due to reduced gaseous exchange. Cyanosis is also related to the development of complications, such as poor cardiac output due to ventricular failure leading to increased peripheral oxygen extraction. Cyanosis may also be due to an increase in red blood cells (polycythaemia) in response to chronic hypoxaemia.

Cor pulmonale

This may occur in the later stages of COPD. The impaired gas exchange in COPD caused by the disruption of ventilation and perfusion and the resulting hypoxia leads to widespread hypoxic pulmonary vasoconstriction. This leads to an increase in pulmonary vascular resistance resulting in pulmonary hypertension (Vender 1994). The increase in the pressure within the pulmonary artery will create a resistance, which the right ventricle must overcome. This eventually leads to hypertrophy and dilatation, a condition known as ‘cor pulmonale’.

Right heart failure leads to an increased pressure in the peripheral tissues resulting in the development of peripheral oedema. The combination of renal hypoxia and the increase in blood viscosity from polycythaemia increases the systemic blood pressure (BP) and eventually leads to left heart failure. The development of pulmonary oedema, which exacerbates the hypoxia and low cardiac output in patients with COPD, leads to a terminal stage of the disease. The mechanism of this cycle is illustrated in Figure 14.1.

Lung function

There is reduction of FEV and the forced vital capacity I (FVC) is grossly reduced. The residual volume (RV) I will be increased at the expense of the vital capacity I (VC) because of air trapping and the inability of the! expiratory muscles to decrease the volume of the I thoracic cavity. The expiratory flow-volume curve is I grossly abnormal in severe disease; after a brief interval I of moderately high flow, flow is strikingly reduced as I the airways collapse, and flow limitation by dynamic I compression occurs. A scooped-out appearance i<1 often seen.Ventilation/perfusion abnormality

Hypoxia

Hypoxic pulmonary vasoconstriction Pulmonary hypertension

Right heart failure + renal hypoxia + polycythaemia

Increase in systemic blood pressure

Left ventricular failure

Mechanism of development of cor nonale and congestive heart failure in COPD.

Blood gases

Ventilation/perfusion mismatch is inevitable in COPD and leads to a low arterial oxygen pressure (PaO,) with or without retention of carbon dioxide (CO₂). As the disease becomes severe, the arterial carbon dioxide pressure (PaCO₂) may rise, and there is some evidence that the sensitivity of the respiratory centre to CO, is reduced (Fleetham et al. 1980), which may leave the respiratory stimulus dependent upon the hypoxic drive. However, more recent evidence suggests that the administration of high levels of oxygen (>70%) in patients with COPD may increase hypercapnia owing to the reversal of pre-existing regional pulmonary hypoxic vasoconstriction, resulting in greater dead space (Crossley et al. 1997).

Auscultation signs

There will be inspiratory and expiratory wheeze with added coarse crepitations. The breath sounds are vesicular with prolonged expiration.

X-ray signs

No characteristic abnormality is seen in the early stages of the disease. If there is significant airways obstruction there may be signs of chest over-expansion (flattening of the diaphragm) and an enlarged reterosternal airspace.

EMPHYSEMA

The condition is probably highest in England when compared to the rest of Europe, especially in the major centres of industry – although often there is a family history of the disease.

Definition

Emphysema is a condition of the lung characterised by permanent dilatation of the air spaces distal to the terminal bronchioles with destruction of the walls of these airways. It is nearly always associated with chronic bronchitis from which it is difficult to distinguish during life.

Causes and Types of Emphysema

Causes and predisposing factors

Congenital or primary emphysema may be caused by alpha^antitrypsin deficiency. This is a rare inherited condition, which affects one person in 4000 and results in the complete absence of one of the key antiprotease systems in the lung. The consequence is the early development of COPD, especially if the patient is already a smoker. Although alphaj-antitrypsin deficiency is responsible for fewer than 1% of cases of COPD, its hereditary nature means that it is worth diagnosing. It should, therefore, be considered in any young COPD patient.

Emphysema may be secondary to other factors, such as:

• obstructive airways disease – e.g. asthma, cystic fibrosis, chronic bronchitis

• occupational lung diseases – e.g. pneumoconiosis

• compensatory to contraction of one section of the lung – e.g. fibrous collapse or removal, when the remaining lung expands to fill the space.

Types of emphysema

Definition

Centrilobular (centri-acinar) emphysema tends to affect the respiratory bronchioles with most of the alveoli remaining normal. Perilobular (panacinar) emphysema results in widespread destruction of most alveoli as well as respiratory bronchioles.

Primary emphysema is usually of the panacinar (pan-lobular) type. In centrilobular emphysema the upper zones of the lung are usually affected. This causes gross disturbance of the ventilation/perfusion relationship since there is a relatively well preserved blood supply to the alveoli but the amount of oxygen reaching the capillary is decreased owing to the damage to airways proximal to the alveoli. Panacinar emphysema predominantly affects the lower lobes. This has a less drastic effect on the ventilation/perfusion relationshipsince the blood supply in the damaged areas is decreased in proportion to the decreased ventilation in those areas.

Pathology of Emphysema

Smoking causes the clustering of pulmonary alveolar macrophages (which are the major defence cells of the respiratory tract) around the terminal bronchioles. These macrophages are abnormal in smokers and they release proteolytic enzymes, which destroy lung tissue locally. Polymorphonuclear leucocytes, necessary to combat infection in the lung, release an enzyme which also destroys lung tissue. The defence mechanism against the unwanted action of these enzymes lies in the serum alpha!-antitrypsin, which is normally present in the airway lining fluids. Oxidants released by both cigarette smoke and the leucocytes tend to inactivate the antiproteolytic action of the alphaj-anti-trypsin, which causes destruction of lung tissue as seen in centrilobular emphysema.

Subsequently the walls of the airways become weak and inelastic owing to the damage from repeated infections. They tend to act as a one-way valve with the walls collapsing on expiration. This causes air trapping and consequent increase in the intra-alveolar pressure during expiration. The alveolar septa break down and form bullae (Figure 14.2).

During expiration, the pressure from the trapped air in the bullae may compress adjacent healthy tissue, thus causing occlusion and trapping of air in that tissue. The capillaries around the alveolar walls become

stretched, causing the lumen to decrease and atrophy to occur. This causes an alteration in the ventilation/per-fusion relationship, owing to the loss of surface area for gaseous exchange and the decrease in blood supply resulting from damage to the pulmonary capillary network.

Clinical Features of Emphysema

Progressive dyspnoea

Shortness of breath occurs initially on exertion, but as the disease progresses it will gradually occur after less and less activity and finally at rest. This disabling breathlessness is what prevents the patient from working and gradually transforms the patient into a state of severe exercise intolerance and disability.

