MEDICAL REHABILITATION OF CHILDREN.
MEDICAL
REHABILITATION OF GYNAECOLOGICAL PATIENTS.
MEDICAL
REHABILITATION OF PATIENTS WHICH SUFFERED AS A RESULT OF INCIDENT ON
CHORNOBIL AES (CHAES).
Massage benefits individuals of all age groups and
different conditions. Touch is as important to any infants and kids like eating
and sleeping. Massaging involves loving, gentle stroking or kneading by a
parent or caregiver on various parts of a child's body like the face, head,
arms, shoulders, neck, hands, back, legs and feet.
Use of oils on the body of your precious little ones to soothe, relax and heal
affirms a strong, close bond conveying a comforting sense of trust and
security.
Early infant massage enhances the development of the nervous system and
stimulates all other systems of the body. It improves circulation, respiration,
aids digestion and eases elimination of wastes from the body. It also makes
your little one less prone to gas and colic ailments. Massage of baby in its
growing years prepares the body for sitting, standing and walking.
Massage is a
wonderful stress buster for children who are prone to all kind of stress. Like
a child starting a school in a new area, health, fights amongst parents, exams
or peer pressure, etc produce emotional, physical and mental stress. Massage
reduces stress hormones and heals the body.
Each child responds differently to massage. Some may squirm, cry, or some might
just appear more relaxed and calm and also fall asleep.
There is no fixed time to massage your baby. Find a time suitable for you and
your baby. Some enjoy in the morning after their feed, some in the afternoon
before or after their naps. Massage before bedtime can put a cranky baby to
sleep peacefully. Follow the massage with a warm bath.
While giving a massage, sit straight either on the floor or on the bed or stand
before the table. The room is warm enough as your little one can shiver when
undressed. The place where you massage you baby should be quiet and away from
distractions of all kinds.
Lay your child on soft surface like thick set of towels so it may not hurt it
self when it wriggles or squirms. Keep aside towel, pair of wash cloths, clean
diaper and baby clothes for use after the massage.
Oils are good for lubrication, helping your hand glide smoothly over your
baby's soft and rather delicate skin. Small babies have a habit of putting
their hand or fingers in their mouth all the time, so its
ideal to use oil that is of good quality. Use cold pressed (oils extracted by
means of pressure) or unscented oils. Alternatively you can use baby oils
produced by many companies which specialize in baby products. Grape seed oil
has nice texture, apricot and almond oils are smooth, light and easily
absorbable into the body. To massage your babies, use coconut oil in summers
and mustard oil in winter.
Intensive
Neurophysiological Rehabilitation System The
Kozijavkin Method
It is well
understood that Cerebral Palsy is caused by many different noxious factors
applied to the developing brain. Nowadays, more than 400 different causes are
known, which determine very different clinical signs in each child affected.
Each patient is a peculiar individual, and therefore one universal way of
treatment cannot be applied to all patients.
Unfortunately,
the use of only traditional methods of physical therapy and rehabilitation fail
to bring the desired results in many cases. The therapy should not have a
single focus. Only an individualized combination of different treatment
modalities can achieve the desired results.
One such multimodal approach to the
rehabilitation of patients with CP is the Intensive Neurophysiological
Rehabilitation System (INRS), also known by the name of its author – the
Kozijavkin Method.
Stimulating compensatory possibilities and brain
plasticity, this method creates a new functional state which opens the
possibility for faster motor and mental development of the child.
Different rehabilitation modalities of this
system complement and intensify each other, and are aimed at the main task of rehabilitation:
improvement in the quality of the patient’s life.
It is important to stress that the Kozijavkin
Method is not an alternative to existing rehabilitation approaches. It
complements and significantly increases the efficiency of many other existing
rehabilitation systems.
The new
functional state, created by the INRS, along with muscle
tone
normalization, joint mobility restoration, improvements of tissue
trophicity
and blood circulation, opens new wide possibilities for the
development
of the child and enhances the results of other
rehabilitation
treatments.
The
Kozijavkin Method was created 15 years ago in the
thus
far, more than 15, 000 patients have been treated by this method,
including
about 7,000 from
More than 40 families from the
the
Already in 1993, the rehabilitation system has
been officially recognized by the Ukrainian government. Due to the high level of
success with the Kozijavkin Method, it has received international approval and
has been included in the encyclopedic edition of child orthopedics by the
well-known German professor, Frits Niethard (1998), as one of the four most
effective approaches to the
rehabilitation
of Cerebral Palsy.
Statistical analysis of the medical records of a
group of 12,256 patients treated by the Kozijavkin Method confirmed the high
efficiency of this rehabilitation system.
Muscle tone normalization was noted in 94% of
patients, improvement of head control in supine position was noted in 75% of patients,
62% of the patients who were unable to sit before the treatment have learned to
sit, 19% of patients began to walk without assistance, and 87% of patients
after the treatment were able to
open
their spastically fisted hand∗.
Fig 2.
Results of the rehabilitation by the Kozijavkin Method
Over the past
few years, the interest in our rehabilitation system has grown in the USA.
Beginning in 1999, our doctors have made presentations of the Kozijavkin Method
in the USA and this information was accepted with great interest at the
University of Illinois in Chicago (1999), the Cleveland Clinic (2000), the
conferences of the American Academy of Physical Medicine and Rehabilitation
(2000), and at the American Congress of Rehabilitation Medicine (2001).
Several
special conferences and workshops have been conducted in New York, Ohio,
Florida, California and Washington.
This article
about the basics of our rehabilitation system will provide a clear explanation
of the Intensive Neurophysiological Rehabilitation System for health
professionals, patients and parents.
History of the Kozijavkin Method
In the process of its rise and development, the
Kozijavkin Method, Intensive Neurophysiological Rehabilitation System went
through several evolutionary stages, constantly improving and adjusting.
The basis of the rehabilitation system – the
method of the biomechanical correction of the spine was worked out already in the
late 1980’s. The author of the method, Prof Kozijavkin, while treating patients
with diseases of the nervous system and spine, had utilized the methods of
manual therapy. With long-term experience, he discovered that the use of
certain spine mobilization techniques resulted in normalization of muscle tone.
This
practical experience encouraged the successful use of the spine mobilization
techniques for the reduction of muscle spasticity in children with Cerebral
Palsy.
However, the
anatomical and physiological peculiarities of the child’s spine required an
adaptation of the classical methods of the manual therapy. Therefore, V
Kozijavkin developed the original technique of the polysegmental biomechanical
correction of the spine specific to the child.
For the first
time a report about the new method of rehabilitation was delivered at the
All-Union Research Conference on child neurology and psychiatry in Vilnius in
1989.
The new
rehabilitation system awakened interest among doctors and researchers of the
Soviet Union. In the same year, a commission of experts headed by the leading
Soviet neurologist, Prof K. Semenova, confirmed the effectiveness of the new
rehabilitation
system.
In 1990 to enable wider implementation of the new
rehabilitation system in Lviv (Ukraine), a new contemporary Rehabilitation
Center was founded. This center began treating patients from the Ukraine and
Russia. However, as information about the new rehabilitation system spread to
Europe, the first group of patients from Germany arrived in the Ukraine for
treatment in 1991. Positive treatment
results
have since led to an increase in the number of patients.
Since
In order to broaden the range of the research
work and further refine the rehabilitation approach, a new Institute for
Medical Rehabilitation was established. The main direction of its work was the
further research in the medical rehabilitation of patients with diseases of the
nervous system and spine.Employees of the Institute collaborate with Lviv
Medical University, Ukrainian Research Institute of Neurology and Psychiatry,
Kiev Medical Academy of Postgraduate Education, German Academy for Rehabilitation
and Development, Munich Child Center, and many other scientific and practical
institutions.
Fig
3. Institute for Medical Rehabilitation
was
established in 1996
Good results and the high efficacy of the new
rehabilitation technology assisted in its recognition not only in the Ukraine,
but also far abroad.
Well-known German professor Frits Niethard in his
encyclopaedic edition of child orthopedics (1998) includes the Kozijavkin
Method in the four most effective approaches to rehabilitation of Cerebral
Palsy.
Fig
4. The encyclopedic edition in child
orthopedics included
the
Kozijavkin Method in a list of the four most effective
rehabilitation
systems for patients with CP
For major achievements in rehabilitation
research, a group of physicians headed by Prof Kozijavkin received the State
Prize of Ukraine in the Field of Science and Technology in 1999.
To spread the advanced experience in the field of
rehabilitation, our Institute in close cooperation with the department of
physical therapy and rehabilitation of Kiev Medical Academy of Postgraduat Education
has established educational postgraduate courses.
Since 1999, over 750 physicians of different
specialties have become acquainted with the basics of the Intensive
Neurophysiological Rehabilitation System during the advanced training courses.
In order to provide high-level accommodations for
an increasing number of patients, and permit continued improvements and expansion in the
rehabilitation system, a new contemporary International Clinic of
Rehabilitation was put into service in the summer of
Pathophysiological basis of the
rehabilitation system
The damage of
the central nervous system in Cerebral Palsy is accompanied by the secondary
changes of the muscloskeletal system and other systems of the body.
High muscle
tone, pathological reflexes, improper body position, and pathological movement
patterns cause changes of the joints, shortening of the spastic muscles,
tendons and ligaments, and abnormalities of blood circulation and metabolism.
Those
pathological changes are accompanied by restriction of joint movement and
development of functional blockages.
As is evident
in literature, functional blockages by themselves augment disturbances in
trophicity, circulation, and autonomic functions resulting in further slowing
and distortion of motor development in the child. A pathological vicious circle
is formed.
In Cerebral
Palsy, functional blockages develop in the majority of the joints. In the study
of this phenomenon, most authors haveaddressed joints in the extremities, but there is little
discussion of the more than 100 joints of the human spine in which functional blockages
are also developing.
Our studies, which began in the mid eighties,
showed the important role of the spine in the pathogenesis of Cerebral Palsy.
The functional blockages are not limited to a single joint of the spine, but rather
the blockages occur in several adjacent vertebrae resulting in polysegmental
spinal blockages.
These spinal blockages influence all the organs
of the human body which are innervated by the corresponding segments of the
spinal cord. The segmental interactions are disturbed (both with respect to innervation
of the organs and systems innervated by the same segment of the spinal cord),
as well as those innervated by vertical connections of the segment with the
higher centers of the nervous system (connections with brain stem, basal
ganglia and cortex).
Proprioception may also be affected in CP. In the
joints, tendons and muscles there are receptors that relay information about
body position, equilibrium and movements. There are muscle spindles in the
muscles, Golgi tendon organs in the tendons, and joint kinesthetic receptors in
the joints.
Information from those receptors is essential,
not only for the performance of all movements, but also for motor training and learning
new movements.
Recent
studies have shown that functional spinal blockages are blocking and distorting
the flow of proprioceptive information from the musculoskeletal system through
the central nervous system, which further complicates the motor development of
the CP patient.
In an attempt
to correct the above-mentioned pathological signs, the method of biomechanical
correction of the spine and large joints has been developed. This method became
the basis of the Intensive Neurophysiological Rehabilitation System.
The technique of the biomechanical correction
releases functional blockages of the spine, restores joint mobility and opens
the “gate” for the flow of the proprioceptive information to the central
nervous system.
Fig
5. Releasing of functional spinal
blockages opens the flow of
the
proprioceptive information to the central nervous system and
creates a
new functional state in the individual.
The results of this technique are not limited to
the changes in joint mobility, but are accompanied by complex changes in the
body – the so-called new functional state is created. The muscle tone is
normalized, and tissue trophicity, blood circulation, and metabolism are
improved.
The new functional state significantly enhances
the possibility for faster motor and mental development. However, isolated use
of the biomechanical correction of the spine is not sufficient. It only creates
the basis for the possible future development of the child.
This
rehabilitation approach assumes that the human body is a complex self-organizing
system, made up of many subsystems which can exist and develop normally only if
their interconnections are ordered and harmonious.
The damage or
malfunction of one subsystem disturbs the function of the entire organism as is
the case in CP. When self- regulation is not sufficient, the dysfunction of the
whole body occurs.
