Introduction to Rehabilitation MedicineChapter 1

Three such factors in the 20th century led to the creation of a new specialty, physical medicine and rehabilitation. For much of the last century, medicine revolved around the concept of saving lives. The result has been prolonged quantity of life with an increase in the prevalence of chronic disease. During the same decades, armed conflicts not only redefined geographic maps but also enhanced the public’s awareness of people with disabilities; in some instances, this group came to represent a new segment of society. In addition, the polio epidemic of the 1950s left many people with friends and family members with disabilities, and the presidency of Franklin Roosevelt in the United States led to an awareness that a disability does not have to be a social handicap. The recognition of the inherent value of people with disabilities and of their needs resulted in the development of the specialty of physical medicine and rehabilitation. At its most 2 basic, this specialty focuses on maximizing a person’s independence through medical, psychological or physical treatments or through modifications to their environment.

Common causes of disability requiring complex rehabilitation include cardiovascular diseases, respiratory ailments and arthritis. Less common but potentially devastating conditions such as spinal cord injury, acquired brain injury, amputation and congenital neurologic or musculoskeletal conditions often require lifelong medical follow-up. Each of these conditions presents its own subset of medical complications and rehabilitation needs. Fortunately for the physician, some of the complications and needs overlap between conditions. For example, understanding the principles of spasticity management can help the clinician to treat the child with cerebral palsy, the adult with a spinal cord injury and the elderly patient with a stroke.

It is very difficult to define the physiatry in a single word. While the fields of neurology or orthopedic deal with nerve and brain or bones and joints, like as physiatry focuses on assisting the general improvement of functional recovery in disabled patients. Historically physiatry originated from two different fields, physical medicine and rehabilitation. According to Dorland dictionary, the word” physio” which means nature and” iatrke” which means operation or medicine. Therefore, the physiatry involves treating and diagnosing diseases using light, heat, cold, and electricity. Between the late 1930s and early 1940s doctor who treated arthritis using ultrasound or microwaves were called physical therapy physicians which is the origin of the term physiatrist.

Cardiopulmonary rehabilitation involves optimizing function in those afflicted with heart or lung disease. Chronic pain management is achieved through a multidisciplinary approach involving psychologists, physical therapists, exercise therapists, anesthesiologists, and interventional procedures when indicated.

Stroke, in addition to the previous methodology, is often treated with the help of a speech therapist and recreational therapist when possible. Physical medicine and rehabilitation physicians utilized electrodiagnostic medicine studies to help diagnose patients with symptoms of numbness, cramps or tingling.

In the majority of cases, the damage results from physical trauma such as car accidents, gunshots, falls, or sports injuries, but it can also result from no traumatic causes such as infection, insufficient blood flow, and tumors. Efforts to prevent SCI include individual measures such as using safety equipment, societal measures such as safety regulations in sports and traffic, and improvements to equipment. Known since ancient times to be a catastrophic injury and long believed to be untreatable, SCI has seen great improvements in its care since the middle of the 20th century. Treatment of spinal cord injuries starts with stabilizing the spine and controlling inflammation to prevent further damage. Other interventions needed can vary widely depending on the location and extent of the injury, from bed 5 rest to surgery. In many cases, spinal cord injuries require substantial, long-term physical and occupational therapy in rehabilitation, especially if they interfere with activities of daily living. Research into new treatments for spinal cord injuries includes stem cell implantation, engineered materials for tissue support, and wearable robotic exoskeletons.

The main risk factor for stroke is high blood pressure. Other risk factors include tobacco smoking, obesity, high blood cholesterol, diabetes mellitus, previous TIA, and atrial fibrillation among others. An ischemic stroke is typically caused by blockage of a blood vessel. A hemorrhagic stroke is caused by bleeding either directly into the brain or into the space surrounding the brain. Bleeding may occur due to a brain aneurysm. Diagnosis is typically with medical imaging such as a CT scan or MRI scan along with a physical exam. Other tests such as an electrocardiogram (ECG) and blood tests are done to determine risk factors and rule out other possible causes. Low blood sugar may cause similar symptoms.

Prevention includes decreasing risk factors as well as possibly aspirin, statins, surgery to open up the arteries to the brain in those with problematic narrowing, and warfarin in those with atrial fibrillation. A stroke often requires emergency care. An ischemic stroke, if detected within three to four and half hours, may be treatable with a medication that can break down the clot. Aspirin should be used. Some hemorrhagic strokes benefit from surgery.

Treatment to try recover lost function is called stroke rehabilitation and ideally takes place in a stroke unit; however, these are not available in much of the world.

In 2013, approximately 6.9 million people had an ischemic stroke and 3.4 million people had a hemorrhagic stroke. In 2010, there were about 33 million people who had previously had a stroke and were still alive. Between 1990 and 2010 the number of strokes which occurred each year decreased by approximately 10% in the developed world and increased by 10% in the developing world. In 2013, stroke was the second most frequent cause of death after coronary artery disease, accounting for 6.4 million deaths (12% of the total). About 3.3 million deaths resulted from ischemic stroke while 3.2 million deaths resulted from hemorrhagic stroke. About half of people who have had a stroke live less than one year. Overall, two-thirds of strokes occurred in those over 65 years old.

