Published on February 19, 2014
BY : Dr DAULAT RAM DHAKED
Physiotherapy >> Merriam-Webster’s definition • Preservation, enhancement, or restoration of movement and physical function • Impaired or threatened by disability, injury, or disease • That utilizes therapeutic exercise, physical modalities, assistive devices, and patient education. • Has a very important role in encouraging patient to remain positive and in control of their condition.
• Although physiotherapy techniques may not change underlying pathological changes, or prevent all disability, may improve function by minimizing – Contracture, – Loss of strength and – Decreased skin compliance. (Askew et al 1983, Br J Rheum 22, 224-32)
A physiotherapeutic approach Stiffness Pain Fatigue / sleep Patient’s Knowledge Nutritio n Skin Body image Mobility Self-care Self esteem, Limitations in insight
Advantages of physiotherapy treatment • Quick – results are achieved in a rapid fashion • Efficient – addresses both aetiology and pathogenesis to • • • • eliminate cause not just symptoms Safe – causes minimum adverse reactions Specific – drugs or treatment delivered to affected organs or tissues Painless – uses non-invasive procedures Stressless – avoids unnecessary surgical procedures and use of general anaesthetics
• Dermatological patients are often polymorbid • During hospitalization, especially older patients are compromised • Physiotherapeutic care can prevent complications such as pulmonary affection or joint contractures
Major physiotherapy techniques: • Therapy by mechanical treatment (Exercise, Massage, • • • • • • and Pressure therapy) Non-electric thermotherapy – (Heating and Cooling, Hydrotherapy) Electrotherapy (Electrostimulation, Interferential, Ultrasound, Magnetotherapy, Pharmacological phoresis, SCENAR) Ozonetherapy Vacuum therapy Balneotherapy Phototherapy
Clinical effects of electrotherapy Electrostimulation Anti-inflammatory Analgesic Sedative Tranquilising Spasmolytic Vasodilating Trophic Stimulation of secretion function Metabolic Interferential Analgesic Trophic Spasmolytic Defibrosing Ultrasound Anti-inflammatory Analgesic Spasmolytic Metabolic Defibrosing
Magnetotherapy Sedative Trophic Spasmolytic Vasoactivating Antiedemic Hypocoagulating Myorelaxation Metabolic SCENAR (Self Controlled Energo-Neuro Adaptive Regulator) therapy Metabolic Immunostimulating Vasoactivating Endorphine and encephaline release Correction of DNA spontaneous structural changes Neurotransmitters release
Advantages of pharmacological phoresis Effectively enhances delivery of topically applied drugs, specifically to the affected organ or tissue Avoids or minimises adverse reactions Maintains local drug effect for a prolonged period Avoids potential gastrointestinal degradation Reduces dose Suitable for various drug groups (corticosteroids, NSAIDs, analgesics, vasodilators, hormones, anticoagulants, antibiotics, vaccines, antfungal, antimicrobial etc.) Eg : Iontophoresis for hyperhidrosis
Indications for electrotherapy •Throphic ulcers, •Hyperhidrosis and bromidrosis, •Eczema, •Neurodermitis, •Herpes, •Neuralgia, •Varicose veins, •Atherosclerotic occlusions, •Phlebitis, •Thrombophlebitis,
Reduction of itch in allergic dermatitis following electrical cutaneous field stimulation (J. Wallengren, Allergy, 2002) 1 – reactions after 1 h of CSF treatment administered 30 min prior to provocation (n = 12) 2 – reactions after 4 daily (CSF) treatments, the last treatment given 1 day before provocation (n = 10)
Use of electrotherapy which demonstrated effective clinical results (PubMed database) Pathology Treatment Chronic wounds Ultrasound Peripheral arterial occlusive disease Prostaglandin E1 iontophoresis Hyperhidrosis Iontophoresis with tap water Author Source W.J. Ennis et al. Advances in Skin and Wound Care, 2008 K. Yamamura The Annals of Pharmacotherapy , 2003 M. Connolly and D. de Berker American Journal of Clinical Dermatology, 2003
Therapy by mechanical treatment Massagesmanual or instrumental changes in blood circulation, muscular relaxation Rehabilitative exercises increase of body strength and mobility, psychical effects, improvement of body posture
Thermotherapy • Application of heat is an intervention in body thermoregulation. • Positive or negative thermotherapy • body response depends on: • Way of application • Intensity, penetration ability and duration of the heat stimulus. • Size and geometry of the application area • Mainly packs and compresses Compresses can be dry (blankets, bottles), peloids (mud) and paraffin. peloids (mud) paraffin. 15
Hydrotherapy Acts mainly on cardiovascular system, vegetative nerves and psychology. Heat helps muscles to relax, reduces pain, accelerates resorption of oedemas. Whirling baths Alternative application of sharp hot and cold water jets – a method with outstanding activation effect. For upper and lower limbs moderately hyperthermic – increasing blood supply and metabolism skin receptors activated 16 16
Sauna Effects of hot (80 - 100°C) air of low relative humidity (1030%) are utilised, followed by cooling in cold water. Outstanding tonic action. 17
Magnetotherapy Interactions of magnetic fields with human tissues are utilised in both diagnostics and therapy. Magnetotherapy is an example of healing procedure
IR lamps • Radiation is absorbed mainly in body surface. • Skin receptors are stimulated, • Subjective feeling of heat, reflex vasodilatation and muscular relaxation takes place.