Influencing
the different chains of the pathological process with different modalities, our
task is to break the pathological vicious cycle, create a new functional state
in the body, and open up the possibilities for faster motor development.
Hence, the Intensive Neurophysiological
Rehabilitation System was created. It combines different treatment modalities
that complement and reinforce each other. The method of biomechanical
correction of the spine, combined with other treatment methods, is used to
prepare the child for the correction, sustain the achieved results, create
correct movement patterns, and accelerate motor and mental development.
The pathophysiological mechanism presented above
is only one of several hypotheses regarding the effects of this treatment
method.
Other hypotheses of the therapeutic influence of
the Kozijavkin Method are now in the process of development.
Principle of the Star in
Rehabilitation
Some rules of the medical rehabilitation by the
Kozijavkin Method could be illustrated using the principle of a pentagon star.
A man could be represented as a star and the
points of which correspond to the hands, legs and head. All the points are
joined around the center and the axis of the body – around the spine and spinal
cord. Each point includes main structures – muscles, bones, joints, vessels,
and nerves. The proximal large joints, big muscle groups, large vessels and
nerves are situated near the center of the star. Distal small joints and muscles,
tiny vessels and nerves are on the ends of the star points. Phylogenetically
older structures of the brain stem occupy the most proximal areas of the point
representing the head, followed by younger structures (basal ganglia), and
distally the youngest structures, which determine higher functions – the brain
cortex.
Tight
interconnections of all the structures are necessary for the normal development
of the body achieved by the efferent (from center to periphery) and afferent
(from periphery to center) informational flow.
Functional
blockages of the spine in cases of CP patients disturb this interconnection,
and block the flow of proprioceptive information.
This could be
presented as a disturbed interrelation of the star points. Restitution of normal
interconnection among the points to achieve harmony of the star in the
Kozijavkin Method is achieved using the principle from the “center to the
periphery”.
Fig
6. Principle of the
Star in the Rehabilitation.
The therapeutic influence starts on
the central structures
(circle A),
then gradually added the influence on the proximal
-B, middle–C, and distal–D structures
of the body
In the early sessions the therapy is applied
primarily on the central structure, the spine (circle A on the picture).
The purpose
of this method is to release the functional spinal blockages, normalize muscle
tone, tissue trophicity and blood circulation, and create a new functional
state in the organism.
In the
central nervous system this new functional state is manifested by the mental
arousal of the patients, a psychological “awakening”, opening possibilities for
the motor and mental development of the child and enhanced effectiveness of
other treatment modalities.
The next step
is meant to influence the proximal structures. The large joints of the shoulder
and pelvic girdle are influenced utilizing the mobilization techniques of
physical therapy and massage (circle B).
Gradually the
methods aimed at activation of the medium sized joints (circle C) are added,
and finally the small distal structures are treated (circle D).
Creation of
the higher and more “distal” fine motor functions of the hand, development of
balance, and improvement of speech is possible only after the development of
the previous, more “proximal” functions.
The
correction begins with the “central” structures, which affect phylogenetically
older and more simple functions. Then the influence on
the “proximal” and “middle” structures is added, and ultimately, the treatment
of the “distal” structures, which fulfill a new and higher function merged.
Short Description of the Kozijavkin
Method
The Kozijavkin Method or INRS consists of two
subsystems – The Intensive Correction Subsystem and The Stabilization and
Effects Potentiation Subsystem. The Intensive Correction is performed in the
Rehabilitation Center and lasts for two weeks. In the period of Stabilization
and Effect Potentiation, treatment is continued at home according to the
recommendations given to the patient at the center.
This period usually lasts from 6 to 8 months, at
which point the patient is admitted to the center again for the next course of
Intensive Correction.
Fig
7. The Kozijavkin Method is a
multimodal rehabilitation
system
INRS is a multimodal rehabilitation system in
which the influence of one component is complemented and intensified by the
others. The main treatment programs include biomechanical correction of the spine,
extremity joint mobilization, reflexotherapy,
mobilizing physical exercises, special massage system, rhythmical group exercises,
mechanotherapy and apitherapy which are described in the next section. ...
Biomechanical Correction of the Spine
The basis of the rehabilitation system is the
polysegmental biomechanical correction of the spine created by Prof. V.
Kozijavkin MD. It is aimed at releasing the functional blockages of the spinal segments
and resumption of normal mobility of the joints of the spine.
Fig.
8. Biomechanical correction of the
spine is an
important
part of the treatment
Biomechanical
correction of the spine is carried out consecutively in lumbar, thoracic and
cervical regions. Lumbar spine correction includes simultaneous mobilization of
all blocked movement segments using our method of “backward rotation”.
Correction of the thoracic blockages is performed starting from the upper
regions to lower using special impulse techniques. Corrections of the cervical
spine are performed using movement with complex trajectory to simultaneously
influence all blocked segments.
Extremity Joint Mobilization
Extremity joint mobilization is used for the
improvement in mobility of the joints, stretching and improving muscle
elasticity, stimulating blood circulation, and for prevention of joint
contractures.
Mobilization starts with the treatment of the
large joints (hip, knee, shoulder) and then gradual involvement of the small
joints. In our work we use classical principles and also newly created
techniques.
The joints in our rehabilitation system are
brought out of the passive range of motion using a certain limited force. Gentle
tactile traction methods are used in combination with vibrating movements, as well
as an impulse technique of tapping along the joint cleft. During the treatment
course the intensity of the mobilization increases gradually. Mobilization of
the mandibular joints with the facial massage is used for improvement of
articulation and chewing movements.
Reflexotherapy
The method of
reflexotherapy serves to intensify the achieved spasticity reduction, eliminate
trigger points in the muscles and correct autonomic disturbances. The
biologically active points are influenced by means of a portable electric low
voltage stimulator, which is applied to the points of classical meridians, as
well as
specific
points. Influence on the trigger points is performed simultaneously with the
post-isometric and post-isotonic muscle relaxation. Reflexotherapy is performed
through intact skin and is painless.
Mobilizing Physical Exercises
Physical therapy is an essential part of the
rehabilitation system. In our program we use mobilizing physical exercises that
are aimed at the improvement of mobility of the joints of both the spine and
extremities, creation of new motor patterns, and acquisition of the necessary mobility
for daily life skills. The exercises are performed following the rule “from
center to periphery”, so that the main influence is on trunk movement and
proximal joints with gradual involvement of movement
in
distal small joints. New motor acts are taught first through passive movement,
then through passive- active movement, and finally through active movement.
Simple movements are undertaken first, followed by more complex movements.
Daily sessions include breathing exercises, exercises for joint mobilization,
as well as strengthening exercises.
Fig
9. Physical therapy is an essential
part of the
rehabilitation
system
Special Massage System
In our
rehabilitation program the special massage system is used to prepare for the
biomechanical correction of the spine, muscle relaxation and reflexotherapy. It
includes techniques of classical, segmental, and periosteal massage in
combination with post- isometric and postisotonic relaxation. In order for the
biomechanical correction of the spine to be effective, the appropriate
preparation of the musculoskeletal system is essential. Such preparation is
provided by means of relaxation massage techniques. Elements of joint
mobilization and acupressure are also included in the massage system.
Techniques of stimulating massage are used for activation of hypotonic, weak
muscles.
Rhythmical Group Exercises
Rhythmical group exercises are used to encourage
emotional development and social integration of the child. Group exercises are performed
with the elements of play therapy using music and dance.
The patients are grouped by age and the level of
motor ability and parents are also involved in these sessions. A positive
emotional attitude assists in the stimulation of the patient’s motivation for recovery
and strengthens their belief in their own power and potential.
Apitherapy
The method of apitherapy (treatment with bee’s
products) in our rehabilitation system includes beeswax wraps and the
application of bee venom. Apitherapy is used for the improvement of local blood
circulation, metabolism and tissue trophicity. Allergy testing is performed
prior to this treatment. In the technique of beeswax wraps, the warm packages
of beeswax mixed with paraffin, honey and propolis are applied to selected
joints or muscle groups. Along with the thermal
influence,
the diffusion of biologically active substances through the skin is important
for muscle growth.
Mechanotherapy
Several
methods of mechanotherapy are used to strengthen muscles, improve coordination
and correct movement patterns. Lower extremity training is done using lever
devices. The optimal training regime is set by adjusting levers, weights and
the number of repetitions.
Treadmill and
cycling devices are used for the correction of lower extremity movement
patterns. For the upper extremities we use primarily block devices. Devices
such as the “Vibroextensor”, which combines heat, vibration and mechanical
massage of the para-vertebral regions are also used.
Fig
10. Methods of mechanotherapy are used
to strengthen
muscles,
improve coordination and correct movement patterns
Indications and Contraindications
Main
Indications
• Cerebral
Palsy (all forms)
• Gross and
fine motor delay
• Post
traumatic brain injury, stroke and neuroinfectionsat least 6 months after the
event
• Vertebral
pathology with low back pain
• Impairments
of the autonomic nervous system, e.g.functional cardiac and respiratory
complaints
• Headaches
and Migraine
Contraindications
• Congenital
anomalies of the vertebral column and of the central nervous system
• Expressed
spine instability – spondylolisthesis, and osteoporosis
• Acute
inflammatory and infectious diseases of the central nervous system
• Acute
period after brain trauma and stroke
• Severe
brain damage
•
Decompensated Hydrocephalus
• Severe
epilepsy and convulsions with frequent seizures
• Tumors of
the spine, spinal cord and brain
•
Inflammatory diseases of the spine
• Prior spine
surgery
• Fragile
medical condition
• Pronounced
psychiatric disorders
In doubtful cases, the decision is made
individually after extended examination and review of medical records.
Treatment results
The primary
goal of the outcome studies of the Intensive Neurophysiological Rehabilitation
System is the assessment of those functions which influence the quality of
life, the main aim of our rehabilitation treatment. Therefore, the studies evaluate
gross motor function, fine motor function of the hand, and mental
development.
A four-level
diagnostic algorithm has been worked out for the complex patient evaluation. It
includes the preliminary selection of patients for treatment, obtaining data
necessary for the development of individual rehabilitation programs,
observation of the changes in the patient’s conditions during the treatment and
preparation of the home program for the patient.
In 2002, the extended analysis of the medical
data of 12,256 patients treated with Intensive Neurophysiological
Rehabilitation System was reported.1 In this group, 89% of the patients were
children with different forms of Cerebral Palsy, 6% - with disorders of the
spine, 3% with residual conditions after damage of the central nervous system (stroke,
brain trauma), and 2% with other conditions.
Among the CP patients, 73% had spastic
quadriplegia, 16% spastic diplegia, 7% hemiplegia, 2% had hypotonic form and 2%
- hyperkinetic.
The largest age group consisted of patients from
7 to 14 years – 36% (Fig 11). Unfortunately, only 3% of the patients began treatment
below 4 years of age.
Fig
11. Distribution of Patients by Age and
Gender
Before treatment in our clinic, patients have
tried other
rehabilitation
methods: 73 % neurodevelopmental therapy
(Bobath), 59% rehabilitation by Vojta, 18%
Conductive
Education by Petö, and 22% tried other
treatment methods ..
(Fig
12)......... ......................................................
Fig 12.
Rehabilitation Methods Used Before our Treatment
37% of patients were treated in the Clinic for
the first time. 26% came for the second treatment, 14% of patients for the
third visit, 9% for the fourth visit, and 14% for five or more times.
One of the important clinical signs of the CP
patient is the alteration of muscle tone.
The Ashworth Scale was used for the assessment of
muscle tone.
Among the group of 10,793 patients with spastic
forms of Cerebral Palsy , 93% of patients experienced
a reduction in muscle tone.
(Fig 13).
In 7% of the cases, the muscle tone remained unchanged.
Fig
13. Changes in Muscle Tone
Range of passive and active joint movements is
one of the important rehabilitation goals. Our results
presents the changes of active and passive range of motion in large joints
in a group of 10.793 patients with a movement limitation before the treatment.
After the treatment, the range of passive
movement increased in 91% of the cases. The volume of active movements
increased in 84%. Passive and active movements remain unchanged in 8 and 15 % of
cases respectively, and there was some reduction of the movements’ volume in
only 1%.