Respiratory pattern

The patient has a ‘fishlike’ inspiratory gasp, which is followed by prolonged, forced expiration usually against ‘pursed lips’. This creates back-pressure to try to prevent airways shutdown during expiration. Owing to increased intrathoracic pressure the jugular veins fill on expiration. A ‘flick’ or ‘bounce’ of the abdominal muscles may be seen on expiration as the outward flow of air is suddenly checked by the obstruction of the airways (Figure 14.3).

Cough with sputum

This will be present if the disease is associated with chronic bronchitis or if there is infection.Chest shape

The chest becomes barrel-shaped, fixed in inspiration with widening of the intercostal spaces. There may also be indrawing of the lower intercostal spaces and supraclavicular fossa on inspiration. This is associated with the difficulty of ventilating stiff lungs through narrowed airways. The ribs are elevated by the accessory muscles of respiration and there is loss of thoracic mobility.

Poor posture

There may be a thoracic kyphosis plus elevated and protracted shoulder girdles.

Polycythaemia

This may develop if there is a prolonged decrease in PaO₂ owing to the ventilation/perfusion imbalance.Cor pulmonale

This occurs in the advanced stages of the disease.

Lung function

The FEV/FVC ratio is usually below 70%. Residual volume (RV) is increased and lung volume may exceed the predicted total lung capacity (TLC) (Decramer 1989).

Examination

The percussioote will be normal or hyper-resonant due to air trapping. Auscultation will reveal decreased breath sounds and prolonged expiration. The chest radiograph shows low flat diaphragms and hyperinflation.

Prognosis of Emphysema

The patients become progressively more disabled, with death ultimately occurring from respiratory failure. Complications of the disease are pneumothorax due to rupture of an emphysematous bullae, and congestive cardiac failure.

COMBINED CHRONIC BRONCHITIS AND EMPHYSEMA________________________

Within the spectrum of COPD, two extremes of clinical presentation are recognised: type A and type B. At one time these were classified either as ‘pink puffers’ (type A) or ‘blue bloaters’ (type B) to correlate with the relative amounts of emphysema and chronic bronchitis respectively (Figure 14.4). Whilst these definitions are over-simplistic, it is worth remembering that patients can present in dramatically different ways (Kesten and Chapman 1993).

Blue bloaters

Patients with this syndrome often show the following symptoms:

Blue bloater and pink puffer.

• obesity

• comparatively mild dyspnoea

• copious sputum which may become infected

• low PaO, and high PaCO₂ (PaO,>8kPa; PaCC\ > 6.5kPa) because they tend to hypoventilate

• central cyanosis with cor pulmonale.

• peripheral oedema

• an increased residual volume but normal total lung capacity.

Pink puffers

Patients with this syndrome often show the following symptoms:

• an anxious expression

• general thinness

• severe breathlessness

• little or no sputum production

• relatively normal PaO₂and PaCO, (PaO,<8 kPa; PaCO₂ normal/low) due to hyperventilation early on in the disease

• central cyanosis and the development of cor pulmonale in the later stages of the disease

• generally no peripheral oedema until the late stages of the disease

• an increased total lung capacity due to hyperventilation.

MEDICAL TREATMENT OF COPD________

Principles of Treatment

1 Decrease the bronchial irritation to a minimum. The patient should be advised to stop smoking and avoid dusty, smoky, damp or foggy atmospheres. Occupation or housing conditions may need to be changed.

2 Control infections. All infections should be treated promptly as each exacerbation will cause further damage to the airways. The patient should have a supply of antibiotics at home and receive a vaccination against influenza each winter. The main affecting organisms are Streptococcus pneumoniae and Haemophilus influenzae, which are usually sensitive to amoxycillin or trimethoprim.

3 Control bronchospasm. Although bronchospasm is not a prominent feature of this disease, drugs (e.g. salbutamol) may be given to relieve the airways obstruction as much as is possible.

4 Control/decrease the amount of sputum. Patients with chronic bronchitis may present with excessive bronchial secretions and are usually able to eliminate this by themselves. However, during an episodewhen secretions may become difficult to eliminate, physiotherapy techniques including humidification, positioning and manual techniques may aid expectoration and reduce airflow obstruction in the short term (Cochrane et al. 1977).

5 Oxygen therapy. Oxygen must be prescribed and should be given with great care, especially if a normal pH indicates a chronic compensated respiratory acidosis (renal conservation of bicarbonate ions (HCO₃) to maintain pH within 7.35 to 7.45). In this instance HCO₃ is raised above 24 mmol/L whilst PaO, is low and the PaCO₂ is raised. Controlled oxygen may be given via a Ventimask (or equivalent) with careful monitoring of blood gas levels.

6 Long-term oxygen therapy (LTOT). As respiratory function deteriorates, the level of oxygen in the blood falls leading to an increase in pulmonary hypoxic vasoconstriction and a deterioration in cardiac function. In 1981, the Medical Research Working Party examined the effects of supplementary low-concentrations of oxygen (24%) for 15 hours a day in COPD and found that it reduced 3-year mortality from 66% to 45%. The British Thoracic Society guidelines (1997) suggest that patients who have a PaO₂ of less than 7.3 kPa, with or without hypercapnia, and a FEy, of less than 1.5 lYfres, should receive LTOT. This therapy should be considered also for patients with a PaO₂ between 7.3 and 8.0 kPa and evidence of pulmonary hypertension, peripheral oedema or nocturnal hypoxia.

Medications

Drugs used in the treatment of respiratory disease broadly fall into two categories: relievers and preventers.

I • The relievers are used to reduce bronchospasm and include the beta, agonists (which may be short- or long-acting), the anticholinergics and the xanthene derivatives.

The preventers may be used to prevent bronchial hyper-reactivity and reduce bronchial mucosal inflammatory reactions – they include the corticosteroids.

Ma₂ (B₂) agonists

Beta-agonists such as salbutamol (Ventolin) and ter-abutaline (Bricanyl) work by stimulating beta₂-recep-tors, which are widespread throughout the respiratory system. These stimulate adenylate cyclase, which leads to bronchodilation. Beta-receptors are also found in other tissues, including the heart, although these are of subtype.

Even though modern bronchodilators are designed to be beta₂-selective, they may still cause an increase in heart rate and other side-effects, which include fine tremor, tachycardia, hypokalaemia (low potassium) after high doses. Inhaled therapy is therefore preferred to oral, as the former limits the amount of drug that finds its way into the general circulation. The long-acting beta-agonist agents salmeterol and eformoterol offer a more favourable dose regimen, and respiratory physicians are adding a long-acting beta-agonist for patients who have not responded fully to short-acting beta-agonists and an anticholinergic used together.

