POM III - Overview of PM&R - Exam 2

Physical Medicine and Rehab

Branch of medicine that focuses on improving functional ability and quality of life of people with physical impairments

Trained physicians complete a 4-year residency

Physicians are called physiatrists

PM&R Basics

Understanding the physical changes that occur with:

-congenital abnormalities

-complications from an injury, disease, amputation

Restoring or improving how that person functions daily

Acute Rehab Goals

Stabilize the problem

Prevent secondary complications

Restore lost functionality

restore lost or maintain functionality

what is the goal of chronic rehab?

Geriatric Rehab Goals

recovery of lost physical, psychological, or social skills so that the person may become:

-more independent

-live in personally satisfying environments

-maintain meaningful social interactions

PM&R - Patient Types

Geriatric patients

Athletes

Amputees

Stroke patients

Cardiac patients

COPD patients

COVID patients

Rehab Settings

Acute inpatient rehab

Sub-acute rehab (skilled nursing facility - SNF)

Long term care unit

Day rehab

Home health

Outpatient - PT, OT, Speech therapy

Physiatrist

Physician who specializes in PM&R

May have sub-specialty --> neuromuscular medicine, pain medicine, pediatric rehab medicine, spinal cord injury, sports medicine, brain injury, hospice and palliative medicine

Focus on treatment of function; aim to improve patient's QOL

Internal Classification of Function, Disability, and Health

Developed by WHO

Measures health and disability of individuals and populations

Three components: body functions and structure, activities and participation, severity and environmental factors

WHODAS 2.0

Assessment instrument for health and disability

Helps to standardize disability levels

Can be used in all cultures and adult populations

Linked to the ICF

WHODAS 2.0 - Domains

Cognition - understanding and communicating

Mobility - moving and getting around

Self-care - hygiene, dressing, eating, staying along

Getting along - interacting with other people

Life activities - domestic responsibilities, leisure, work, school

Participation - joining in community activities

WHODAS 2.0 36-item Version

More detailed

Overall score and domain-specific functioning scores

Can be administered via interviewer, self, or proxy

Takes about 20 min

Domain Scores: none, mild, moderate, severe, extreme

full disability

what does a score of 100 mean on the 36-item WHODAS 2.0?

Functional Capacity Eval

Evaluates ability to perform work activities related to employment

Measures physical and cognitive demands of their job

Standardized tests to eval RTW status

Typically admin by PT or OT

1:1; takes 4-6 hours to complete

Functional Capacity Eval Uses

Workman's comp cases

Disability applications

Victims of catastrophic accident

Functional Capacity Eval Components

Client interview

Medical record review

MSK screening

Functional Tests

Graded material-handling activities (lifting, carrying, pushing, pulling)

Positional Tolerance Activities -> sitting, standing, walking, stooping

Functional Capacity Eval - Report

Overall physical demand labor

summary of job-specific physical activities

summary of performance consistency and overally voluntary effort

job match information

adaptations to enhance performance

treatment recommendations

Rehab Interventions

Exercise

Assistive Technology

Environmental modification

Modifications to pain

Orders for PT/OT

Order should state "eval and treat"

EMR or order sheet from PT/OT office

Duration/frequency must be specified

Diagnosis with ICD10 code required

Can include goals of treatment

May specify therapy provider feels is necessary

PT/OT Certification

Required for Medicare

Physician/APP approval of plan of care

Indicates service was provided with direction from provider and was necessary

First appt within 30 days of initial order

Recertification every 90 days

PT/OT Certification Acceptable Documentation

Physicians/APP progress note

Physician/APP order

Plan of care signed and dated by physician/APP

Exercise

reduces overall morbidity and mortality

Modified for medical disorders

Resistive exercise and power training improve function in frail older adults

Early mobilization during hospitalization can improve outcomes

Assistive Technology

Mobility aides

Canes

10% older adults use canes

Crutches

Walkers

Wheelchairs

Bathroom and Self-care aides

Prosthetics and orthotics

Environmental Modification

Enhance access and utility of living spaces

OT expertise

PT can help with assessment of mobility/impairment if environment needs changes

Pain Modifications

Heat/cold

TENS (transcutaneous electrical nerve stimulation)