We have developed a scale of gross motor
function, which was used to evaluate a group of 12,256 patients following
treatment.
75% of patients without prior head control in the
supine position had learned to control their head. 62% of patients who were
unable to sit, had learned to sit, 28% of patients had learned to crawl, 41% of
patients who earlier were unable to stand, had learned to stand, and 19% of
patients began to walk without assistance.
Fig
14. Development of New Motor Functions
The ability of the hand to grasp an object and
release it are both important functions for
independent life and both components are often disturbed in CP. The Sollerman
Hand Test (1995) was used to evaluate the grasp function. Improvement of fine
motor skills was noted in 87% of the patients that had problems with grasp
before the treatment. Hand function was unchanged in 13% and there was no
deterioration in any case.
Fig 15.
Function of the Hands
Once the child with CP returned home, further
improvement of motor function was noted in 45% of cases if therapy was
continued at home. In 47%, the achieved results remained at the same level and
the results were deteriorated in only 8%, mostly after infection, diseases, or
surgery.
Fig 16.
Results of Treatment between Intensive Courses
It was noted that the Kozijavkin Method of
rehabilitation resulted in improvement not only of movement and posture, but
also in the development of the psychological and mental function of the CP patient.
300 patients with CP were evaluated together with the Ukrainian Research
Institute of Neurology and Psychiatry2.Using the British Picture Vocabulary
Scale, a significant increase of the intelligent quotient after the treatment
was noted. In the case of the patients with spastic quadriplegia, the scores
increased from 76 to 89 points.
Fig
17. Changes of Intelligent Quotient (IQ)
Novelties in the Kozijavkin Method
Through activation of both internal compensatory
potential and plasticity of the nervous system, the effect of Intensive Neurorehabilitation
is the new functional state of the child’s body.
The next important step after the normalization
of muscle tone and increase in range of passive and active movements during a rehabilitation
course is to eliminate previous pathological movement patterns and to develop
new, correct movements.
To solve the above problem, we created a new
component and it was added to the program, which is based on the principles of dynamic
proprioceptive correction.
All exercises of this program are carried out
with the use of a biodynamical correction “Spiral” suit, which applies
additional exertion to certain joints. This creates forces for the dynamic correction
of movements and posture of the patient, and assists in acquiring new movement
patterns. While strengthening relatively weak muscle groups, especially the
extremity extensors, this program promotes vertical positioning of the child.
Fig
18. Biodynamical Correction Suit
“Spiral” with elastic
straps
to provide the necessary corrective force
The suit
consists of a system of elastic straps which are wrapped in a spiral across the
body and extremities. Imitating the positions of main muscle groups, they provide
the necessary corrective force.
The straps
can be attached to the supportive elements on the trunk and extremities (vest,
shorts, knee, elbow, foot and wrist pieces).
Velcro
attachments on the straps allow for various adjustments to be made optimizing
the corrective action desired.
The
development of a new movement pattern and the correction of the posture of the
patient is attained through the sum of forces applied
by the appropriate placement of the elastic straps. Attention is paid to the
peculiarities of a patient’s musculoskeletal system and the goals of treatment.
Fig
19. Training in Biodynamical Correction . .
“Spiral” Suit
enhances physical therapy
The biodynamical correction suit is used to
enhance remedial gymnastic exercises, mechanotherapy, treadmill training, training with play therapy devices, and plain movement
activity of the child.
For the relaxation of muscles and joint
mobilization a “Dolphin- Imitator” is used. This device causes wavy movements
of the ankles, which are propagated along the body. Those movements are much
like the movements of a dolphin in the water.
Fig
20. Wavy movements of the ankles
spreading along the body
assists
in spinal joints mobilization, relax spastic and overstrained
muscle
groups
An individual selection of frequency and
amplitude provides
movement
waves, which pass along the whole spine and body
assisting
in spinal joint mobilization, relaxation of spastic and
overstrained
muscle groups, and improvement in blood supply
and
trophicity of the musculoskeletal system. This effect can be
enhanced
by comfortably positioning the patient, and by adding
acoustic
or visual stimulation during the treatment.
American psychologist, O’Gorman (1975) has
mentioned that:
“Motivation of the patient is the most important,
yet the most
difficult
part of the work of the therapeutic professions”. Keeping
this
in mind, we have developed a series of special game- training
devices
aimed at the improvement of different movements and
the
activation of the patient’s motivation for training sessions.
One of these is a hand-training device, which
requires the patient
to
perform a specific exercise in order to successfully play a
computer
game. This stimulates the development of movement
speed,
increases movement amplitude, shortens reaction time
and
improves eye-hand coordination.
Specially developed existing computer games turn
physical
training
into an effective, and most important, an interesting
treatment
procedure. Simultaneously, game software measures
movement
parameters – volume, speed, frequency, and all the
data
of each training session is stored, and can be used to analyze
the
patient’s progress.
Fig 21.
Hand training device improves hand function
in
the game
Another device is a training chair in which a
game is played with trunk
movements.
The training chair provides a method for developing body
movement
coordination and improvement of postural control. The chair
is
equipped with a special system of sensors, which determine position
and
movement of the body in three dimensions. The information is
transmitted
to a computer that operates a computer game. While taking
part
in the game, the patient directs a virtual object by bending forward
and
back, tilting to the side and rotating the trunk. To enhance emotional
involvement
of the patients, in some cases, virtual reality may be used.
Fig 22. Training chair. By
bending
forward and back,
tilting
to the side and rotating his
trunk , a
child plays a com
International Clinic of
Rehabilitation
Increasing number of patients, constant
development and expansion
of
our rehabilitation system, and the need of the patients for
comfortable
accommodations forced the creation of a new
rehabilitation
facility.
In the summer of
mountains,
in the health resort Truskavets, a new 14 thousand sq.
m
International Clinic of Rehabilitation was opened. The new
building,
situated near a lake, is created in the Secession
architectural
style, distinguished by the escape and release from
the
old traditions and dogmas.
Fig 23.
International Clinic of Rehabilitation
All the lobbies of the clinic are ornamented with
flower decorative patterns made with stained glass with internal lighting.
Stylized snowdrops and violets symbolize spring and revival of nature.
Decorative patterns and ornaments are part of the
art- therapy aimed at stimulating the patient’s motivation for recovery and
freedom from disease. Internal decorations, parquet and furniture were made
with birch, a tree, known for its healing influence.
Fig 24.
Lobbies of the clinic are ornamented with flower
decorative
patterns made with stained glass with internal lighting
The medical departments of the clinic are
situated on the first and
ground
floor of the clinic and in the tower. Diagnostic departments
were
planned bearing in mind the main task of the diagnostics in the
Intensive
Neurophysiological Rehabilitation System – assessment
of
the functional condition of the child, his adaptation and
compensatory
possibilities.
Contemporary
diagnostic equipment makes a wide range of
Neurophysiological
examinations possible including tests of
respiratory
and cardiovascular systems, extensive study of gross
motor
functions, gait analysis, and hand functions.
Fig 25.
Diagnostic equipment makes possible a wide ............
range
of examinations
Spacious rooms in the rehabilitation department
with comfortable
furniture
and modern rehabilitation equipment ensure that training
sessions
may be carried out effectively and provide for the comfort
of
the patients and the medical personnel
Special rooms for mechanotherapy and physical
therapy are equipped
with
the gear for strength training, improvement of movement
coordination,
gait training, and gradual body adaptation to its new
functional
state.
Fig 26.
Rooms for mechanotherapy are equipped
with
all the necessary gear
Several rooms are specially equipped for training
in the biodynamical
movement
correction program and for sessions of computer game
training.
Computer network and specially developed software
automate
storing
and analysis of all the medical data.
The Clinic also includes 100 living quarters,
which provide all the
necessary
comfort for the patients and accompanying persons during
the
entire rehabilitation course. Modern interior design, nice furniture,
and
comfortable beds make the stay in the clinic suitable and cozy.
Spacious one, two or three-room suites with the
living space of
over
connection.
Roomy bathrooms with the space of
accommodated
to the special needs of the residents.
Fig 27.
The Clinic includes 100 living quarters
accommodated
to the special needs of the residents
Standard services – laundry, ironing, clothes
repair, etc are available
for
guest use. Room security is provided by electronic locks and a
reliable
access control system. Most technological processes of the
clinic
are automated according to the technology of “Clever House”.
A comfortable restaurant, which seats up to 180
people is situated
on
the second floor of the clinic. Self-serving tables adapted for
people
with disabilities feature a large assortment of meat, fish and
vegetable
dishes, different juices, fruits, and confectionaries.
Fig
the second
floor
Patients, parents and accompanying persons may
spend free time
in a
bar located on the first floor of the clinic. Different drinks,
snacks,
and confectionaries are served here in a cozy setting.
GENERAL PEDIATRIC
REHABILITATION
Earliest signs of
Duchenne muscular dystrophy:
Early
diagnosis of Duchenne muscular dystrophy is desirable because its X-linked
recessive mode of inheritance places the family at risk for giving birth to
additional cases. The early developmental history is normal with
age-appropriate achievement of milestones, such as raising head from prone and
sitting independently. In retrospect, there is often a history of difficulty in
arising from the floor, frequent falls, or an abnormally loud thud when
walking. Neck flexor muscles are involved early, and these children have a
characteristic difficulty in raising their heads when supine. These subtle
deviations are regarded as permissible in the child who is just beginning to
ambulate and go unnoticed or are attributed to clumsiness. Around age 3-6
years, the lag in motor development becomes inescapable. The child shows
difficulty with climbing stairs, develops a waddling gait to compensate for
proximal weakness with lordosis, and
develops toe-walking to maintain the center of gravity over the feet and to
prevent collapse at the knees.
Genetic abnormality in
Duchenne muscular dystrophy:
The Xp21 site on the short arm of the X chromosome. The surprise is the enormous size of the gene, which spans 2.3 million
base pairs of DNA. It in turn codes for dystrophin,
a muscle-specific protein of leviathan size. The specific function
of this protein is still being determined, but it is believed to be a component
of the muscle cell membrane. The protein participates in the stabilization of
muscle cell membrane.
What
is the most common peripheral neuromuscular
disorder affecting infants? Is it really
associated with all of the "fibs and positive sharp waves" you
heard about in medical school?
Spinal muscular atrophy (SMA) type 1, which affects the anterior horn
cell and is present in infancy (Werdnig-Hoffman disease), is the answer. Although electrodiagnostic evaluation of SMA demonstrates significant
membrane instability with numerous fibrillations and positive sharp waves,
clinical studies do not report an overabundance of these findings. In fact, if
fibrillation potentials are profuse, think of other disorders, such as type I hypotrophy with central nuclei, mitochondrial myopathy, or storage diseases.
In children, when
do motor nerve conduction velocities (MNCV) approach adult values?
MNCV
parallel the development of myelination. Myelination begins at about the 15th
week of conceptional age. After birth, there is a direct relationship between
conceptional age (defined as gestational age
plus age from birth) and MNCV, which is independent of birth weight. By 3-5
years, MNCV has reached adult values.
What musculoskeletal condition is common to
preadolescent female gymnasts and professional football lineman?
Spondylolysis. It is the probable
result of nonunion of a stress fracture of the posterior elements of the
lumbar vertebrae brought on by repetitive high-stress hyperextension
activities. The L5 vertebra is most commonly involved, but any spinal segment
may be affected. Spondylolisthesis refers to slippage of one vertebra on the one below it and, if severe,
may compress spinal nerve roots, causing an impingement syndrome. Just remember
that spondylo means spine, lysis means a breakdown, and listhesis
slips off your tongue.
When do you worry
about idiopathic adolescent scoliosis?
Although
idiopathic scoliosis is the most common
form of childhood scoliosis, other causes
must be considered before the diagnosis is made. These include relatively minor
problems, such as a leg-length discrepancy or poor posture, as well as serious
conditions such as vertebral and spinal cord tumors, osteoid osteomas, and spondylolisthesis.
Muscle spasms and hysteria are other conditions that may present as a scoliosis.
