Physical medicine & rehabilitation & rheumatology or physiatry (rehabilitation medicine)

Rehabilitation includes assisting the patient to compensate for deficits that cannot be reversed medically

Amputations,
orthopedic injuries
arthritis
cardiac disease, cancer
neurological problems,
spinal cord injuries, stroke, &
traumatic brain injuries..
It is prescribed after many types of injury, illness, or disease, including

GOALS
Minimize functional deficits
Use remaining function to maximum
Prevent complications
Minimize functional deficits
Prevent complications

The key to Good
Rehabilitation

Physician specialists head Rehabilitation teams including a
The physical therapist.
occupational therapist.
The social workers.
Rehabilitation nurse.
psychological counselor.
Speech& respiratory therapist .
Rehabilitation engineer.
Orthotist &Prosthetist.

The physical therapist
*The physical therapist assists the patient in functional restoration.
*Tasks may include the following
ROM,Muscle Strength, Sitting , Standing , Balance, Coordination ,Transfers, and Ambulation, Including wheelchair and Bipedal.
*Progressive Gait training.

OCCUPATIONAL THERAPISTS Are responsible for those therapeutic activities associated with patient’s daily life, (ADL)
from simple Household and Personal Activities to
Work and Leisure.

Occupational therapy
helps the patient regain the ability to do normal everyday tasks.
This may be achieved
by restoring old skills or
teaching the patient new skills to adjust to disabilities through
adaptive equipment, orthotics, and modification of the patient's home environment.

Speech therapy
helps the patient
correct speech disorders or restore speech.
Speech therapy may be prescribed to rehabilitate a patient after a brain injury, cancer, neuromuscular diseases, stroke, and other injuries/illnesses

Key terms
Orthotist — A health care professional who is skilled
in making and fitting
orthopedic appliances.
Prosthetist — A health care professional who is skilled I
n making and fitting artificial parts (prosthetics) for the human body.

social worker
A social worker help to Communicate
the patient and family with the
outside world.

Evaluation of the patient’s
total Living Situation,
Including
Lifestyle,
Family Finances, &
Community resources.

Therapeutic Recreation
Therapeutic Recreation implements various interventions as a form of treatment
to increase physical, cognitive, emotional and social abilities which may have been altered due to personal trauma or disease.
SPORTS ACTIVITIES

The Vocational rehabilitation program will assist in training and placing disabled persons in new jobs.
Vocational Rehabilitation

What diagnostic tools are used in physiatry
medical history, physical examinations,
X-rays.
.Electromyography (EMG), nerve conduction studies, and somatosensory and motor – evoked potentials.
Musculoskeletal ultrasound
is a rapidly developing technique that is also performed by many physiatrists

Physiatrists utilize
Medications
Injections.
Physical modalities.
Exercise.
Education individualized to the patient`s needs.
Assistive Devices

What Are Assistive الاجهزه المساعده Devices?
Assistive devices can help a person function better and be more independent.
Assistive devices can make daily tasks easier.
.

Many devices are available to help with activities of daily living (ADLs). ADLs are the normal everyday tasks that people do.
These include:
cooking, eating&house cleaning. also include personal care tasks like bathing and using the bathroom.

Hand Held Reacher
Flexible Sock Aid
Grip Drink Holder
Grip Drink Holder

Bath Lift
Bathroom
Wheelchair
Raised Toilet Seats
Makes for an Easy On and Off the Toilet
Uplift Commode Assist

What Are the Different Types of Mobility Aids?
Mobility aids help with walking or moving from place to place.
They can help
prevent falls and improve independence.

Pediatric
Walkers

NECK PAIN
لواءاستاذ دكتور
محمد رضا محمد عوض

Anatomy
Head weighing 6:8 1b
7 cervical vertebrae
5 intervertebral discs
12 joints of Luschka
14 apophyseal joints.
System of ligaments
(ant. long, post. long ,lig. flavum , interspinous and ligamentum nuchae)
Muscles
(14 paired anterior lateral & post)

Prevalence
Neck Stiffness
25 : 30 % Age 25-29 year
Up to 50 % Age over 45 year
Neck Stiffness with Brachialgia
5 : 10 % Age 25 – 29 year
25:40 % Age over 50

Musculosketetal Causes
Osteoarthritis
Diffuse idiopathic skeletal hyperstosis
Cervical spondylosis
Disk disease
Rheumatoid arthritis
Fracture
Neoplasm
Thoracic outlet syndrome (cervical rib, first rib,and clavicular compression syndromes)
Osteomyelitis

Osteoarthritis

Neurological Causes
Nerve root syndromes
Cervical myelopathy
Neuritis (brachial,occipital)
Torticollis
Meningitis
Cord tumors

Soft tissue and muscular pain
Acute cervical strain
Cumulative trauma, overstrain syndromes
Tendinitis, bursitis
Postural disorders
Fibrositis, fibromyalgia, and myofascial syndrome
Pharyngeal infection

whiplash injury or neck sprain injury
The term “whiplash,” used to describe an injury mechanism of
sudden hyperextension (backward motion) followed by hyperflexion (forward motion) of the neck.
The injury mechanism is commonly seen in sports and auto accidents

The most common
whiplash symptoms are
neck pain, neck stiffness, headache, shoulder pain, back pain, and difficulties with concentration and mmemory. Dizziness, buzzing in the ears, insomnia, depression, and anxiety also are reported