Anticholinergics

Anticholinergic bronchodilators work by preventing bronchoconstriction, mediated by the parasympathetic nervous system. Two agents are currently available, –ipratropium bromide and oxitropium bromide. Most studies suggest that these agents are at least as potent as beta-agonists when used alone in COPD (Tashkin et al. 1986). A short-acting bronchodilator (beta,-agonist or anticholinergic) used ‘as required’ is recommended as initial therapy in the British Thoracic Society guidelines (BTS 1997).

Xanthene derivatives

The precise mode of action of the xanthene derivatives such as theophylline and aminophylline remains somewhat uncertain although they are moderately powerful bronchodilators. They have, however, been shown to improve symptoms in COPD by increasing the contractual ability of the diaphragm (Murciano et al. 1989).

Corticosteroids

The role of inhaled steroids (beclomethasone, budes-onide) in COPD will vary from patient to patient. Steroids work by reducing inflammation and reducing bronchial hyperactivity. Trials have shown that about 10-20% of COPD patients will improve significantly following a short course of high-dose oral steroids (Gross 1995).

The most serious limitation to oral steroid therapy is the risk of long-term side-effects, which include osteoporosis, adrenal suppression, muscle wasting, poor immune response and impaired healing. However, a positive response to corticosteroids justifies the administration of regular inhaled steroids.

Drug Delivery Systems

The objective of inhaled therapy in COPD is to maximise the quantity of drug that reaches its site of action while minimising side-effects from unintendedsystemic absorption. Most metered-dose inhalers (which are later described in detail for asthmatic patients) are designed to deliver particles of between 0.5 and 10 microns (micrometres). Unfortunately, poor inhaler technique tends to mean that only a relatively small proportion of the drug actually reaches its site of action. It is therefore imperative that a good inhaler technique be adopted (as described for patients with asthma).

In acute exacerbations, when conventional inhalers have proved inadequate, nebulisers may be used to deliver a therapeutic dose of a drug as an aerosol within a fairly short period of time, usually 5—10 minutes (British Thoracic Society 1997). The type of neb-uliser for home use consists of a compressor or pump, a chamber and a mask or mouthpiece. The compressor blows air into the chamber, where it is forced through a drug solution and past a series of baffles. The solution is converted into a fine mist, which is then inhaled by the patient through the mask or the mouthpiece.

PHYSIOTHERAPY TECHNIQUES IN COPD

General Aims of Treatment

The general aims are:

• to relieve any bronchospasm and facilitate the removal of secretions

• to improve the pattern of breathing, breathing control and the control of dyspnoea

• to teach local relaxation, improve posture and help allay fear and anxiety

• to increase knowledge of the patient’s lung condition and control of the symptoms

• to improve exercise tolerance and ensure a long-term commitment to exercise

• to give advice about self-management in activities of daily living.

The treatment given must be appropriate to the stage of the disease and the patient’s general health.

Treatment in the Early Stages

The most important themes are clearing the airways of secretions, establishing a correct breathing pattern, improving or maintaining exercise capacity, and patient education into self-management.

The active cycle of breathing technique (ACBT)

This is a cycle of breathing control, thoracic expansion exercises and the forced expiratory technique (FET) and has been shown to be effective in the clearance of bronchial secretions (Prior et al. 1979; Wilson et al. 1995) and to improve lung function (Webber et al, 1986).

Thoracic expansion exercises are deep breathing exercises (three or four) which may be combined with a 3-second hold on inspiration (unless the patient is very breathless when this may not be tolerated). This increase in lung volume allows air to flow via collateral channels (e.g. the pores of Kohn) and may assist in mobilising the secretions as air is able to get behind the secretions. The increase in lung volume during the inspiratory phase of the cycle may also be achieved by the patient performing a ‘sniff manoeuvre at the end of a deep inspiration. Manual techniques, for example shaking, vibrations or chest clapping, may further aid in removal of secretions.

The FET manoeuvre is a combination of one or two forced expirations (huffs) against an open glottis (as opposed to a cough, which is a forced expiration against a closed glottis). An essential part of the FET manoeuvre is a pause for some breathing control, which prevents an increase in airflow obstruction.

Postural drainage

This may also aid sputum removal and may be combined with the ACBT technique. The optimum position for effectiveness must be established with each individual, although postural drainage for the lower lobe segments may be difficult as some patients may not tolerate the head-down position or even lying flat.

Humidification

If the secretions are very thick and tenacious the patient may be given humidification via a nebuliser, Inhalations with pine oil added to near-boiling water may also be given prior to treatments to remove excessive bronchial secretions.

Improving the breathing pattern

The patient is taught how to relax the shoulder girdle in a supported posturally correct position such as crook half-lying. Breathing control is taught following clearance of secretions. If the patient is breathless, respiratory control is regained starting with short respiratory phases and allowing the rate to slow as the patient’s breathing pattern improves.Increasing/maintaining exercise tolerance

The patient may be treated as an inpatient or as an outpatient, in a health centre or at home by a community physiotherapist. It is important to see the patient regularly. Advice should be given on taking regular exercises, as for example a short walk every day. If possible, the patient should be offered participation in a multi-disciplinary comprehensive programme of pulmonary rehabilitation.

Definition

The National Institutes of Health in the USA defines pulmonary rehabilitation as ‘a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual’s maximum level of independence and functioning in the community’ (American Thoracic Society 1995).

There is unequivocal evidence to suggest that pulmonary rehabilitation improves both exercise capacity and health-related quality of life (Lacasse et al. 1996). In essence, the components of a pulmonary rehabilitation programme include aerobic exercise training, education about the background of the disease, smoking cessation, compliance with medication, nutritional support and energy-conserving strategies for activities of daily living (ADLs). Pulmonary rehabilitation programmes may also include psychosocial support with regard to advice on benefits, sexual function and anxiety management.

pulmonary disease (Clanton and Diaz 1995; Polkey et al. 1995). It therefore follows that training techniques, which might specifically target the respiratory muscles, may prove beneficial in patients with COPD who may develop respiratory muscle weakness due to a loss of muscle mass.

Many studies have been performed examining the benefits of inspiratory muscle training (IMT), particularly in patients with chronic obstructive pulmonary disease (Smith et al. 1992). Despite this intensive investigation, IMT has failed to become part of routine clinical practice. In part this has been due to the paucity of controlled clinical trials, but more importantly due to the nature of the training adopted. In general the trials were confounded by the nature of their training methodology in which the frequency, duration and intensity of training were less than that required to achieve a true training response (Smith et al. 1992). Therefore the training methodology employed during IMT should follow the same principles that are applied to other skeletal muscles in terms of the frequency, duration and intensity of the training.