Systemic Changes A/W Immobility • Metabolic • Respiratory • Atelectasis, Hypostatic Pneumonia, and Decrease oxygenation, • Cardiovascular • Orthostatic hypotension, Increased workload of heart, Risk for thrombus • Musculoskeletal • muscle atrophy, osteoporosis, contractures and foot drop • Integumentary • skin breakdown, skin hygiene
Management • Respiratory System • Promote lung expansion • Deep breathing and coughing exercises • Chest physiotherapy • Positioning every 2 hours • Cardiovascular System • Prevention of oedema and thrombus formation • TED Stockings • Calf pumping exercises • Sequential compression stockings • Musculoskeletal System • Passive ROM for all immobilized joints • Prevent foot drop and contractures
Foot wear • Crutches are good alternative • Felt pad to take the weight off • Plaster of Paris boot • Molded double rocker boot • Curative foot wear
Commonly used footwear • Flat soled Microcellular-padded slippers (MCR chappals) • Low molded shoe with arch support & metatarsal pad (ASMP) • Metatarsal bar • Molded boot
Deformity Prevention • Rest, body position and POP cast • Prevent/Reduce swelling : Elevation, active and passive exercise • Providing hand, eye and foot protection. • Prevention of contractures • Exercises • Active exercises • Passive exercises
Systemic sclerosis • For Raynaud's phenomenon: • Prevention - avoid cold and trauma; use warm clothing or heated clothing. • For an attack - warm the body, hands and feet gently (skin may be numb and unable to feel if heat source is too hot); • Use gentle arm movements or gentle massage to help restore circulation. • Promote joint mobility and muscle strength. • Exercises and stretches for hands, face and feet are essential. • Exercise for lungs and respiratory muscles should also be taught concentrating on lung expansion.
• Aerobic activities to induce deeper breathing could be • • • • • suggested, e.g. swimming and walking. Application of wax to hands and feet has been found to be beneficial by some patients. Oils in wax and warmth serve as a useful preparation for exercise. Massage of skin helps to mobilize stiff connective tissues Have beneficial effect on circulation and nutrition of skin Hot water bottles, electrically heated pads, hot bath or shower also beneficial.
Hand exercise Hips, Knees and Ankles Inner thigh stretch Wrist extension stretch Calf stretch Elbow stretches Quadriceps stretch Wrist flexion stretch
Psoriatic arthritis Acute phase • Encourage rest. • Splints may be used for rest and pain relief, especially for hands, wrists, knees, or ankles. • Cold modalities should be used to decrease inflammation and assist with pain relief. • Joints should not be moved beyond limit of pain; • passive movements should be limited • Education about disease itself, importance of rest, exercise program, joint protection, energy conservation, and weight loss
Subacute and long-term phase • Isometric exercises are begun, with progression to active movement. • Gradual range-of-motion (ROM) exercises include passive and active exercises; • areas with subluxation should not be forced passively. • Heating modalities, including moist heat packs, paraffin wax, diathermy, and ultrasound, can be used to decrease pain; • heat therapy should be performed just prior to performance of ROM exercises.
• Institute gait activities, with patient bearing weight as • • • • • tolerated, with or without an assistive device. Gentle stretching should be gradually introduced. If pain persists beyond 2 hours after therapies, then intensity should be decreased. If a joint is swollen, then no resistive exercises should be performed through full ROM. Axial spine involvement, spine extension exercises help with flexibility and strength. Sausage toes, use extra-depth shoes with a high toe box.
Dermatomyositis • Activity should be maintained as much as possible • Vigorous physical training should be avoided when myositis is active. • Strengthening to prevent atrophy • Range of motion exercises to prevent contractures • Passive stretching and splinting
Lymphedema • Interventions include: • Manual lymph drainage (to help improve flow of lymph from affected arm or leg from proximal to distal). • Short/low stretch Compression garment wear following lymphatic drainage. • Skin Hygiene and care (such as cleaning skin of arm or leg daily and moisten with lotion). • Exercise to improve cardiovascular health and help decrease swelling in some cases. • Compression pumps • Garment fitting.
• Complex Decongestive Therapy: • Phase 1: • Skin care • Light manual massage (manual lymph drainage) • ROM • Compression (multi-layered bandage wrapping, highest level tolerated 20-60 mm Hg) • Phase 2: • Compression by low-stretch elastic stocking or sleeve • Skin care • Exercise • Light massage as needed • Contraindications:- arterial disease, painful postphlebitic syndrome, and occult visceral neoplasia
Venous insufficiency • Leg elevation; • Elevating leg above level of right atrium decreases venous hypertension and edema, • Done minimum of 3 times/day for ≥ 30 min • Compression • Bandages, stockings, and pneumatic devices; • Intermittent pneumatic compression (IPC) uses a pump to cyclically inflate and deflate hollow plastic leggings. • External compression, squeezing blood and fluid out of lower legs. • Treats severe postphlebitic syndrome and venous stasis ulcers • Topical wound care; and surgery, • Weight loss, regular exercise, and reduction of dietary sodium.
Bedsore or pressure ulcer DO • Change position 2 hourly to relieve pressure. • Use pillows, sheepskin, foam padding, to reduce pressure • Exercise daily, including range-of-motion exercises for immobile patients. • Keep skin clean and dry. DO NOT •Do NOT massage the area of the ulcer. Massage can damage tissue under the skin. •Donut-shaped or ringshaped cushions are NOT recommended. They interfere with blood flow
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