Since
idiopathic scoliosis is generally a painless
condition, a report of pain, especially at the convexity of the scoliotic curve, must be taken seriously, and
further evaluations to determine an etiology are mandatory. Other red flags
which signal the need to evaluate a child in greater detail are onset before
puberty and presentation in a male.
What
degree of spinal curvature is of concern in cerebral palsy, muscular dystrophy,
and idiopathic scoliosis?
The
degree of curvature determines the recommended treatment. In muscular
dystrophy, surgical stabilization should be done before the decline in vital
capacity makes surgery risky. This occurs when the patient's vital capacity
falls below 35% of expected, which equates to a curvature of 35° or more in
muscular dystrophy patients. Surgery when vital capacity is < 25% of expected
may lead to postoperative ventilator dependence. In patients with quadriplegic
cerebral palsy, correction of scoliosis is
usually indicated when the curvature exceeds 45°, but additional risk factors
such as epilepsy, respiratory capacity, and overall general health make these
children poor candidates for major surgery. These factors as well as
alternative interventions such as the use of a spinal orthosis should be considered before surgery is undertaken.
Who
was Gavriil Ilizarov and what was he doing in
He
was perfecting a technique for lengthening limbs. In 1951, Professor Ilizarov
developed a surgical procedure for treating many pathological conditions of the
musculoskeletal system. His method involves
creation of an osteotomy followed by application of an external fixator to apply controlled distraction of the
bone. The gap caused by slow separation of the ends of the bone is filled in
with new bone tissue. The rate of lengthening is approximately 1 mm/day. The
amount of length achieved is related to the bone being treated and the etiology
of the limb-length discrepancy. In general, the femur should not be lengthened
more than 6 to
Should surgical exploration with microsurgical reconstruction be attempted for
obstetrical brachial plexus injury?
The
answer is not clear cut and a number of opinions exist. Proponents of surgery
suggest that the absence of deltoid or biceps function at 3 months of age is
the key clinical finding and that surgery is indicated. They believe that it
should not delayed to more than 6 months of age if
there is no evidence of further spontaneous recovery. A large study of 470
Swedish patients didGeneral Pediatric not support this point of view. No difference in outcome
was found in upper plexus palsies in those children in which surgery took place
before or after 6 months of age.
Why
are the neonatal reflexes an important part of the examination of infants suspected
of having neurologic disorders?
The
neonatal or primitive reflexes are part of the bundled software with which we
are born. These provide a temporary set of automatic instructions for
protecting the defenseless newborn in the hostile extrauterine world. These include the Moro reflex, asymmetric tonic
neck reflex, tonic labyrinthine reflex, positive supporting, rooting, palmar
grasp, plantar grasp, automatic neonatal walking, and placing. As the brain
completes its myelination and the ability to control movements
increases during the first year, the child needs to be able to control
voluntary movements. If the neonatal reflexes persist beyond 4-6 months of age
or manifest themselves in a mandatory fashion which
"locks" the child in specific positions, they become chains that bind
rather than rails to guide the child on the path to independent movement.
Therefore, their presence in a persistent or obligatory fashion is one of the
earliest clues of impairment to the motor control centers of the nervous
system.
How do the
asymmetric (ATNR) and symmetric (STNR) tonic neck reflexes differ?
The
ATNR is one of the classic neonatal reflexes that gradually fades
away by age 6 months to allow independent reaching and head-turning. It is a
fencer's pose: head turned toward the opponent with rapier extended, and
opposite arm flexed at the elbow with finger pointed toward the shoulder. In
contrast, the STNR is the only reflex that is not present at birth and again
absent at the first birthday. It provides postural stability as the child makes
the precarious transition from crawling to standing. Think of it as the
"Aesop's fables" reflex: when the child's neck is flexed, the arms
flex and the hips extend, recalling the "dog and the bone." If the
neck extends, the arms extend and the hips flex, a perfect position for
steadying oneself before attempting to pull up to stand, reminiscent of the "fox
and the grapes."
What
is the earliest age at which a child can learn to operate an electric
wheelchair safely?
Children
attain the cognitive and perceptual skills required to safely drive a motorized
wheelchair around 3 years of age. Because exploration of surroundings through
movement is one of the chief means of learning in early life, introduction of
an alternative to ambulation for children
for whom mobility is severely limited is desirable as early as possible. Don't
forget that a child in a wheelchair requires the same vigilant supervision as
any other rambunctious preschooler.
Is
cerebral palsy caused by obstetrical misadventure?
Unfortunately,
the perception that cerebral palsy is caused by something that went wrong at
birth has been a part of popular folklore since its initial description by
William John Little in 1868. This issue has since been scrutinized carefully by
many epidemiologists. An association between asphyxia at birth and the
development of cerebral palsy was detected in only about 3% to 13% of cases.
Furthermore, cerebral palsy rates have not shown a decrease despite major improvements
in obstetrical and neonatal care between the 1950s and 1970s.
Do Apgar scores
predict cerebral palsy or mental retardation?
The
Apgar score was developed to quickly identify the newborn infant in need of
resuscitation and has little predictive significance for the development of
neurologic problems—unless it is depressed at 15-20 minutes after birth. In a
large multicenter collaborative project, 4.8% of surviving infants had Apgar
scores of < 3 out of 10 at 1 minute. In this group, the risk of cerebral
palsy was only 1.7%. However, 15% of infants who had 5-minute Apgar scores of
< 3 had cerebral palsy. A score of < 3 at 15 minutes was associated with
mortality in about 53% of cases, with a risk for cerebral palsy of 36% in
survivors.412 General
Pediatric Rehabilitation
How
do brain MRI scans correlate with gestational age
and type of cerebral palsy?
Most
children with cerebral palsy who were born prematurely had periventricular leukoma-lacia (PVL) on brain
MRI. The second but much less common finding was posthemorrhagic porencephaly. Abnormalities seen at term or near
term in children with cerebral palsy were border zone infarcts, bilateral basal ganglia-thalamic lesions, subcortical leukomalacia, and mul-ticystic
encephalomalcia. Ninety percent of those with PVL were born prematurely.
In
patients diagnosed with diplegia, most
had PVL. In quadriplegic patients, term type brain injuries were seen in 22 of
45 patients and brain anomalies in 10 patients. In hemiplegics, 17 of 26
patients had unilateral lesions and 7 had bilateral lesions.
Are acquired
spinal cord injuries (SCIs) more common in children than adults?
No.
The incidence of all new SCIs is 10,000 per year in the
What
is SCIWORA?
SCIWORA
is a medical acronym that stands for "spinal cord injury without radiographic abnormality." About 20% of children under age 12 years having serious SCI do not
have evidence of fracture or dislocation. The inherent elasticity of the
fibrocartilaginous spine and its surrounding
soft tissue in the growing child is believed to account for the phenomenon.
Fifty percent of children with SCIWORA have delayed onset of paralysis up to 4
days following injury. Therefore, every effort should be made at the time of
presentation to rule out potential spinal instability with CT and controlled
flexion-extension radiographs.
Should
every child born with myelomeningocele have
it surgically repaired?
Advances
in surgical care and antibiotics have taken away the need for haste in
decisions regarding surgery. Charney et al. reported the relationship between
time of surgery and eventual outcome in 110 newborns
with myelomeningocele. They found
no significant difference in mortality, development of ventriculitis, developmental delay, or worsening of paralysis among
groups that were surgically repaired within 48 hours, 3-7 days, or 1 week to 10
months of life.
The
fact is that currently most myelomeningoceles are
surgically repaired shortly after birth and the children survive. Studies that
look at functional outcome suggest that adults with myelomeningocele have difficulty achieving independence from
parents, finding suitable living accommodations, and landing a reasonable job.
The environmental support systems available to the child appear to be at least
as important in determining life satisfaction as the severity of the medical
condition.
Are
there signs that help distinguish fractures resulting from child abuse versus
accidental trauma?
Nonaccidental
trauma to children unfortunately continues to be a serious health problem. A
high index of suspicion, backed up by appropriate medical findings, is very
important. Fractures suggestive of abuse include:
1. Multiple fractures in various stages of
healing
2. Growth plate fracture
3. Transverse metaphyseal
fracture ("bucket-handle" fracture) near the growth plate of
femur, tibia, and humerus
4. Spiral fractures of long bones
5. Unusual locations of fracture (posterior rib,
sternum, scapula)
The
above fractures are helpful in establishing the diagnosis of child abuse. If
abusive head trauma is being considered, important nonskeletal associated
findings include retinal hemorrhages and subdural
hemorrhages (especially when multiple and of different ages). It is
extremely important to have a high index of suspicion when ruling out the
possibility of a diagnosis of child abuse, because of the malignant nature of
the syndrome and the significant risk of fatality following repeated episodes.
Remember, we are all required by law to report any suspected abuse. If you're
wrong, the result of the investigation is inconvenience and ruffled feathers.
If you're right, the result may well be a saved life.
What
is the Wee-FIM?
It's
not just a small functional independence measure (FIM). Developed in 1987, the WeeFIM is a measure of functional
abilities and need for assistance associated with disability in children age 6
months to 7 years. It can be used above the age of 7 as long as the child has
delays in functional abilities. There are six subdomains which include items
that are rated on a 7-point ordinal scale (from dependence to independence).
What is the COAT?
COAT
stands for Children's Orientation and Amnesia Test. It is a 16-item test
of orientation and memory designed for children recovering from traumatic head
injury, which is easily administered at the bedside. It assesses three areas:
general orientation, temporal orientation, and memory. Post-traumatic amnesia
(PTA) is that period after the injury during which the brain is unable to store
and recall new events or information. On the COAT, a score within 2 SD of the
mean for age defines the end of PTA. The duration of PTA has been correlated
with prognosis. In a controlled study by Rutter, children with PTA of < 1
week were doing well 27 months following injury. However, persistent
psychiatric problems were noted in approximately 50% of children with PTA for
> 1 week. PTA of > 3 weeks was associated with significant educational
problems related to attention deficits and disinhibition.
Does outcome after
traumatic brain injury (TBI) follow the general pediatric
brain injury rule that "outcome is better with earlier
insults" (due to plasticity of the developing
Unfortunately,
for younger children this is not the case. While some studies using narrower
age ranges have shown no significant differences with age, others have shown that
older children and adolescents do better than younger children.
Why
does this not follow the general rule in pediatric
brain injury? There are many possible explanations. Plasticity,
which is so important in recovery from focal brain injuries (i.e., infantile
strokes), may be at a disadvantage due to the diffuse nature of the injuries.
The younger brain may be more susceptible to the effects of trauma due to its
different physical (i.e., less myelinated) and
neurochemical (i.e., increased excitatory
amino acids) properties. Also, the mechanism
of injury is different depending on age, which may result in differences in the
primary injury. Also, if the injury results in deficits of new learning (which
TBI does), the more one needs to learn in life, the more one is at a
disadvantage.
Which
groups are most at risk for injuries and therefore the focus of any injury prevention
strategies in the rehab setting?
While
the care and treatment of the patient with traumatic injuries are improving,
prevention is the most effective intervention. Prevention should be given
highest priority by any professional working with children.
Trauma
is the major cause of childhood morbidity and mortality, and head trauma is the
single most important determinant of the severity of injury and outcome. The
incidence of TBI is highest in males aged 10-29 years, with the peak incidence
between 15 and 19 years. A shocking statistic is that the estimated cumulative
risk of brain injury for children through age 15 years is 4% in boys and 2.5%
in girls.
Injury
does not occur randomly across the population. Race and socioeconomic status are major determinants
of risk. Death rates for unintentional injury among children < 15 years old vary with race: Native Americans > African-Americans > whites >
Asian-Americans. For all races, injury death rates are inversely related to
income level.
One
of the most significant risk factors for a head injury is a history of
previous head injury. This means that patients in a rehab setting are at
higher risk for injury, which further highlights the importance of and need for
injury prevention.
What
injury prevention strategies are most effective?
The
main principles of brain injury prevention include:
1. Anything that can decrease the amount and
rate of energy transfer will decrease the severity of injury to the brain, if
not prevent it entirely.