Training methodologies should also control for the lung volume at which the training takes place, otherwise the patient may alter the lung volume at which the training is performed in order to cope with the resistive load more easily (Goldstein et al. 1993). However, recent studies which have incorporated these principles during training at 80% of maximum inspiratory pressure (MIP) have shown evidence of muscle fatigue (Chatwin et al. 2000) which indicates an appropriate training response has been applied. Furthermore, by using an appropriate training methodology, increases in exercise capacity in both moderately trained and highly trained subjects and in adult patients with cystic fibrosis have been achieved (Chatham et al. 1999, Enright et al. 2000).

Inspiratory muscle training

The potential for fatigue of the ventilatory muscles is now recognized as an important component of ventilatory limitation in patients with COPD (Moxham 1990; Green and Moxham 1993). Fatigue may be due to a combination of:

• increased mechanical load on the respiratory muscles

• reduced muscle strength

• reduced energy supply to the respiratory muscles (Roussos and Zakynthinos 1996).

It has also been established that respiratory muscle weakness, which may be a predisposition to muscle fatigue, is present in patients with chronic obstructive

Treatment in the Later Stages

It is imperative that patients with COPD be able to maintain as much independence and maximum function as is possible through the support from the hospital or community healthcare team. During acute exacerbations, the active cycle of breathing technique (ACBT) may be continued to assist clearance of secretions. Breathing control should be emphasised so that the patient can walk or climb stairs with confidence. Relaxation positions should be taught for regaining breathing control after activity has made the patient breathless. If the patient becomes very disabled, a walking frame may help to retain some degree of independence as the arms are fixed and accessory muscles of inspiration may be used.Non-invasive positive-pressure ventilation (NIPPV)

Tracheal intubation and mechanical ventilation providing intermittent positive-pressure ventilation (IPPV) is used in-intensive care units or high-dependency units to manage patients with deteriorating respiratory failure. However, tracheal intubation may result in complications, which include tracheal injury and infection. Furthermore, some patients find it difficult to stop using IPPV, resulting in a prolonged stay in intensive care.

Non-invasive positive pressure ventilation (NIPPV) is therefore indicated for the delivery of intermittent positive pressure and may be applied via the nose or mouth using a silicone mask attached to a bedside ventilator. Unlike IPPV, NIPPV can be administered on a general ward for patients in respiratory failure (Sinuff et al. 2000). The ventilator is programmed to supplement the patient’s own respiratory effort and if required oxygen therapy may be given in conjunction with NIPPV. NIPPV can be used during an acute exacerbation and has been shown to improve quality of life and arterial blood gas pressures (Meecham-Jones et al. 1995) and to reduce mortality in patients with COPD (Brochard et al. 1995).

Physiotherapy will be required for short spells but frequently throughout the day and sometimes at night. Intermittent positive pressure breathing (IPPB) may also be given using a mask if the patient is too drowsy to use a mouthpiece. Postural drainage may be necessary, if tolerated, together with rigorous shaking applied during the expiratory phase of the ventilator. Patients should be positioned appropriately in order to facilitate gaseous exchange.

Suction via an airway or nasal suction may have to be used as a last resort to remove secretions if the patient is unable to cough spontaneously. If PaCO, is high and PaO, is low the patient should not be given a high concentration of oxygen. Two litres of oxygen through a nebuliser with the IPPB respirator driven off air gives a 25% oxygen-to-air mix which is generally suitable. Drugs such as mucolytic agents or bron-chodilators may be provided through the nebuliser attached to the ventilator. The patient should be encouraged to sip drinks because dehydration makes the secretions viscid.

As the patient recovers, treatment should be directed towards that given in the ‘early’ stages, with special emphasis on a daily maintenance programme of regular exercise, sputum clearance and breathing exercises.

The main theme is to keep the patient as comfortable as possible. Treatment needs to be short and frequent.

Non-invasive nasal ventilation may be provided for home use. Inhalations may be used to loosen and liquefy secretions. Suction may be necessary and the general practitioner may provide medication for the patient if the person is being managed at home.

ASTHMA

Definition

Asthma is a clinical syndrome characterised by attacks of wheezing and breathlessness due to narrowing of the intrapulmonary airways. The severity of the narrowing varies over short periods and is reversible either spontaneously or as a result of treatment (Hargreave et al. 1990).

Types of Asthma

It has been common practice to divide asthma into extrinsic and intrinsic forms. There is a degree of overlap, and many asthmatics, particularly adults, do not fall clearly into either group.

Extrinsic asthma

Extrinsic (atopic) asthma occurs in the younger age groups and is caused by identifiable trigger factors, such as specific allergens. Patients are usually sensitive to different factors (e.g. pollen, house dust mites, feat?* ers, fur, dust, pollution and, occasionally, food, drugs and exercise) and have a family history of similar sensitivities. Atopic subjects show an immediate skin reaction, elicited by pricking the skin through a drop of antigenic extract. Exposure to the precipitating factor causes a mucosal inflammatory allergic reaction. This type of asthma tends to be episodic. House dust mites provide the most common positive skin test in Britain, being positive in 80% of children with severe asthma, Extrinsic asthma is common in young people and is associated with a family history of asthma, hay fever and eczema.

Intrinsic asthma

Intrinsic (non-atopic) asthma tends to occur in the older patient as a chronic condition. It has no apparent allergic cause or family history. This type of asthma is precipitated by, or associated with, chronic bronchitis, strenuous exercise, stress or anxiety. Respiratory infections are also a common factor in precipitating acute attacks although the majority of these are viral in origin (Nicholson et al. 1993) – so antibiotics are inappropriate in their treatment.Aetiology and Prevalence of Asthma

The condition can occur at any age but is most common in children, especially boys (ratio of about three to two). Approximately 10% of children under 10 years of age in the United Kingdom have bouts of coughing and wheezing related to narrowing of the airways. Asthma accounts for more absences from school than any other chronic disease, although days lost from school may be under-estimated owing to the under-diagnosis and under-treatment of childhood asthma (Speight 1983).

Childhood asthma generally remits after puberty but it may return in later life. Asthma that starts in middle age is more common in women than men and remission in this age group is rare.

The majority of cases of asthma are mild, although the course of the disease is unpredictable. The mortality rate is unacceptably high and has shown a slow rise since the 1960s to around 2000 deaths per year in England and Wales. Under-treatment and inadequate appreciation of the severity of asthma by patients and doctors are important factors, with up to 86% of asthma deaths being preventable (British Thoracic Association 1982). Those most at risk are the patients who under-estimate their symptoms. About 15-20% of asthmatics do not notice moderate changes in their airflow obstruction (Rubinfeld and Pain 1976) and may quickly deteriorate until they suddenly present with severe asthma (Kikuchi et al. 1994).

Pathology of Asthma

In all types of asthma an underlying problem seems to He in abnormal reactivity of the airways; that is, they narrow excessively in response to stimuli which would not affect normal subjects (Bone 1996). The main pathological changes occurring during an asthmatic attack are:

• spasm of the smooth muscle in the walls of the bronchi and bronchioles (bronchoconstriction)

• oedema of the mucous membrane of the bronchi and bronchioles

• excessive mucus production and mucus plugging.