Iontophoresis

Phonophoresis

Iontophoresis

electric current forces therapeutic med into tissues

soft-tissue MSK injuries

Phonophoresis

Ultrasound forces therapeutic med into tissues

soft-tissue MSK injuries

Dysphagia Coping Mods

Special feeding techniques -> chin tuck, swallow twice

Dietary mods -> softened foods, thickened foods

SLP assessment to clarify etiology and treat accordingly

Functional Decline

Bed rest + Reduced Mobility --> physical deconditioning and muscle weakness

Immobility associated with incr risk for falls, delirium, skin breakdown, VTE

most medical conditions do NOT necessitate immobility

Functional Decline Prevention - Patient

Prevent prolonged periods of bed rest

Choosing housing that will meet future needs

Functional Decline Prevention - Clinician

Eval need for rehab

Intervene when patient presents with a fall

Encourage physical activity

Avoid bed rest orders unless medically required

Ensure nursing staff works on mobilization

Gait Cycle

Repetitive pattern of walking or running movement

Complete Gait Cycle/Stride

One foot makes initial contact with the ground

Progressing through each phase of gait

ending when the same foot makes contact again

with running, a float phase is added

Stance Phase

Foot on the ground

Contact, including foot strike and early stance

Mid-stance

Terminal or late stance, including push off and transition to swing phase

Swing Phase

Foot is off the ground, transitioning between stance phases

Early swing, including acceleration of non-stance leg

Mid-swing

Late swing, including deceleration of non-stance leg

Float Phase

Running gait only when neither foot is on the ground

Occurs after completion of push off

Gait Observation

Strength: 30 second chair stand test

Mobility: timed up and go

Balance: 4 stage Balance test

Gait symmetry

Stride length

Step height

Width of stance

Gait Analysis

Standard, systematic approach

Posture -- observe for asymmetry

Visual Analysis

Have patient walk normally

Use assistive devices as necessary

Ideally, observe without shoes in bare feet

Observe from front, back, and sides

Observe from proximal to distal

Gait Analysis - Why

Abnormal patterns to confirm pathologic conditions or injury

Rule out pathologic conditions

Runners

Popular

ID poor running mechanics that may contribute or predispose to injury

Gait Abnormalities Causes

Inadequate muscle strengths

Inadequate sensation in the foot

Inadequate muscle strength in the leg to maintain extension of the leg

Inability to relax the muscles of the leg as the body moves over the extended leg

Cerebellum disorders

Malingering patient

have wide swings side to side

will lurch from the hips

Cerebellar Dz

Patient will lurch from the knees

Unless intoxicated, patients will consistently deviate to one side

Do not assume cerebellum is healthy because patient can successfully perform testing

All patients should have ambulation observed

Foot Drop Gait

Hip is flexed excessively to avoid dragging toe

At initial Contact, foot slaps the ground

Foot drop Causes

Ankle dorsiflexor weakness -> peroneal nerve injury, peripheral neuropathy, L4-5 radiculopathy

Plantar flexor spasticity

Plantar flexion contracture

Antalgic Gait

Any abnormality resulting from pain

Self protective mechanism

Antalgic Gait - Hip

Patient leans laterally over affected hip in stance phase

Antalgic Gait - Knee

Patient maintains knee in slight flexion

Antalgic Gait - Ankle

Normal heel to toe motion absent

Plantar Flexor Weakness

Excessive forward motion of tibia in mid to terminal stance

Prevents normal heel rise

Shortens step length of contra-lateral leg

Shortened stance phase on affected leg

Impairs toe off

Gluteus Medius Gait

weakness causes pelvis to tilt excessively during single leg stance

result of muscle weakness, not pain

Uncompensated Glut Med Gait

lateral protrusion of pelvis during stance

Steppage gait on contralateral side

Compensated Glut Med Gait

Excess trunk lean (Trendelenberg)

Bilateral weakness - waddling gait

Hemiparetic Gait

Increased LE extensor tone with decreased ankle dorsiflexion and knee flexion

Patient circumducts leg during swing phase

Decreased ankle dorsiflexion leads to decreased heel strike

Stance phase on hemiparetic leg is shortened with decreased weight shift over leg