2. Strategies that rely as much as possible on
"passive" or automatic strategies are likely to be more effective
than those based solely on behavioral change, especially since behavior changes
are most difficult to achieve in the population at most risk (e.g.,
adolescents, the poor, the intoxicated).
3. Strategies and recommendations should be
focused and specific (e.g., don't say "be careful"—instead say
"use a car seat, buy and use a bike helmet, and throw out the baby
walker!").
Because
of the limitations of education and other strategies in isolation, prevention
will need to be approached from multiple simultaneous angles—passive
strategies, education, financial incentives (e.g., bicycle helmet
coupons/subsidies), and "mandatory use" legislation. However, the
first step is for all professionals working with children to remember the need
for and importance of prevention.
Is
there such a thing as executive function in children?
The
executive system describes those mental processes necessary for formulating
goals, planning how to achieve them, and carrying out the plans effectively.
Executive function can also be thought of as those processes that allow mental
flexibility—the ability to mentally initiate and sustain thoughts and plans
appropriately, inhibit unwanted thoughts and actions, and yet mentally
"shift gears" when appropriate. Remember the mnemonic
Executive dysfunction is commonly seen in children after closed head
injury (as it is in adults). As with many other functions, it is developmental
in nature and may become more obvious (and testable) with increasing age..
In
children with spastic quadriplegia, also described as 'whole body involvement',
spasticity can interfere with motor function, contributes to the development of
deformities and adversely impacts on care, positioning, and comfort. In this
population, spasticity interventions address goals such as improving comfort,
reducing pain, easing the burden of carers, slowing the progression of
musculoskeletal deformities and perhaps improving function. Children with
severe diplegia are distinguished from those with quadriplegia by their ability
to ambulate, as well as by a greater emphasis being placed on functional motor
goals even though similar treatment modalities are often employed to manage
spasticity. The many treatment options currently available include, but are not
limited to, botulinum toxin type A, phenol neurolysis, oral medications,
intrathecal baclofen, selective dorsal rhizotomy, and orthopaedic surgery. The
integration of these treatment modalities can help to optimize the overall care
and function for a child with spastic quadriplegia or severe diplegia. However,
the development of a management programme is complex and needs to take into
account many factors, including age, weight and nutritional status, rate of
progression of musculoskeletal deformities, developmental potential, comorbid
conditions, current functional status and prognosis, and family and patient
treatment goals. Children with marked spasticity are likely to benefit from a
combination of interventions, rather than a single treatment modality. Because
of these complexities, management should be planned and coordinated by a
multidisciplinary team of medical and allied health professionals which
recognizes the central role of the family in all decisions. Once the special
characteristics of the child with spastic quadriplegia and the various
treatment options are understood, outcomes can be maximized.
MEDICAL
REHABILITATION OF GYNAECOLOGICAL PATIENTS.
PHYSIOTHERAPY IN THE CHIL-DBEARING YEAR
The
women's health physiotherapist works as part of the multidisciplinary team
caring for the pregnant woman, along with obstetricians, general practitioners,
midwives, health visitors, occupational therapists, social workers or other
physiotherapists. Contact with the pregnant woman may be in the community,
health centre, leisure centre or the physiotherapy department. The role of the
women's health physiotherapist is to:
• educate the pregnant woman for pregnancy,
labour and beyond (see the section on antenatal classes)
• advise on safe and
appropriate exercise (see the section on exercise and pregnancy)
• identify, assess and treat musculoskeletal problems (dealt with in this
section).
Pelvic
Floor Dysfunction
See
the section on urogenital dysfunction.
During pregnancy, physiotherapists may consider it prudent to limit their
intervention to advice.
Spinal
and Pelvic Pain
Spinal
and posterior pelvic (sacroiliac) pain is
common during pregnancy with an incidence described variously as ranging from
50% to 70% (Mantle et al. 1977; Fast et al. 1987; Berg et al. 1988; Ostgaard et
al. 1991; Mantle 1994; Russell et al. 1996; Heiberg and Aarseth 1997). It is
often regarded as 'a normal part of pregnancy' but, without appropriate
treatment, a minor episode may develop into a chronic problem. A third of women report severe back pain that interferes with daily
life and compromises their ability to work (Ostgaard et al. 1991; Mens et al.
1996). Most backache resolves in the first few weeks postpartum, but for some may continue for 18
months (Ostgaard and Andersson 1992), or may present postpartum for the first time (Russell and Reynolds 1997). Some
patients may experience a relapse around menstruation and in a subsequent
pregnancy (Mens et al. 1996).
The
anatomical origins of peripartum spinal and pelvic pain vary and are difficult
to determine and diagnose (Nilsson-Wikmar and Harms-Ringdahl 1999). Women
describe pain variously as occurring in the low back, sacral, posterior thigh
and leg, pubic, groin and hip areas. These may occur simultaneously or
separately, antenatally, during delivery or postnatally (Heiberg and Aarseth
1997). There is often associated cervical, thoracic or coccygeal pain. Sciatic pain is common and may be of lumbar origin
or from sacroiliac joint involvement as
the L5 and Si components of the lumbosacral plexus
run immediately anterior to the sacroiliac joints.
Postural
adaptations, fatigue, increased joint mobility, increased collagen volume
causing pressure on pain sensitive structures, weight gain, and pressure from
the growing fetus may all contribute to spinal and pelvic pain (Polden and
Mantle 1990). Poor passive stability from lax joints plus poor active stability
from altered muscle recruitment and stretched pelvic and abdominal muscles
probably contribute to spinal and pelvic pain (Watkins 1998; Coldron and Vits
2001). Other musculoskeletal factors
include physically strenuous work and work involving bending, twisting, lifting
and sitting (Heiberg and Aarseth 1997), large abdominal sagittal and transverse
diameters and a naturally large lumbar lordosis (Heckman
and Sassard 1994), prepregnancy low back
pain, and decreased fitness level before pregnancy (Ostgaard et al. 1993).
Pelvic pain appears to be associated particularly with high mean relaxin values
(Kristiansson 1997) or a susceptibility to relaxin and the other hormones of
pregnancy (MacLennan and MacLennan 1997), parity (Heckman and Sassard 1994),
weight of the newborn, and smoking (Ostgaard 1997).
Conclusive
association between new-onset postpartum backache
and epidural analgesia has not been
demonstrated. (Breen et al. 1994; Macarthur and Weeks 1995), though the masking
effect on pain may lead to women adopting unsuitable positions in labour
(Macarthur et al. 1990; Russell et al. 1993).
Management
of spinal and pelvic pain and dysfunction
Advice,
posture, education and general exercise
Antenatal
education on posture and back pain by a physiotherapist has been shown to
reduce back and pelvic pain, reduce sick leave and continue to benefit women in
the postnatal period (Noren et al. 1997). Advice in pregnancy includes adopting
comfortable resting positions, advice on moving out of bed, chair or car,
advice on postures in walking and standing, and advice on lifting and handling.
In addition, postnatal advice includes positions for breast-feeding, nappy
changing, bathing and handling the growing baby.
Treatment
of articular/joint dysfunctions
Peripartum
spinal and pelvic pain often responds to manual therapy, though correct
assessment of the spine and pelvis is imperative to enable treatment to be targeted
at the correct structures. Common conditions include unilateral sacroiliac dysfunction, symphysis pubis dysfunction, minor lumbar disc herniation, lumbar zygapophyseal joint
problems, thoracic spine pain and coccydinia.
Manual
therapy techniques used for joint hypomo-bility/dysfunction in the non-pregnant
population can be utilised, but with appropriate precautions. Abdominal, spinal
and pelvic muscle recruitment needs to be retrained to stabilise an unstable
spinal segment or sacroiliac joint.
TENS
may be used postnatally, but the use of TENS antenatally is controversial.
Current advice recommends that TENS should not be used before 37 weeks
gestation because of unknown effects on the fetus and the hypothetical risk of
possible induction of premature labour.
The
use of a sacroiliac/trochanteric belt for
sacroiliac and symphysis pubis instability both ante-and postnatally may decrease
pain (Mclntosh 1995; FryI lay 5 rnysiorrierupy and Tudor 1997) and substitute the work of the internal oblique muscle
(Snidjers et al. 1998). A large tubular bandage for the abdomen, or maternity
belt, may give added support.
Costal
margin pain along the anterior surface of the lower ribs (possibly related to
pressure from the ascending uterus, and commonly called 'rib flare') may be
accompanied by thoracic spinal and lateral chest pain. This may be relieved by
side flexion manoeuvres away from the pain, and manual therapy techniques.
Muscle
re-education
Non-obstetric
research on patients with spinal instability problems and low back pain has shown
active trunk stabilisation programmes to be of benefit (Richardson et al. 1990;
Richardson et al. 1993; Jull et al. 1993; O'Sullivan et al. 1997; O'Sullivan
2000). In addition, postpartum rehabilitation
of pelvic and abdominal muscles is believed to increase active stability of the
pelvis (Vleeming et al. 1992).
Rehabilitation
exercises antenatally and postnatally should concentrate initially on correct
recruitment of both pelvic stabilising muscles (gluteus
medius and maximus) and prime spinal stabilising muscles (trans-versus abdominis, lumbar multifidus, pelvic floor muscles).
Exercise for global stabilising muscles such as the oblique abdominals, erector
spinae, latissimus dorsi, and iliopsoas should
follow, though probably only postnatally.
Divarication
of the recti abdominis should gradually
reduce after delivery, so exercises at 6 weeks postnatally should include
those that shorten the muscle. Once core stability has been gained, the woman
should be encouraged to increase her strength, and general aerobic and
cardiovascular fitness.
Rehabilitation
exercises need to be functional, as many women cannot regularly attend a
physiotherapy department owing to family commitments.
Symphysis Pubis Dysfunction/Diastasis
Symphysis pubis dysfunction (SPD)
is a relatively common complaint with varying incidence figures of
SPD
may occur because of an abnormal separation of the symphysis pubis (diastasis). However, the amount of symphyseal
separation does not always correlate with symptoms (Snow and Neubert 1997) and
not all symptomatic patients have an increased gap. The abnormal symphyseal gap
may vary from
to
Common
complaints are severe pain in the groin, anterior thigh and sacroiliac joint, pain on abduction of the
thighs, shuffling or waddling gait, severe symphyseal tenderness, and an
inability to weight-bear unilaterally (Fry 1999). Minor trauma may cause
pelvic joint asymmetry. A forward rotation and oblique slip of the innominate
caused by overactivity in the adductor
muscles of the thigh may contribute to SPD (Rost 1999). With poor use of the glutei and lack of force closure of the pelvis,
disruption of the self-locking mechanism of the pelvis ensues.
Management
of SPD
SPD
is often associated with sacroiliac joint
dysfunction and can be treated by all of the methods described above with the
aim of restoring pelvic ring stability (Fry 1999). Special attention should be
paid to overactive pelvic adductors, underactive abductors, unilateral iliac
displacement (Rost 1999) and poor pelvic and spinal stabilising muscles. Advice
regarding unilateral weight-bearing activities and hip abduction should be
given. Crutches, or in the most severe cases a wheelchair, may be required.
Liaison
with midwives is essential. Women should be aware of the masking effect of epidural and spinal anaesthesia in relation to
excessive abduction of hips during labour and delivery. If possible, they
should adopt the most comfortable position during labour (for example
left-side-lying, or kneeling upright with support). They should be discouraged
from placing their feet on attendants' hips and care should be taken if
lithotomy is required. Suturing should take place in the most comfortable
position for the mother (ACPWH 1996).
Diastasis Rectus Abdominis (DRA)
Diastasis rectus abdominis (DRA) is an excessive gap between the bellies of rectus abdominis at the level of the umbilicus (Boissonnault and Blaschak 1988). It normally appears in pregnancy
but can occur during the second stage of labour. The gap may be as wide as
Management
of DRA
It
is advisable for physiotherapists to examine the gap manually in postnatal
women and assess the degree of separation. Advice regarding exercise should
then be given, including initial training of the deep abdominal muscles
(transversus abdominis) (Potter 1997) and
avoidance of strong trunk curling exercises.