These changes result in airways obstruction. The bronchial walls become infiltrated with eosinophils and there is thickening of the epithelial basement membrane.

At the end of an attack these changes are almost totally reversible, but if attacks occur frequently then long-standing changes will occur. Such changes are hypertrophy of the smooth bronchial muscle, which

increases the effect of bronchial spasm during an attack; permanent thickening of the mucous membrane with an increase in the number of goblet cells and mucous glands; over-distension of the alveoli due to trapping of air; and atelectasis of alveoli when a bronchiole, already narrowed, becomes blocked by mucus plugs.

Where the predominant factor precipitating asthma is an allergic reaction there is antigen-mediated bronchoconstriction. This means that the antigen (allergen or precipitating factor) binds to two IgE molecules (immunoglobulin antibodies) on the membranes of mast cells present in the bronchial lining. This binding releases mediators which act on receptor sites on smooth muscle cells, causing changes in intracellular cyclic AMP levels which result in muscular contraction. The mediators histamine, neutrophil chemotactic factor (NCF-A), platelet activating factor (PAF) and eosinophil chemotactic factor (ECF-A) are stored in granules within the mast cells as preformed mediators. This antigen-antibody reaction is part of the body’s immune response, and previous exposure to the antigen results in greater bronchoconstriction.

Clinical Features of Asthma

Extrinsic asthma

In extrinsic asthma the onset is often sudden and paroxysmal, often at night. An attack starts with chest tightness, dryness or irritation in the upper respiratory tract. Attacks tend to be episodic, often occurring several times a year. Their duration varies from a few seconds to many months and the severity may be anything from mild wheezing to great distress. The most predominant features are summarised below.

Wheeze and dyspnoea

Dyspnoea may be intense and chiefly occurs on expiration, which becomes a conscious exhausting effort with a short gasping inspiration. Wheezing is always present on expiration but may also occur on inspiration in severe asthma.

Cough

At the initial stage of an attack the cough may be unproductive and ‘barking’ in nature. It causes an increase in bronchospasm and dyspnoea. As the attack subsides, the cough becomes productive of casts or plugs of sputum. Such plugs – made up of yellow viscid mucus and desquamated epithelial cells and eosinophils – are often coughed up during acute attacks, which may produce a marked relief of symptoms. Particularly in children, a cough may be theonly presenting symptom of asthma (Corraco et al. 1979).

diminished and occasionally become inaudible (silent chest) due to diminished airflow.

Posture

The patient will prefer to sit upright with the shoulder girdle fixed (by grasping a table or bed) to assist the accessory muscles of respiration. The chest is hyperin-flated.

Pulse

This is rapid and there may be an increased drop in blood pressure during inspiration (>10mmHg) owing to an exaggeration in intrathoracic pressure swings due to severe airways obstruction (pulsus paradoxus). However, pulsus paradoxus may be absent even in very severe attacks of asthma. When it is present, the measurement is easily performed with a sphygmomanometer and provides a guide to progress and response to treatment (Pearson et al. 1993).

Electrocardiogram (ECG)

This will show a tachycardia and may show signs of right ventricular strain or the development of a large P wave (P pulmonale). These abnormalities will return to normal as the attack subsides.

Cyanosis

This may occur at a very late stage in the progression of the disease due to worsening hypoxaemia (low PaO,) if this is not corrected with adequate oxygen therapy.

Blood gases

Analysis of blood gases provides important information to help the management of severe asthma. The usual finding is of a low arterial PaO, (hypoxaemia) due to ventilation/perfusion mismatch, and a low PaCO, (hypocapnia) due to the effects of hyperventilation. Later in the disease process, the PaCO, may be found to be high because the hyperventilation fails to compensate for the fact that there are many underven-tilated alveoli which are distal to the blocked bronchioles. When the PaCO, is found to be increasing and the pH is low this should be a danger sign that the patient may be becoming tired and be likely to need assisted ventilation if immediate improvement cannot be achieved (British Thoracic Society 1997).

Breath sounds

These are vesicular with evidence of a prolonged expiration and high-pitched wheeze. Crackles may also be heard if sputum is present. During severe attacks with worsening obstruction, the breath sounds may be

Percussion note

The note may be hyper-resonant if the patient is hyper-inflated.

Chest X-ray

Radiography is not usually helpful in the management of asthma. It usually shows only overinflation although may also show a pneumothorax if this is suspected.

Lung function

FEVj and FVC drop during a severe attack with little sign of reversibility (Figure 14.5). However, if FE¹^ is measured before and after giving bronchodilators and there is a 15% increase in FEVj – this amounts to significant reversibility. The FEVj maybe less than 30% of FVC. Total lung capacity, FRC and RV maybe increased due to overinflation of the lungs. Recovery is associated with a reduction in these lung volumes. Recordings of the peak expiratory flow rate (PEFR) for a week at home will often make the diagnosis of asthma obvious (Prior and Cochrane 1980). PEFR dips in the morning especially during the recovery phase (Figure 14.6). If the dip is severe (less than 33% of predicted) then respiratory arrest may occur (British Thoracic Society 1997). In a severe attack, the PEFR may drop below 1O0 litres/minute.

Between attacks

No abnormality should be detectable between attacks, although children with severe asthma may develop a

pigeon chest or have a persistent, low-pitched

wheeze with a productive cough.

Intrinsic (chronic) asthma

This is less paroxysmal in character than extrinsic asthma and is often associated with chronic bronchitis, Clinical features are similar to those described above for extrinsic asthma, but wheeze and dyspnoea tend to be continuous and worse in the morning, cough produces mucoid sputum, respiratory infections occur with increasing frequency, and radiographs may show emphysematous changes.

Acute severe asthma

As asthma is by nature a paroxysmal condition, acute attacks that are resistant to bronchodilators may occur, Such attacks are potentially life-threatening, so

PHYSIOTHERAPY TECHNIQUES IN ASTHMA____________________________

General Aims of Treatment

The principal aims are:

• to relieve any bronchospasm and to facilitate the removal of secretions

• to improve breathing control and the control of dyspnoea during attacks

• to teach local relaxation, improve posture and help allay fear and anxiety

• to increase knowledge of the lung condition and control of symptoms

• to improve exercise tolerance and ensure a long-term commitment to exercise

• to give advice about self-management.

The management of asthmatic patients should include maintenance of a good general fitness, and a vital part of asthma management is to educate the patient.

Patient education

All asthmatic patients and their close relatives should be aware of how to manage their asthma, and the physiotherapist is integral is the education process. Prevention of infection is important. The patient should have plenty of fresh air, avoid smoky atmospheres and keep away from people with infections suchas bronchitis and influenza. Stress or anxiety must be minimised as these can precipitate an attack.