In most episodes of low back pain, a specific underlying cause is not identified or even looked for, with the pain believed to be due to mechanical problems such as muscle or joint strain. If the pain does not go away with conservative treatment or if it is accompanied by “red flags” such as unexplained weight loss, fever, or significant problems with feeling or movement, further testing may be needed to look for a serious underlying problem. In most cases, imaging tools such as X-ray computed tomography are not useful and carry their own risks. Despite this, the use of imaging in low back pain has increased. Some low back pain is caused by damaged intervertebral Disks, and the straight leg raise test is useful to identify this cause. In those with chronic pain, the pain processing system may malfunction, causing large amounts of pain in response to non-serious events.

The treatment of acute nonspecific low back pain of rapid onset is typically with simple pain medication and the continuation of as much normal activity as the pain allows. Medications are recommended for the duration that they are helpful, with paracetamol (also known as acetaminophen) as the preferred first medication. A number of other options are available for those who do not improve with usual treatment. Opioids may be useful if simple pain medications are not enough, but they are not generally recommended due to side effects.

8 Surgery may be beneficial for those with Disk-related chronic pain and disability or spinal stenosis. No clear benefit has been found for other cases of non-specific low back pain. Low back pain often affects mood, which may be improved by counseling or antidepressants. Additionally, there are many alternative medicine therapies, including the Alexander technique and herbal remedies, but there is not enough evidence to recommend them confidently. The evidence for chiropractic care and spinal manipulation is mixed. Approximately 9 to 12% of people (632 million) have LBP at any given point in time, and nearly 25% report having it at some point over any one-month period. About 40% of people have LBP at some point in their lives, with estimates as high as 80% among people in the developed world. Difficulty most often begins between 20 and 40 years of age. Men and women are equally affected. Low back pain is more common among people aged 40–80 years, with the overall number of individuals affected expected to increase as the population ages.

The cause of fibromyalgia is unknown but believed to involve a combination of genetic and environmental factors with half the risk attributed to each. The condition runs in families and many genes are believed to be involved. Environmental factors may include psychological stress, trauma, and certain infections. The pain appears to result from processes in the central nervous system and the condition is referred to as a “central sensitization syndrome”. Fibromyalgia is recognized as a disorder by the US National Institutes of Health and the American College of Rheumatology. There is no specific diagnostic test. Diagnosis involves first ruling out other potential causes and verifying that a set number of symptoms are present.

9The treatment of fibromyalgia can be difficult. Recommendations often include getting enough sleep, exercising regularly, and eating a healthy diet. Cognitive behavioral therapy may also be helpful. Dietary supplements also lack evidence to support their use. While fibromyalgia can last a long time, it does not result in death or tissue damage.

Fibromyalgia is estimated to affect 2–8% of the population. Females are affected about two times more often than males. Rates appear similar in different areas of the world and among different cultures. Fibromyalgia was first defined in 1990 with updated criteria in 2011. There is controversy about the classification, diagnosis, and treatment of fibromyalgia. While some feel the diagnosis of fibromyalgia may negatively affect a person, other research finds it to be beneficial. The term “fibromyalgia” is from New Latin, fibro-, meaning “fibrous tissues”, Greek myo-, “muscle”, and Greek algos, “pain”; thus the term literally means “muscle and connective tissue pain”.

TBI is a major cause of death and disability worldwide, especially in children and young adults. Males sustain traumatic brain injuries more frequently than do females. Causes include falls, vehicle accidents, and violence. Prevention measures include use of technology to protect those suffering from automobile accidents, such as seat belts and sports or motorcycle helmets, as well as efforts to reduce the number of automobile accidents, such as safety education programs and enforcement of traffic laws.

Brain trauma can occur as a consequence of a focal impact upon the head, by a sudden acceleration/deceleration within the cranium or by a complex combination of both movement and sudden impact. In addition to the damage caused at the moment of injury, brain trauma causes secondary injury, a variety of events that take place in the minutes and days following the injury.

These processes, which include alterations in cerebral blood flow and the pressure within the skull, contribute substantially to the damage from the initial injury.

TBI can cause a host of physical, cognitive, social, emotional, and behavioral effects, and outcome can range from complete recovery to permanent disability or death. The 20th century saw critical developments in diagnosis and treatment that decreased death rates and improved outcome. Some of the current imaging techniques used for diagnosis and treatment include computed tomography and MRI (magnetic resonance imaging). Depending on the injury, treatment required may be minimal or may include interventions such as medications, emergency surgery or surgery years later. Physical therapy, speech therapy recreation therapy, occupational therapy and vision therapy may be employed for rehabilitation. Counseling, supported employment, and community support services may also be useful.

It is important to recognize that “more therapy” does not make a person “better”, but that “appropriate” therapy does. Subacute rehabilitation programs require the same appropriately trained professionals as acute rehabilitation programs do. The goals of subacute rehabilitation should include minimizing morbidity, maintaining functional positioning, hygiene, nutrition, and medication management, as well as providing support for the person with a brain injury and his/her family. Subacute rehabilitation programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing, but are not making rapid functional gains.