Nerve
Compression Syndromes
Fluid
retention may occur during the third trimester, which can lead to a variety of
nerve compression syndromes. These include carpal tunnel syndrome (CTS), brachial plexus compression, meralgia paraesthetica (compression of the lateral
cutaneous nerve of the thigh as it passes under the inguinal ligament, presenting
as tingling and burning in the outer thigh) and posterior tibial nerve compression. These entrapments
normally resolve postpartum.
Wrist
splints and ice are useful for CTS. Postural advice can be used for brachial plexus compression. Ice and elevation
may help posterior tibial nerve compression
(Polden and Mantle 1990).
EXERCISE
AND PREGNANCY
General
Issues
Physiological,
emotional, social and psychological issues influence physical fitness in
pregnancy. The physiotherapist must be sensitive towards these, and be aware of
other issues such as language, ethnic cultures, equal opportunities and women
with special needs. The therapist's approach to the pregnant woman should be
holistic, flexible, individual, and - where available - evidence-based.
Many
women now incorporate regular exercise into their lifestyle, and wish to continue
during their pregnancy. A significant minority of women decide to take up
exercise for the first time when they become pregnant.
The
research available suggests that mild to moderate exercise is beneficial to
the healthy pregnant woman (Clapp 2000) and is not harmful to the fetus
(Riemann et al. 2000; Clapp et al. 2000; ACOG 2002). Moderate intensity is
defined as being able to talk easily, whilst increasing the heart rate to a
maximum 140 beats per
minute. Choice of exercise must be
influenced by the physiological changes, which will occur. For example, plasma
volume increases before red cell volume, leading to a decreased ability to
provide oxygen in response to demand. Also, increased demand causes raised
respiratory rates, cardiac output values increase during pregnancy for the
same activity (over the non-pregnant woman), and there is a loss of cardiac
reserve. Strenuous activity might compromise the mother's health, and that of
the fetus.
Benefits
and Contraindications
Potential
benefits of exercise include:
• maintenance of
cardiovascular fitness
• maintenance of
healthy weight range
• improvement of body
awareness, posture, coordination and balance
• improvement in
circulation
• increase in
endurance and stamina
• provision of social
interaction with exercise, enhancing feelings of social and
emotional well-being
• possible reduction
in problems during labour and delivery
• potentially shorter
labour
• possible prevention
of gestational diabetes
• reduction in minor
complaints of pregnancy
• more rapid
postnatal recovery.
Contraindications
to exercise include:
• cardiovascular,
respiratory, renal or thyroid disease
• diabetes (type \,
\f poorly controlled")
• history of
miscarriage, premature labour,
fetal growth restriction, cervical incompetence
• hypertension,
vaginal bleeding, reduced fetal movement,
anaemia, breech presentation, placenta praevia.
Advice
The
advice given to regular and non-regular exercisers will differ.
Regular
exercisers
• Consult your doctor or midwife before
beginning exercise.
• Exercise at
a moderate level most
days for 30 minutes or more.
• Discontinue contact sports, and activities which
carry a high risk of falling or abdominal trauma.
• Self-regulate both the level of intensity
and duration of exercise, aiming to keep core temperature below
• Aim for low impact activity.
• Wear suitably supportive footwear to reduce musculoskeletal stresses.
• Maintain adequate fluid intake to prevent
dehydration, and avoid exercise during hot and humid weather, or with pyrexia.
• Warm up and cool down for at least 5
minutes.
• Do not use developmental stretching (because
of the effects of relaxin).
• Seek professional advice on specific exercises
(e.g. for the pelvic floor muscles).
• Avoid ballistic exercise, low squats,
crossover steps and rapid changes of direction.
• Do not exercise in the supine position after
16 weeks gestation, to avoid aortocaval compression.
• Eat to appetite without calorific
restriction.
• Work towards cross training to avoid over
training, and stop exercise before fatigue sets in.
Non
regular exercisers
In
addition to the above, women not used to regular exercise should be advised on
the following.
• Do not start an exercise programme until
> 13 weeks gestation.
• Consider
beginning with non-weight-bearing exercises such as
aquanatal.
• Progress from simple and basic levels of
exercise, increasing exercise tolerance gradually, under the supervision of a
suitably qualified professional.
When
to stop
All
women should stop exercising immediately and seek advice from a doctor if they
experience:
• abdominal, back or
pubic pain
• PV (from the vagina) bleeding
• shortness of
breath, dizziness, faintness, palpitations or tachycardia
• difficulty in
walking.
Most
women will naturally reduce the amount of exercise they take during pregnancy
as their weight increases, and they fatigue and become breathless more rapidly.
Types
of Exercise
General
categories
• Walking and swimming. The pace
adopted should be sufficient to cause aerobic changes. If pelvic pain is
a problem, avoid the kicking motion of
the legs during breaststroke swimming.
• Low impact aerobics (or equivalent
classes). The emphasis is on maintaining fitness levels.
• Pilates or yoga (modified for
pregnancy). These cater for the non-aerobic elements of fitness - flexibility,
control of breathing and relaxation.
• Back care classes. Core stability
exercises may be taught, sometimes using a Swiss ball.
• Gym work. The pregnant woman may have
access to a static bicycle, treadmill or cross trainer, all of which encourage
aerobic activity.
Technique
is especially important when strength training. Women should use light weights,
with sub-maximal lifts, aiming to use both upper and lower body muscle groups
in a variety of exercises. Weights, sets and repetitions should be decreased
further as pregnancy progresses.
Aquanatal classes
- water-based exercise groups designed specifically for pregnant and postnatal
women - have grown in popularity in
Women
in aquanatal classes may notice that they get relief from aches and pains, feel
they have more energ, after the class, and sleep better. Another
importan benefit is the absence of post-exercise muscle soreness because,
during immersion, all muscle work is concentric (Newham 1988).
Other
significant advantages are less obvious to the women themselves: exercise in
water helps to tone the respiratory muscles; the leg movements of swimming and
exercise in water aid venous return; and the diuretic effect of immersion is
helpful to a pregnant woman troubled by fluid-retention as immersion for 20-40
minutes results in a loss of 300-400 mL of fluid (Katzetal. 1991).
Women
must be screened by the teacher for any relevant musculoskeletal problem or contraindication (ACPWH 1995). Exercises
can be amended to accommodate back, pelvic girdle, neck or other orthopaedic
problems. Pregnant women with sacroiliac or
symphysis pubis discomfort should be
advised to modify their breaststroke leg movements and take small, rather than
wide, steps sideways. All women should take short backward steps to avoid an increase
in lumbar lordosis.
Exercises
that will overstretch the already compromised abdominal muscles should be
excluded.
Conversely,
squatting, which is difficult on land and thought by some to be damaging, is
safe in water as virtually no weight goes through the knee joints.
The
"aim of the class is to help maintain, not improve, a woman's level of
fitness. Exercises must be safe and carefully chosen, and each included for a
reason. Water exercises should be considered in their own right and not taken unchanged
from exercise classes on land (Evans 2002). Standard antenatal exercises, such
as pelvic tilting, pelvic floor exercises, and hip and shoulder circling (with
the shoulders immersed) can usefully be included. Hydrostatic pressure on the
ribcage makes exercises like gently blowing a table-tennis ball across the
water valuable in toning respiratory muscles. Good posture should be taught at
the beginning of the class, and participants reminded to maintain it
throughout. If the water is warm enough, a relaxation session is an excellent
way to end the class.
Antenatal
classes
Midwives,
physiotherapists and health visitors typically run antenatal classes, though
the latter are more usually involved in postnatal groups. Classes can take many
different formats, and vary in number and timing to suit the needs of the women
and their partners.
'Early
bird' groups are held around 16 weeks of gestation and consist of one or two
classes by a midwife and a physiotherapist, though other speakers might be
invited (e.g. dietitian). As most women will be working at this stage, these
classes are usually held in the evening.
The
physiotherapist's role is to discuss the changes in pregnancy, how these will
affect the working woman, and how to adapt to the changes. One of the most
important topics is correct postural alignment and care of the back during
pregnancy, to alleviate backache and prevent long-term problems. Women's work
activities will be discussed and advice on seating, lifting etc. given. The
structure and function of the pelvic floor muscles and the importance of pelvic
floor exercises to prevent long-term continence problems will be explained.
Transversus abdominis and pelvic floor
exercises will be taught and the importance of bringing these muscles into everyday
functional activities discussed. Relaxation techniques can be introduced, to
be used during pregnancy, labour and for the rest of the couples' lives.
The
majority of the classes are held later in pregnancy from about 30 weeks
onwards, and may be during the day, evening, or at the weekend. Women only or
couples may attend. The classes may be for first-time mothers/parents, or for
women who have had previous pregnancies. Commonly they include a
mixture of both. In some large
hospitals there will be classes for twin pregnancies, for elective caesarean
deliveries, and teenagers. These groups will benefit from meeting other
women/couples in a similar situation. Where appropriate, classes may be held
for women of a particular ethnic group, in their own language if necessary.
Classes
are held centrally in the hospital where the baby will be born and/or in local
health centres.
The
physiotherapy input to the later antenatal classes will include:
• the changes in
pregnancy, good posture in standing, sitting and lying
• the practice of
transversus abdominis and pelvic floor
exercises, relating these to functional activities
• advice on back care
and prevention of long-term problems
• exercises for the
circulation
• breathing awareness and adaptations,
relaxation and positions of comfort
• coping strategies for labour
• advice on sport and
leisure activities
• early postnatal
exercises and advice.
Midwives
will discuss care in pregnancy, labour, feeding and baby care.
Ideally
the classes are held once a week for 5 or 6 weeks. However, the physiotherapy
content may have to be prioritised to fit into one 2-hour session, according
to the availability of resources.
Postnatal
physiotherapy
The
role of the physiotherapist in the days, weeks and sometimes even months
following the birth includes advice for the new mother on how to regain and
perhaps improve her former level of fitness through appropriate exercise and
education. Also included is the assessment and treatment of specific physical
problems, emotional support, and health education. Contact with the new mother
may be in the postnatal ward, as an outpatient in the physiotherapy department,
or in community-based postnatal groups.
Although
it might be considered the ideal for every woman to be advised by a women's
health physiotherapist postnatally, this is becoming increasingly uncommon.
Many women will not be seen by a physiotherapist, but should be given
appropriate literature.
Physiotherapy
intervention may be limited to some or all of the following.
Caesarean
section
Education
during antenatal classes may help to prepare the mother for a caesarean.
Postnatally, the physiother apist
should be aware of the reasons for the caesarean and offer emotional support
and advice when required. Bed exercises and mobility followed by early ambulation reduce the risk of respiratory
problems, back pain or deep venous thrombosis. Wound haematomatas may respond
well to ultrasound or pulsed electromagnetic energy (PEME). Abdominal and
pelvic floor exercises and optimal feeding postures should be taught.
Painful
perineum
A
prolonged or difficult delivery,
episiotomy or an extended tear may result in a bruised, painful and oede-matous
perineum. Physiotherapeutic interventions
might include ice packs, PEME, pelvic floor exercises (to increase blood supply
and aid healing), advice on supported defaecation, and the use of pillows under
each buttock when sitting to prevent pressure on the wound. Scar tissue may
cause longer-term pain or psy-chosexual problems.
Incontinence
Urinary
or faecal urgency and incontinence can occur after delivery, particularly after
a prolonged second stage, episiotomy, instrumental delivery, or delivery of a
large baby. Initial treatment can comprise advice and pelvic floor exercises
(Morkved and B0 2000). Persistent pelvic floor dysfunction should always be
assessed and treated (see the section on urogenital
dysfunction).
Musculoskeletal problems
See
the earlier section on musculoskeletal problems
in the childbearing year.
Postnatal
groups
Many
new mothers find difficulty adjusting to, and caring for, a baby during the
first few weeks. Extreme fatigue may result. Physiotherapists are well placed
to motivate women, encouraging them to attend postnatal groups, support
groups, relaxation or exercise classes. Input from a team of health
professionals provides education and information on a wide range of topics,
relevant to the new mother. Physiotherapists may lead a low-impact aerobics or
Pilates exercise class, teach baby massage, or hold discussion/support groups.