Patients must know what therapy to take and how to take it and where they should go to seek further help. All this should be carefully planned beforehand and incorporated into a written action plan and self-management strategy (refer to Table 14.3).

Acute attacks

Treatment during acute exacerbations will involve the physiotherapist in aiding removal of excessive bronchial secretions using the ACBT technique (see above), with the addition of postural drainage, if tolerated. Percussion and shakings should be applied sensitively as they may increase bronchospasm. Breathing control and the adoption of relaxed positions may be necessary.

Pulmonary rehabilitation

Pulmonary rehabilitation has largely been confined I to patients with COPD, but there is now a recogni- I tion that other patient groups may benefit. The prin- J ciples are the same as those previously described for patients with COPD but with some additional considerations.

Patients with asthma are younger but very commonly have a fear and inhibition of exercise (Cochrane et al. 1990) and therefore can benefit from improved cardiorespiratory fitness (Patessio et al. 1993). Also, unlike patients with COPD, individuals with asthma usually show a greater variability in airflow obstruction, and are more susceptible to exercise-induced exacerbations (EIEs). Consideratioeeds to be given to the prevention of exacerbations (such as by the self-administration of beta agonists prior to exercise), although certain exercises – for example swimming — are the least likely to cause an EIE. In addition to whole-body programmes, inspiratory muscle training may also be incorporated into the exercise programme (as described previously for COPD patients).

Some patients, especially children, have constant excessive secretions and may require postural drainage with the ACBT on a daily basis. It may be essential to teach forced expiration technique for clearing secretions without increasing bronchospasm.

Relaxation

If the patient is able to practice relaxation it may be possible to ward off an attack when there has been exposure to an allergen. The onset of an attack is often preceded by a ‘tickle’ in the throat or a sensation of

tightness in the chest. Relaxation and breathing control in an appropriate position may prevent an attack developing. ‘Appropriate position^, depends on where the patient is and may have to be against a wall or the back of a chair.

Breathing control

Encouraging a longer expiratory phase is helpful, but neither inspiratioor expiration should be forced. This may be helped by counting (e.g. ‘in 1-2, out 1-2-3’) and by manual pressure just under the xiphis-ternum to encourage diaphragmatic excretion. The patient must breathe at a rate and rhythm that suits him or her. Children may be taught to breathe to a nursery rhyme.

BRONCHIECTASIS

Bronchiectasis is an abnormal dilatation of the bronchi associated with obstruction and infection (Cole 1995).

The most common cause of bronchiectasis is damage to the bronchial tree after infection. Bronchiectasis may also complicate bronchial obstruction or a more widespread disorder (e.g. cystic fibrosis).

Types and Prevalence of Bronchiectasis

The condition most commonly affects the lower lobes, the lingula and then the middle lobe. It tends to affect the left lung more than the right, although 50% of cases are bilateral. The upper lobes are least affected since they drain most efficiently with the assistance of gravity. There are broadly two types of disease.

Congenital bronchiectasis

This is very rare and occurs in Kartagener’s syndrome (‘immotile cilia’ syndrome) where there is a congenital microtubular abnormality of the cilia that prevents normal cilial beating. It is characterised by bronchiectasis, sinusitis, dextrocardia and complete visceral transposition. There may also be associated male infertility.

Acquired bronchiectasis

Bronchial obstruction and bacterial infection are the principal factors responsible for this disease. Obstruction of a bronchus, which may be due to a tumour or foreign body, will cause collapse of the lungtissue supplied by that bronchus. Bronchiectasis may also occur following an infection, which causes the production of sticky sputum leading to obstruction of multiple small bronchi. Classically this is associated with whooping cough, tuberculosis, measles and pneumonia in childhood, when the airways are smaller and therefore more easily ‘plug’ with sputum. Very occasionally, bronchiectasis may occur as a late complication of tuberculosis, which has affected the right middle lobe causing that segment to collapse. It may also occur following lung abscess and pneumonia and be associated with immune defects in patients with hypogammaglobulinaemia. Allergic bronchopulmonary aspergillosis, which is associated with an autoimmune response, can cause formation of mucus plugs resulting in bronchiectasis of the medium-sized bronchi.

Prevalence

The prevalence of bronchiectasis following a childhood infection is decreasing dramatically since these infections are now treated with antibiotics, but bronchiectasis is a common feature of cystic fibrosis.

bronchial walls anastomose with the pulmonary capillaries and this results in the common feature of haemoptysis.

Clinical Features of Bronchiectasis

Although symptoms often begin in childhood, diagnosis is not usually made until adult life.

Pathology of Bronchiectasis inhaled foreign body such as a peanut or broken tooth or obstruction due to a tumour or enlarged gland) or generalised (e.g. pneumonia that is slow to resolve owing to whooping cough or measles).

The bronchial obstruction will cause absorption of the air from the lung tissue distal to the obstruction and this area will therefore shrink and collapse. This causes a traction force to be exerted upon the more proximal airways, which will distort and dilate them. If the obstruction can be cleared and the lung re-tspanded quickly then the dilatation is reversible. Secretions may collect distal to the obstruction if it is lot relieved quickly and these easily become infected. His causes inflammation of the bronchial wall with destruction of the elastic and muscular tissue. These infections occur repeatedly with the walls becoming weaker and weaker. They will eventually dilate owing to the negative intrapleural pressure. As the disease advances, the bronchi become grossly dilated and pockets containing pus are formed. The elastic and muscle tissue is destroyed and the mucous lining is

iced by granulation tissue with loss of cilia. Therefore, the mucociliary transport mechanism is disrupted and passage of mucus out of the lungs is therefore hindered.

Several types are recognised pathologically: tubular, fusiform or sacular. The arterial vessels within the

Cough and sputum

Patients complain of persistent cough with purulent sputum since childhood. Initially it would be present only following colds or influenza, but if the disease is allowed to progress in its severity the affected segments continually accumulate purulent secretions resulting in cough and sputum production. The sputum is usually green, often foul smelling and present in fairly large volume. The breath is fetid. The cough is particularly troublesome on a change of position and on rising first thing in the morning.

influenzae and/or Staphylococcus. In the later stages of the disease Pseudomonas aeruginosa and Klebsiella may be isolated.

Dyspnoea

Shortness of breath is noticeable only if the disease is particularly severe and widespread. If the bronchiectasis is localised, other well-ventilated and perfused alveoli should maintain blood gases at a reasonable level, although bronchospasm may be a feature particularly during an exacerbation.

Haemoptysis

This occurs quite commonly, usually associated with an acute infection. It can be life-threatening if severe and may require surgical resection of the affected lung tissue.

Recurrent pneumonia

Characteristically this will affect the same sites and is a common feature.