Spastic Gait

Increased adductor tone at hips pulls knees together

Increased extensor tone creates difficulty advancing legs

Results in circumducted quality to gait

Great effort noted to advance legs

Parkinsonian Gait

Flexed hips, knees, and trunk

Decreased stride length

Decreased base of support

Decreased arm string

Festination

Shuffling

Short, rapid steps

Freezing

Cardiac Rehab Goals

Increased functional capacity

Reduce risk factors

Improve QOL

Improve outlook and emotional stability

Increase knowledge about disease and increase self management

Cardiac Rehab Components

Exercise counseling and training

Education for heart-healthy living

Counseling to reduce stress

Class A Risk - Exercise Training

Healthy

No apparent increased risk of CV complications with exercise

Class B Risk - Exercise Training

Stable heart disease

Low risk for complications with exercise

Class C Risk - Exercise Training

Multiple MIs

Severe angina

Restricted exercise capacity

Mod/high risk of complications with exercise

Class D Risk - Exercise Training

Unstable cardiac disease

Exercise is CI

Phase I Cardiac Rehab

Within 14 days of cardiac event

Hospital - 6 wks post event

Goal: early mobilization and ROM, decrease effects of inactivity

Light activity: should be able to hold a convo during exercise

Phase II Cardiac Rehab

6 wks after cardiac event

Ambulatory setting

Goal: educate patient on how to exercise safely in a structured environment

Often has exercise stress test prior to starting

Phase III Cardiac Rehab

Independent cardiac rehab program

Supervised by PT

2-3x/week

Phase IV Cardiac Rehab

Completely independent exercise in a gym or health club venue

Pulmonary Rehab Indications

Asthma

COPD

Pulm HTN

CF

Pulm Fibrosis

Lung transplant patients

Pneumonia

COVID

Pulm Rehab Goals

Improve pulmonary function

Reduce exacerbations

Educate patients

Improve upper body strength and exercise tolerance

Improve QOL

Pulm Rehab Components

Nutrition education/intervention

Education: smoking cessation, use of inhalers, devices

Breathing retraining -> shallow breathing leads to increase in dead space ventilation

Chest physiotherapy

Airway secretion elim

Supplemental O2

Respiratory Muscle Rest - Components

Noninvasive intermittent positive-pressure ventilation (NVS)

Nocturnal bilevel positive airway pressure (PAP)

Noninvasive intermittent positive-pressure ventilation (NVS)

reduces dyspnea, improves gas exchange, increases minute ventilation, greater exercise tolerance

Nocturnal bilevel positive airway pressure

can normalize ABGs, improve QOL, 12-min walking distance, resp muscle endurance; decrease dyspnea

Resp muscle training

incentive spirometry

inspiratory resistive exercises

Stroke Rehab Goals

Prevent, recognize, and manage risk factors, medical, comorbidities, and secondary complications

Training to achieve maximal independence in functional tasks

Facilitating psychological and social adaptation and coping, by the patient and family

Promoting resumption of prior life roles and reintegration into the community

Improve QOL

PT - Paralysis/Plegia

Maintain passive ROM with stretching and formal strengthening exercises

Training to form ADLs independently

Use of specialized equipment if necessary

PT - Spasticity

Stretching

Proper positioning through splints

Use of vibration or electrical stimulation

Use of oral/injectable meds

Speech Therapy - Stroke Rehab

Aphasia

Dysarthria

Swallowing

Visuo-Spatial training - Stroke Rehab

One-sided neglect

-tendency to ignore one side of the environment or body

-affects approx 1/3 of stroke patients

-Can lead to falls failure to dress/clean a portion of the body, reading impairment

-Teach patient to compensate for neglect via cues and reminders

Cognitive Training - Stroke Rehab

>1/3 of stroke survivors

-Treatment plan tailored to patients' needs

-Attention

-Concentration

-Processing Speed

-Memory

-Executive functions (planning, organizing, sequencing, prioritization, reasoning, problem solving, judgment)

Physical Therapist

-Evaluate and treat pain issues

-Focuses on improving ability to perform movement of the human body

-Evaluate/treat muscle performance

-Evaluate/treat joint structure and function

-Evaluate for assistive devices

-Provide family training and education

-Fall reduction education

-Home assessment

-Education = doctorate degree

Occupational Therapist

-Address ADLs

-Address gross and fine motor skills

-Address visuo-spatial skills

-Address sequencing and planning

-Evaluate for upper extremity orthotics

-Evaluate strength and ROM

-Family training and education

-Education = masters or doctorate degree

Speech Language Pathologist

-Address communication

-Address cognition

-Address swallow function

-Works on oral stimulation and exercises

-Evaluates for adaptive communication devices

-Family training and education

Recreational Therapist

-Address recreational activities

-Evaluate need for adaptive devices to participate in premorbid recreational activities

-Family training and education

Vocational Therapist

-Evaluate work skills

-Develop skills needed for the workplace

-Explore vocational and avocational alternatives

-Assist in job placement