They should be aware of the development of new or previously undisclosed
symptoms (e.g. postnatal depression) and be instrumental in referring the
sufferer to an appropriate health professional. Postnatal groups promote a positive
outlook, reinforcing healthy living for life.
UROGENITAL DYSFUNCTION
Problems
relating to the female urinary and ger tracts are common and often complex.
Increasii physiotherapy is the first line of treatment. The pi lems encountered
most frequently are bladder dysfi tion and
genital prolapse.
Bladder
Dysfunction
Most
common is urinary incontinence, which occur at any
time in a woman's life, but incidence with age. A study of women aged 50—74
found that s leakage of urine was reported by 47%, and regular 31% (Holtedahl
and Hunskaar 1998); other au1 report similar findings. Four categories of
incontin are described: stress, urge, retention and neurogenic it is important to distinguish between these.
Stress
urinary incontinence
This
was originally termed 'retention with overflow' and may be acute or chronic.
In
hypotonic ('floppy') bladders, the normal
response to the increase in pressure, which occurs during filling, may be
absent, and the detrusor fails to
contract. Retention is associated with outflow obstruction (e.g. in men with
prostate disease), neuropathy, low spinal cord lesions, radical pelvic surgery
and multiple sclerosis, or it may be secondary to drug therapy (especially
with psychotropic drugs). Incontinence
sometimes, but not always, occurs with retention.
Neurogenic detrusor overactivity
This
term replaces 'hyperreflexia' and describes bladder dysfunction of
neurological origin.
Neurogenic detrusor overactivity occurs
in the presence of a suprasacral cord lesion where the bladder is isolated
from cortical control (e.g. cerebrovascular incident,
tumour, spinal cord injury or multiple sclerosis). One of the earliest
symptoms of multiple sclerosis may be urinary urgency an"d
it is important that physiotherapists be aware of this.
Genital
Prolapse
Pelvic
organ prolapse is the descent of one or more of:
• the anterior/posterior vaginal wall (known as cysto-cele and rectocele
respectively)
• the top of the vagina (cervix, uterus)
• or the vault (cuff) after hysterectomy.
Symptoms
include the feeling of a lump ('something coming down'), low backache,
heaviness and dragging sensation, or the need digitally to replace the prolapse
in order to defaecate or pass urine. It can occur with other lower urinary
tract dysfunction and may mask incontinence.
Prolapse
occurs when the fibromuscular supports of the pelvic organs fail. Fifty per
cent of parous women (those who have had
children) have some degree of genital prolapse but only 10-20% are symptomatic. Severity increases with age (Sultan et al.
1996). Norton (1990) reports a link between joint hypermobility, the presence
of striae ('stretch marks') and prolapse, features which are present in other
connective-tissue disorders. It is suggested that some women exhibit an
immature collagen type and that total collagen content maybe reduced
significantly (Jackson et al. 1995), leading to genital prolapse.
A
trained pelvic floor will contract reflexly in response to a sudden rise in intra-abdominal pressure, thereby limiting
downward movement of the organs and reducing the risk of damage to their
supports. A voluntary contraction performed before such episodes (e.g.
coughing, lifting) will afford protection and should become a life-long habit.
|
|
Factors
Contributing to Urogenital Dysfunction
It
is widely accepted that urogenital problems
are associated with vaginal delivery (Wilson et al. 1996; Toozs-Hobson 1998).
For many women, childbirth is probably the most significant factor contributing
to the development of symptoms. Allen et al. (1990) suggest that a woman's
first vaginal delivery causes muscle, fascial and
nerve damage, and it is likely that further damage will occur with future
deliveries. Chiarelli and Campbell (1997) suggest that forceps delivery
increases this risk. There are other reported risk factors: pregnancy itself,
straining at stool, heavy lifting, inappropriate exercise, chronic cough,
obesity, pelvic surgery, hormonal status and ageing.
PELVIC
FLOOR EXERCISES______________
Women
with stress, stress with urge, and urge incontinence and/or genital prolapse
may all benefit from specialist physiotherapy.
The
pelvic floor muscles have a significant role to play in the continence and
organ support mechanisms; they contribute to urethral
closure pressure and provide tonic inhibition to the bladder. They are
capable of a brisk forceful contraction to counteract a rapid rise innays
rnysioinerapy
Key
point
A
Department of Health report (1997) states that 'all women presenting with
incontinence should be offered, as a minimum, one-to-one training, vaginal
examination to determine correct muscle action, and three months' exercise
taught by a specialist physiotherapist or other professional with specialist
knowledge.'
intra-abdominal pressure
or to suppress a sudden compelling need to void.
Bump et al. (1991) state that all women presenting with pelvic floor
dysfunction should undergo a digital vaginal examination to ensure correct
muscle action. Their research
demonstrated that fewer than 50% of women were able to perform an optimal or
correct pelvic floor contraction when given verbal or written instruction only,
and that the feedback provided by digital examination is the only way to ensure
appropriate pelvic floor muscle activity
Teaching
Pelvic Floor Exercises
Many
widely differing exercise protocols are described in the literature and,
unfortunately, no standardised outcome measures have been employed to allow
evaluation. It is generally accepted, however, that certain principles are
fundamental to success. One protocol is described in the boxed text.
Exercising
your pelvic floor
Imagine
that you are trying to stop yourself from passing wind, and at the same time
trying to stop your flow of urine in mid-stream. The feeling is one of 'squeeze
and lift', closing and drawing up the back and front passages. Continue the
lift for as long as you can (up to 10 seconds). Release and rest for several
seconds.
Repeat
as many times as you can (up to a maximum of 10 repetitions at a time). This
will help to increase the endurance of your pelvic floor muscles.
It
is important to do this without tightening your buttocks, holding your breath
or squeezing your legs together. You may feel your lower abdomen working at
the same time, in the area just above your pubic bone.
It
is also important that the muscles are able to react quickly to stop leakage
with coughs, sneezes etc. Practise tightening hard and fast, then relaxing
immediately.
Both
these exercises can be practised anywhere, at any time and in any position,
but not while emptying your bladder.
Specificity,
overload and maintenance Gilpin et
al. (1989) demonstrated that the pelvic floor exhibits 65% type 1 fibres and 35% type 2, although these proportions vary
depending on the subject's age, parity, hormonal status and the pelvic floor
muscle site which is sampled. An exercise regimen should include work for both
fibre types specifically.
Type
1 fibres exhibit tonic activity and are engaged at lower levels of work and
during maximum sustained contraction. Type 2 fibres are recruited during
maximal pelvic floor activity, producing a brisk forceful contraction but
fatiguing rapidly. Overload is developed by increasing the exercise frequency
and duration appropriately as muscle function improves. Maintenance of
improved function requires that exercises be continued for life.
Although
sometimes suggested as an exercise, midstream stop of urine is strongly
discouraged since it may contribute to incomplete emptying and infection.
The
pelvic floor as a synergist
Traditionally,
pelvic floor exercise has been taught in isolation of other trunk muscles.
Although further studies are needed, there is some evidence that the pelvic
floor forms part of the functional unit of local spinal stabilisation, acting
in synergy with transversus abdominis and
other segmental stabilisers (Sapsfordet
al. 1997; Richardson et al. 1999). Appropriate training of transversus abdominis, therefore, may facilitate reeducation
of the pelvic floor.
Adjuncts
to Exercise
The
principal aim of physiotherapy is to strengthen the pelvic floor muscles, and
the basis of treatment is an individualised exercise regimen that is progressed
appropriately. Bo (1995) suggests that a successful outcome depends on 5-6
months of exercise, plus contact with the therapist. Other modalities may
complement this programme, and might include biofeedback,
neuromuscular electrical stimulation (NMES) and behavioural
modification.
Biofeedback
Biofeedback may be via electromyography or a
I pressure sensor. The woman receives immediate visual information regarding
her pelvic floor activity I and is able to modify/increase her effort
accordingly, I This can provide high levels of
motivation. Because I of the many variables involved, biofeedback does not I measure muscle strength but simply monitors
ij trend.Electrical stimulation
NMES
is not an alternative to voluntary exercise, but an additional means of
strengthening and improving the function of a weakened pelvic floor. Detrusor inhibition may be achieved by
targeting the sensory afferent fibres of the pudendal
nerve, using a frequency of 5-10 Hz. Higher frequencies of 30—50 Hz will
reinforce cortical awareness and stimulate the type 2 fibres to produce a
contraction.
Behavioural
modification
Many women experience urinary frequency. Pressure from a prolapse,
urgency or the belief that keeping the bladder empty of urine will prevent
involuntary leakage may all be contributing factors. Bladder training aims to
increase gradually both the amount of urine passed and the intervals between
voiding. Normal bladder capacity is 350-500 mL, and this capacity can be
sustained only if the muscular bladder remains compliant. Allowing it to fill
to normal volumes will maintain its elasticity.
TENS and Obstetrics and Gynecology
A systematic
review of the literature found TENS to be of little use in relieving
labor
pain. Randomized trials were hampered by poor blinding techniques. They
report
that only three of eight studies demonstrated a positive result. The only
study
with appropriate blinding methods and with a positive result used a postlabor
recall
of pain score. The pain score was lower in the TENS group versus the
sham
TENS groups. However, in the pain scores taken during the labor were no
different
between the groups.83 A study using TENS to treat low-back pain specifically during
labor found no difference between TENS and the standard treatment
Electrical
Modalities in Musculoskeletal and Pain Medicine
of
massage and mobilization. Comparison of TENS to sham TENS yielded no difference
in first-stage labor pain as judged by the amount of reduction in
self-administered analgesia. All of these studies used a variety of
frequencies, pulse durations, placement of electrodes, and duration of
treatment, making comparison
difficult.
There is a suggestion that electrical stimulation can improve circulation.
A recent
Cochrane Review of the literature found no supporting studies for the use
of
TENS to improve blood flow in placental insufficiency.
In a cross-over design, women with dysmenorrhea
were treated with 100 Hz TENS, Ibuprofen, both TENS and ibuprofen, or sham TENS
(no electricity delivered). The subjects were not adequately blinded given a
cross-over design. For the active TENS unit, subjects were asked to adjust the
amplitude of stimulation to a comfortable tingling sensation. Thus, the
subjects would be aware of a sham TENS that did not deliver electricity.
Regardless, there were no significant differences in pain and symptom relief
with TENS. Ibuprofen consistently improved pain measures. In a small study comparing intrauterine
pressure, contractions and pain with dysmenorrhea, women experienced
significant relief with either naproxen or 70-100 Hz TENS with high amplitude
(40-50 mA). Only the naproxen group experienced reductions in intrauterine
pressure and contractions.60 Unfortunately, the study
was not blinded.
A comparison trial of TENS alone, lignocaine
injection alone, and TENS combined with lignocaine was performed for the
treatment of pain related to cervical laser treament. TENS alone or in
combination did not provide any analgesic effects compared with lignocaine.12
In a double-blinded randomized, controlled trial using a wrist-adapted TENS
unit for the treatment of chemotherapy-related nausea, no difference was found
in the intensity of the nausea or the percentage of persons with nausea. However, all subjects were treated with
antiemetics, diluting the possible effects of TENS. Overall, further study
needs to be conducted to determine whether certain stimulus parameters might
benefit obstetric and gynecologic patients.
Reproductive System
The female reproductive system is influenced by
exercise. A wide spectrum of
menstrual
dysfunction has been found in athletes and some women involved in a
vigorous
exercise program. Ovarian function and
menstrual regularity depend
on
normal pituitary gonadotropic stimulation. Gonadotropin levels were found to
be
too low or below normal in women long-distance runners, reflecting central
suppression
of the reproductive axis. Hypothalamic hypofunction has been shown
to
be the cause of pituitary hypofunction; however, the cause of hypothalamus
dysfunction in has not be eanth linetveesstigated. Delayed menarche,
oligomenorrhea, anovulation, and amenorrhea are the most common documented
menstrual dysfunctions in female athletes.2122 Exercise-induced menstrual
irregularity is multifactorial in origin and is a diagnosis of exclusion.
Reduction of exercise levels and dietary modification can produce dramatic
changes in menstrual function.