Chronic sinusitis

This occurs in approximately 70% of the patients.nays rnysiornerapy

General ill-health

Patients may suffer pyrexia, night sweats, anorexia, malaise, weight loss, lassitude and joint pains.

Clubbing

In about 50% of the patients fingers and toes become clubbed. The first sign of clubbing is loss of the angle between the nail and the nail bed. This is followed by curvature of the nail, and an increase in the soft tissue of the ends of the fingers to form so-called ‘drumstick’ fingers.

Thoracic mobility

This gradually decreases, as do shoulder girdle movements.

Radiography

Initially the X-ray this will be normal but the patient gradually develops increase in the bronchovascular markings and sometimes shows multiple cysts with fluid levels (Armstrong et al. 1995). Bronchography is used for accurate localisation of the area affected and will reveal dilated bronchi. A CT scan will show bronchial wall thickening and dilation of the bronchi and cysts.

Prognosis of Bronchiectasis

The vast majority of these patients can lead normal lives with a nearly normal life expectancy provided the medical care is adequate. Possible complications, however, are:

• recurrent haemoptysis (common)

• pneumonia (common)

• pleurisy and empyema

• abscess formation (in lung/cerebrum) (rare)

• emphysema (rare) respiratory failure

• right ventricular failure (commonly develops after years of pulmonary sepsis and arterial hypoxaemia if there is widespread bronchiectasis)

• systemic amyloidosis (rare).

MANAGEMENT OF BRONCHIECTASIS

Principles of Treatment

The anatomical picture makes very little difference to the treatment of the disease.

• Relieve the obstruction before permanent damage occurs (recognition of either localised obstruction

or appropriate treatment for whooping cough or measles).

• Control infection. Antibiotics are given prophylacti-cally in all but very mild cases. The dosage of the antibiotics should be altered if an acute infection occurs. Intravenous treatment is indicated for severe infections (Currie 1997). Inhaled (delivered by a nebuliser) or continuous oral therapy may be used for chronic sepsis and more resistant pathogens (e.g. Staph, aureus and P. aeruginosa).

• Promote good health with a good diet and fresh air.

• Maintain and improve exercise tolerance as some patients with bronchiectasis become deconditioned owing to fatigue and shortness of breath.

• Inhaled steroids may be used in order to reduce inflammation and reduce the volume of sputum produced (Elborn et al. 1992).

• Surgery to remove the area of affected lung may be indicated in young patients with localised disease, although there is conflicting evidence regarding the efficacy of surgery when compared to conservative treatment (Corless and Warburton 2000).

Physiotherapy

Aims of treatment

The principal aims of physiotherapy in bronchiectasis are:

• to remove secretions and clear lung fields

• to teach an appropriate sputum clearance regimen

• to educate the patient in the pathology and management of the condition

• to promote good general health and maintain or improve exercise tolerance

• to teach the patient how to fit in home treatment within his or her lifestyle.

Clearing secretions

Postural drainage may be indicated, if tolerated for patients with excessive bronchial secretions. The position must be accurate for the areas of lung affected. Accuracy is judged by production of sputum and by identification of the affected areas on a chest radiograph. This minimises the danger of secretion overspill into the least affected side, which could cause spread of the disease or pneumonia. Percussion, shaking and vibrations with the active cycle of breathing technique (ACBT) are also necessary and must be accurately applied over the affected area of the lungs.

The patient may be taught the forced expiration technique (FET). A flutter or positive expiratory pressure (PEP) valve may be used to facilitate the move-ment of peripheral mucus plugs and pus into the trachea from where they are cleared by coughing. The patient must perform a combination of these treatments 2-3 times daily. It is important to ensure that the patient has disposable sputum pots and polythene or paper bags to dispose of the infected sputum without the risk of reinfection or endangering other members of the family. Should the patient develop a cold or influenza, antibiotics must be readily available together with physiotherapy so that infection and secretions can be cleared promptly.

Maintaining exercise tolerance

Mobility of the thorax, good posture and good general health are achieved by the patient performing a daily exercise programme. This comprises general deep breathing, attention to maintaining a good posture and some aerobic exercise such as brisk walking. The patient may also attend a pulmonary rehabilitation programme if exercise intolerance is impairing mobility and quality of life. The patient should also be encouraged to partake in sports, such as jogging, walking, cycling, tennis or swimming.

CYSTIC FIBROSIS

Cystic fibrosis (CF) is a hereditary disorder of exocrine glands, with a high sodium chloride content in sweat and pancreatic insufficiency resulting in malabsorption. There is hypertrophy and hyperplasia of mucus-secreting glands resulting in excessive mucus production in the lining of bronchi, which predisposes the patient to chronic bronchopulmonary infection.

Cystic fibrosis is the most common hereditary disorder, being transmitted by a recessive gene, which is estimated to be present in 1 in 20 in the United Kingdom. Cystic fibrosis is the most common life-shortening autosomal recessive disorder in the Caucasian population. It is caused by mutations in a single gene on the long arm of chromosome 7 that encodes the cystic fibrosis transmembrane conductance regulator (CFTR) (Collins 1992).

Pathology of Cystic Fibrosis

Mutations in the CFTR gene result in defective chloride” transport, which is accompanied by decreased transport of sodium and water in the epithelial cells in the respiratory, hepatobiliary, gastrointestinal and reproductive tracts and in the pancreas (Quinton 1990). This results in dehydration and hence an increase in the viscosity of secretions that are associated with luminal obstruction and scarring of various exocrine ducts (Oppenheimer and Esterly 1975). Other than in the respiratory system, the resultant clinical manifestations include pancreatic insufficiency, diabetes mellitus, azoospermia in affected men and evidence of biochemical liver abnormality in up to 80% of children (Ling et al. 1999).

The primary causes of morbidity and mortality in patients with CF, however, are bronchiectasis and obstructive pulmonary disease; the latter accounts for over 90% of deaths. Infants with CF have persistent endobronchial bacterial infections (Abman et al. 1991) which are associated with an intense inflammatory response that damages the airway and impairs local host defence mechanisms (Konstan and Berger 1993). Continuous inflammation coupled with thickened pulmonary secretions leads to airways obstruction andhyperinflation (Davis et al. 1996). Hyperinflation becomes a marked feature of the disorder leading to altered pulmonary mechanics, which causes the inspiratory muscles, particularly the diaphragm, to be foreshortened prior to contraction. In such cases, even a small change in breathing pattern (Bellemare and Grassino 1982) or an increase in ventilatory requirement induced by exercise could be enough to induce inspiratory muscle fatigue (Levine and Guillen 1987).

Pulmonary changes

• Excessive mucus. There is excess mucus production especially in the small bronchi and bronchioles. These respiratory passages are structurally normal at birth but become blocked by mucus plugs. Lung disease in CF is also characterised by impaired mucocilary clearance of secretions.