There is an association between body fat
composition and initiation and maintenance of menstrual periods. Seventeen
percent body fat is required for initiation of menstruation, and 22% body fat
is required for maintenance of menstrual periods. Athletes who have amenorrhea
are shown to have a lower percentage of body fat or a lower body weight.
MEDICAL
REHABILITATION OF PATIENTS WHICH SUFFERED FROM ACCIDENT ON
CHORNOBIL’S ATOMIC STATION (AS)
Radiation sickness is caused by exposure to
radioactive sul stances. These are elements made up of unstable atoms thi give
off energy as the result of spontaneous decay of the nuclei. If the energy
released by a radioactive element is stron enough to dislodge electrons from
other atoms or molecule in its path, it can damage or even kill living tissue.
This typ of radiation is called ionizing radiation. Even if only one eel is
exposed to radiation, the radiation can destroy,
damages alter the makeup of that cell. The alteration of cell struchu by
radioactive particles can lead to the development of cancel If a cell's DNA is
damaged, this can cause genetic mutation that can be passed down to offspring.
The type and extent of damage done by exposure I radiation depends on the
total dose of radiation receivec the length of time over which it was received;
and thesiz and location of the body area involved. Damage obviousl tends to be worse with greater degrees of
exposure. Thi may be modified, however, by the length of time involve
Ai Chi (Aquatic Tai Chi)
Developed byjun Konno from
chi techniques.
The benefits include increased flexibility and ROM, improved circulation of
energy along important acupoint meridians, decreased stress, increased mental
alertness, improved kinesthetic awareness, and enhanced breathing through
learned yogic breathing techniques. Diagnoses treated with ai chi include orthopaedic
injuries, neurologic diseases, anxiety or depressive disorders, rheumatic diseases,
fibromyalgia, cardiac conditions, respiratory diseases, and prenatal and
chronic pain. A benefit to ai chi is that it can be performed independently
once the patient has learned a safe program that is appropriate for his or her
needs.
Burdenko Method
The Burdenko method, developed by Igor Burdenko, is a
combination of water
and sports
therapy. The methods are an application of water and land based exercises to
maintain health and quality of life and to enhance physical performance.
His method combines the advantages of both water and
land, using both shallow
and deep-water
activities. The Burdenko method is based on six qualities: balance,
coordination,
flexibility, endurance, strength, and speed.
This method challenges the COG on land and COB in
water. Water characteristics
include
working in a vertical position in deep water, exercising in multiple
directions, exercising at different speeds, and beginning in deep water and
progressing to shallow water. This interaction between the two environments is
believed to be the key to faster, safer, and more efficient body function. The
Burdenko method works on the body as a whole, not just the injured part. The
goal is to establish harmony of function in the body using a holistic approach.
The water and land programs each consist of three stages: (1) warmup (walking,
stretching, running), working out sports qualities (coordination, balance,
flexibility, endurance, strength, and speed), and cool-down (e.g., stretching, breathing
and shaking)
HYDROTHERAPY: METHODS OF
APPLICATION
Wound Healing and Hydrotherapy
There continues to be much controversy and research
regarding the effectiveness
of whirlpool
and Hubbard tank therapy in the management of wound healing.
The Agency for Health Care Policy and Research (AHCPR)
Clinical Practice
Guidelines for the Treatment of Pressure Ulcers
consider the use of whirlpool and
Hubbard tank treatments for the cleansing of pressure
ulcers that contain thick
exudate,
slough, or necrotic tissue. Whirlpool or Hubbard tank treatment should
be discontinued
when the ulcer is determined to be clean.7 Caution must be taken
Aquatic and Hydrotherapy in Rehabilitation
so that wound trauma does not
occur from the high pressure water jets in the whirlpool. The water turbulence
can damage granulation tissue and migrating epidermal cells. As a result, the
water jets should not be positioned close to the wound.
Treatment assessment is essential, and whirlpool use
should be discontinued once
exudate,
slough, and necrotic tissue are cleared to prevent further damage.
Whirlpool Baths
There are basically two types of whirlpool tanks:
fixed and portable tanks.
"Lowboy" and "highboy" tanks are
for extremity or trunk immersion. This treatment provides heat, gentle massage,
debridement, and relief of joint pain and stiffness and promotes relaxation of
muscles. The immersed body parts can perform active, active-assistive, or
passive ROM exercises while the body parts are submerged.
Hubbard Tanks
Full-body immersion whirlpools are known as Hubbard
tanks. An overhead lift
with a stretcher
is usually used to get the patient into the water. Water temperature
should not exceed
1° above normal body temperature. Patients with burns requiring debridement of
necrotic tissue, slough, or thick exudate may benefit from fullbody immersion
treatments. Burn patients may also benefit from dressing removal in water and
from active exercise assisted by the water.
Certain patients with open wounds may also be suitable
candidates for Hubbard
tank therapy. A
study of postabdominal surgical patients found a decreased gas
build-up
after surgery in the intestines, facilitated wound healing, and decreased
anxiety
with tank therapy. The advantages of the Hubbard tank are its ability to obtain
full-body immersion, achieve wound debridement, facilitate active exercise, and
decrease pain and anxiety in patients who have contraindications to
participating in the therapeutic pool .
Duration
Physiologic effects are generally achieved in 20
minutes when used as a heating
modality.
Borrell and colleagues demonstrated that 20 minutes was long enough to
increase
skin, muscle, and joint capsule temperature in the hand and foot.
Entries
For whirlpools, a standard whirlpool chair that sits
outside of the tub to allow
lower extremities
to be immersed or a whirlpool bench that sits inside a tank to
fully immerse the
lower half of the body is available.
For Hubbard tanks, stretchers with mechanical lifts
are available.
Currently, there are no universal standards for
cleaning and disinfecting
hydrotherapy
tanks. The Centers for Disease Control and Prevention recommend
that sodium
hypochlorite 70% per
the patient
enters to produce free chlorine residual of about 15 mg/L. These
concentrations
have been found to reduce the microbial contamination in water
from 104 to less
than 10 colony-forming units per milliliter in a controlled study
with
patients with burns.
Pulsed Lavage
Pulsed lavage offers an alternative or adjunct to
hydrotherapy for wound healing.
Pulsed lavage is described as a system delivering an
irrigation solution under
pressure
by an electrically powered device. This pressure cleanses the wound of
debris, increases
tissue perfusion, and enhances a clean wound bed for granulation
to occur.
Pulsed lavage delivers a pulsating stream of fluid that loosens necrotic
tissue from the
wound and may concurrendy be used with suction to remove debris
and irrigating
solutions. The AHCPR guideline suggest that irrigation pressures
less than 4 psi may
be inefficient to remove surface pathogens and debris, and that
irrigation
pressures greater than 15 psi may cause wound trauma and drive bacteria
into wounds.
These pressure range recommendations were derived from studies
conducted
by Brown et al., Rodeheaver et al., Wheeler et al., and Stewart et al.
and a series of
studies performed at
the preferred
cleansing agent because it is physiologic, will not harm tissue, and
adequately
cleanses most wounds.
Advantages
Pulsed lavage can be used for treatment of patients
who need to remain in their
room secondary to
isolation or medical compromise. Patients with tracheostomies
WHIRLPOOL AND HUBBARD TANK CONTRAINDICATIONS
Incontinence of bowel or bladder
Unstable blood pressure
Uncontrolled seizure disorders
Acute febrile illness
Infectious disease
WHIRLPOOL AND HUBBARD TANK PRECAUTIONS
Increased edema in
extremities
Cardiac disease
Peripheral vascular disease
Decreased cognitive status
Decreased vital
capacity (<1.0—1.5 L)
Controlled seizure disorders
Patients should never be left unattended during a
whirlpool or Hubbard tank treatment. Aquatic and Hydrotherapy in Rehabilitation or
ventilators may receive pulsed lavage treatments for wound care with
significantly decreased risk of water aspiration and increased safety regarding
electrical equipment during treatment with water. Pulsed lavage treatments can
continue after discharge in the home and may promote shorter hospital stays.
Contraindications and
Precautions
Pulsed lavage is contraindicated near exposed blood
vessels, eyes, or dura. The skill of the professional or caregiver performing
the treatment is important to prevent spray from contaminating the surrounding
treatment area, the patient, or the person administering the treatment. The
irrigation fluid should be suctioned as fast as it is sprayed to decrease the
risk of contamination. Two people may perform the technique, with one
administering the fluid stream and the other suctioning the debris and
remaining fluid. Caution must be taken when using pulsed lavage near exposed
muscle.
Research comparing the effectiveness of pulsed lavage
and whirlpool on wound
cleansing
is scant. Additional clinical studies comparing die effects of the two on wound
cleansing and healing are needed. Recognizing the progressive financial restrictions
facing the clinician, future comparisons should also include cost analyses of
the two methods. Total cost per incident, number of treatments required to achieve wound closure, and per-treatment costs should be
included in future research.
Contrast Baths
Contrast baths are an alternating application of hot
and cold generally applied to distal extremities, using a 3:1 ratio of hot to
cold, applied with compresses or immersion. Contrast baths are used primarily
for increasing blood flow through an area. Contrast baths promote a type of
vascular exercise causing alternate constriction and dilation of the local
blood vessels, which stimulates increased peripheral circulation. This process
aids in removing wastes that accumulate in areas of inflammation and assists in
bringing nutrients and oxygen to the area.
Indications
Contrast hydrotherapy is an effective treatment for subacute, postacute,
and chronic cases of tendinitis, bursitis, and arthritis. It is also effective
for desensitization of neuropathic or sympathetic pain syndromes, such as
reflex sympathetic dystrophy (RSD). Contrast baths can assist in the treatment
of RSD by reducing edema and normalizing sympathetic neuroregulation of blood vessels.
Contraindications and
Precautions for Contrast Baths
Advanced atherosclerosis and advanced peripheral
vascular disease should be
treated
with extreme caution to avoid the exacerbation of ischemia. In the presence
of open wounds,
the containers should be sterilized before and after use. Pad
the edges of
containers to avoid constriction of the circulatory or lymphatic system.
Watch skin coloration and monitor patient's pulse.
Adhere to those precautions
and
contraindications relating to other applications of heat and cold.
Contrast
Begin with hot water immersion (Table 7) for 10
minutes then begin alternating
with:
For edema reduction, begin with cold water immersion
for 1 minute, followed
by hot water
immersion for 4 minutes, continuing for 3-5 repetitions, ending with
cold water
immersion.
Sitz Baths
A sitz bath is a bath in which the pelvis is immersed
in hot aor cold water. Traditionally, hot sitz
baths have been used for relief of postpartum perineal pain, and one of the
most routine orders for postpartum patients is the warm sitz bath. Studies have
investigated the effectiveness of hot versus cold sitz baths, intermittently, to
relieve postpartum perineal pain. Scientific observation would suggest a change
to ice therapy to decrease edema and hemorrhage, thus decreasing the length and
severity of postpartum pain.24 Alternative medicine treatments include hot,
cold, and
contrasting (hot/cold) sitz baths to decrease pelvic discomfort. Further research
appears warranted in this area. Warm sitz baths are effective in treating hemorrhoids
and anorectal pain.12 Naturopathic hydrotherapy uses sitz baths for pelvic
disorders, as well as indications for treating sciatica, insomnia, headache, congestion,
constipation, and incontinence.11
SUMMARY
Humans have used hydrotherapy for healing and
spiritual rituals for centuries.
The use of water's therapeutic properties gained
popularity in the medical community in the 1800s, but its frequency of use by
the medical establishment has
varied since then.
The field of aquatic therapy has grown tremendously in the late
20th century, serving as an adjunct
to land-based therapies. Water's physical properties, including
buoyancy and increased resistance to movement compared to air, provide
advantages that cannot be found in land-based programs.
Aquatic therapy techniques need continued development
as health-care professionals acquire skill and comfort in performing them and
continue to note the important role the therapeutic use of water can have in a
patient's rehabilitation.
Research on pulsed lavage techniques and hydrotherapy
immersion in the treatment of wound care remains scant. Further research is
needed to support the
effectiveness
of aquatic and hydrotherapy procedures and to promote evidencebased health-care
practice within the financial constraints now faced in the 21st century.