• Viscid mucus. The abnormality in the mucous glands results in production of mucus with a reduced water content so that the secretions produced are very viscid and stick to the bronchial walls.

• Infection. The accumulated mucus provides a medium for growth of bacteria and so the secretions become infected and purulent. This leads to irritation of the bronchial wall tissue, which then becomes inflamed.

• Bronchiectasis. Inflammation leads to weakening of the bronchial walls and dilatation occurs as in bronchiectasis.

• Lack of development of lung tissue. Mucus and inflammation resulting in airway obliteration inhibits the development of normal lung tissue.

Other pathological changes

Fibrosis of the pancreas causes digestive malfunction and may lead to development of diabetes. Intestinal obstruction may occur owing to gallstones or faecal impaction. Iewborn babies, there is intestinal obstruction – known as ‘meconium ileus’ because there is excess meconium (a greenish black viscid discharge from the bowel of newborn babies) which plugs the small intestine necessitating an emergency operation. Right ventricular hypertrophy occurs owing to pulmonary congestion, which develops as fibrosis, and thickening of the pulmonary arterial walls takes place.

MEDICAL REHABILITATION AT DISEASES OF JOINTS AND CONNECTING FABRIC

When the normal mechanics of joint motion are altered, pain and early signs of joint degeneration often occur. This chapter explores the effects of altered mobility, reviews normal joint function, and provides basic information on appropriate treatment techniques that can be applied. The word manipulation has been used loosely in medicine to mean passive movement of any kind. In this chapter, manipulation will be defined as a sudden movement or thrust, of small amplitude, performed at a speed that renders the patient powerless to prevent it. Joint mobilization is defined as passive movements performed in such a way that, at all times, they are within the control of the patient so that he can prevent the movement if he so chooses. Joint mobilization techniques are applied in the presence of restricted joint motion. The practitioner must make certain, however, that a painful joint exhibits restriction of the capsule and requires mobilization. Often, active range of motion is limited or painful, but the cause of the limitation is found in other peri-articular structures. The effective examination procedures to make an accurate diagnosis and to provide the most effective treatment are covered.

PHILOSOPHY OF JOINT DYSFUNCTION

Joint injury, including conditions, such as osteoarthritis, instability, and the after effects of sprains and strains, are not diseases but dysfunctions. These dysfunctions are manifested as either an increase, a decrease, or abnormality of motion.

When the dysfunction manifests as limited motion, the treatment of choice is mobilization of joint structures, stretching muscles and fascia, and sometimes strengthening of muscles. When the dysfunction is manifest as increased move-

ment, laxity, or instability, the treatment is not mobilization of the joint in question but stabilization. This may be accomplished through correction of joint limitations ieighboring joints that may be contributing to the joint’s need for compensation or through postural training and exercise.

Joint dysfunction responds well to conservative treatment. Even after degeneration has occurred and resulted in a loss of joint space, cartilage can be made to regenerate by removing restrictions, stretching the joint capsule, and promoting normal and frequent use.¹

The effects of continuous passive motion (CPM) have been studied on the healing of full thickness articular cartilage defects. Salter et al. published the results of experimental continuous passive motion on defects in the distal joint surfaces of the femur in 20 immature rabbits. With continuous passive motion, healing through the formation of new hyaline cartilage (chondroneogenesis) occurred in over half of the induced defects within 4 weeks.¹⁵

EFFECT OF IMMOBILIZATION ON ARTICULAR AND PERIARTICULAR STRUCTURES

Each structure responds uniquely to immobilization. It is important to understand each structure’s response to effectively manage the patient during the rehabilitation process.

Cartilage

Cartilage does not have a direct blood supply. It relies on the compressive and distractive forces of joint motion to obtaiutrients and oxygen. When a joint is immobilized, the cartilage weakens and begins to lose its stiffness and resilience to compression. Areas in which the articular cartilage does not make good contact with the articular cartilage on the opposite joint surface develop fibrous changes, or pannus formation, and loss of cartilage results. This accounts for the loss of vertical height in the joint space with degenerative changes. Radiographs exhibit degenerative changes including spurring after as little as 4 weeks of immobilization.

Synovium

In 2 weeks of immobilization, the blood vessels in the subsynovial region proliferate, and increased synovial fluid is produced. After 4 weeks, there is a marked increase in the number of synovial cells, hyperemia is present, and pannus begins to form over the noncontact articular cartilage. Within 6 weeks, the amount of fibroblasts and collagen within the joint increases, giving a fibrotic appearance.¹

Joint Capsule

The joint capsule begins to show signs of increased thickness after 5 weeks of immobilization. Folds of capsular tissue adhere to each other and further restrict

Ligaments and Tendons

Disuse atrophy of the surrounding ligaments and tendons occurs. The tensile or breaking strength reduces, and the strength of the structure’s insertion at the bone

diminishes. Ligaments demonstrate a decrease in fiber bundle thickness. Tissue samples taken from immobilized sites are found to have a reduced amount of aerobic enzymes.¹

Bone

Bone density is maintained through weight bearing. Weight-bearing bones require at least 2-3 hours of vertical weight bearing each day in order to maintain density. After a period of immobilization when weight bearing is prohibited, the capacity of the bone to withstand stress is diminished.¹

Muscle

Similar effects take place at the voluntary muscle groups surrounding the involved immobilized joint. Muscles atrophy, vascularization decreases, and fuel stores and mitochondria within the muscle decrease. The aerobic capacity diminishes, there is loss of volitional control of the muscle and the capacity to withstand tensile forces reduces.

Not all of these structures recover at the same rate. During the rehabilitation process the program must be adapted to allow recovery of the lowest metabolic systems first, progressing over time to the higher metabolic systems.

JOINT MOBILIZATION AND CLASSIFICATION OF MOVEMENT

There are five classifications of joint movement as outlined by Dr. Mennell.

1. Active joint movement. These are the classical gross motions taught by
anatomists, or joint motion that can be actively performed by a voluntary muscle.

2. Passive joint movement. The movement in which a joint is passively put
through the range of motioormally under voluntary control.

3. Joint play movement. This movement is not under voluntary control but is
necessary for the performance of painless, free, voluntary movement. Examples of
these motions are long axis traction, rotation, anterior and posterior gliding, and
medial and lateral gliding.

4. Articulary movement. This is also a nonvoluntary motion. A joint with limited
joint play is taken through the full range of motion, and then a series of passive,
rhythmic repetitions of movement are applied by a practitioner to restore normal
synovial joint play movement.

5. Specific joint manipulation. This movement describes the action in which a
joint with limited synovial joint play is taken through the full range of movement
present, at which point a manipulative thrust is applied to restore the full normal
range. Full joint play allows pain-free active motion.¹²