Referred Pain
Heart and coronary artery disease
Apex of lung: Pancoast’s tumor
Migraine
Muscle tension and myofascial pain
TMJ syndrome
Diaphragm, gallbladder, pancreas, hiatus hernia

Clinical Evaluation
History
Physical Examination
Radiologic Evaluation
Electro - Diagnosis
(assist in confirming the clinical formulation)

Examination of Related Area
Shoulder
(Rotator Cuff Tendenitis – capsulitis)
TMJ
Upper Limb

Management

AIM
Relief of pain and stiffness in the neck and arms
Restore the function of neck and related structures .
Avoid pain recurrence

PATIENT EDUCATION
various types of initial neck pain treatment with
* analgesics, sedatives, antihistamines, nonsteroid anti-inflammatory drugs,
*antidepressive drugs, , muscle relaxants, and
* local anesthetic injections as well as
PHYSICAL THEARAPY
, neck collar immobilization,.
HEAT ,ice
MASSAGE
ACUPUNCTURE
MANIPULATION

LUMBAR DISC PROLAPSE
REDA AWAD

Second only to the common cold in frequency among adult ailments
Fifth most common reason for an office visit
80% of all people experience low back pain at some time during
Their lives
Lifetime recurrence rate 85%
LBP: Statistics

على المستوى المحلى
44 % من عمال الحديد والصلب
.
34 % من سائقى أتوبيس النقل العام .
32 % من سائقى القطارات .
30 % من العاملين بالتمريض .
28 % من أطباء الأسنان .

lumbar spine normal motion segment

The disc is made up of three basic structures: the nucleus pulposus,
the annulus fibrosus and the vertebral end-plates,

The disc is the
largest avascular structure
in the human body.
Nutrition
Nutrients for the disc are found within tiny capillary beds that are in the subchondral bone, just above the vertebral end-plates

Disc innervation
1981 Australian clinical anatomist and physician
Nikoli Bogduk
The outer 1/3 of annulus receive innervation
with small
Afferents.

interadiscal pressure

is a synovial joint between the superior articular process, of one vertebra and the inferior articular process of the vertebra directly above it.
facet joint
These joints are in constant motion, providing the spine with both the stability and flexibility

Degeneration
Before age 40 approximately 25%. Beyond age 40, more than 60% of people show evidence of disc degeneration at one or more levels on a MRI.
the nucleus pulposus begins to dehydrate and the concentration of proteoglycans in the matrix decreases, thus limiting the ability of the disc to absorb shock.
The anulus fibrosus also becomes weaker with age and has an increased risk of tearing.
In addition, the cartilage end plates begin thinning, fissures begin to form, and there is sclerosis of the subchondral bone

As the disc dehydrates
the disc loose ability to support the axial load of the body; this causes a 'weight bearing shift' from the nucleus, outward, onto facet joints .

Recommendation 1
Clinicians should conduct a focused
HISTORY&
PHYSICAL EXAMINATION
to help place patients with low BP
into 1 of 3 broad categories: Diagnostic triage

or back pain potentially associated with another
Specific spinal causes 8%
Nonspecific low back pain. 85%
back pain potentially associated with
Radiculopathy or
spinal stenosis 7%

Non-specific low back pain
Pain, muscle tension, or stiffness that occurs between the( rib cage and the inferior gluteal folds),
with or without (sciatica)&,
has no identifiable cause
Degenerative changes on lumbar imaging are usually considered nonspecific,
as they correlate poorly with symptoms

specific disorder,( 8%)
such as
cancer
compression fracture
spinal infection
Ankylosing sp

symptomatic
herniated disc 4%
Spinal stenosis 3%
cauda equina synd. 0.04%
is most commonly associated
with massive midline
disc herniation
but is rare

Symptoms of Facet Joint Problems
a persisting point of tenderness overlying the inflamed facet
pain from the facet joints often
radiates down into the buttocks& down the back of the upper leg.
The pain is rarely present in the front of the leg, or rarely radiates below the knee
*more discomfort while leaning backward

History
Physical Examination
Radiologic Evaluation
Electro - Diagnosis
(assist in confirming the clinical formulation)
Clinical Evaluation

The Diagnosis of back pain should be
Based on a Good History and
a Competent Physical examination
Clinical examination is the most important
Diagnostic procedure that will be undertaken

Imaging studies should be ordered in patient with :
- progressive neurologic deficits
- failure to improve
- history of truma
- those at elevated risk for malignancy or infection

Goals
*Relieve of pain
*Restoration
of physiological movements
*Prevention of relapses

Surgery should be considered for
* Individuals With Motor Weakness .
* Persistant Radicular pain
*Failure of Conservative therapy
at 3or more months .
*Cauda equina syndrome .

TH
لواء ا.د محمد رضا عوض
Fibromyalgia Syndrome

Typically presents with symptoms of diffuse body pain frequently involving the spinal region
Neurologic Clinics - Volume 25, Issue 2 (May 2007)

Fibromyalgia is associated with :
Fatigue
Sleep disorder
Anxiety , Depression
Cognitive disturbance( memory and thinking skills)
Tension/migraine headaches
Exercise intolerance
Irritable Bowel syndrome

ACR 1990 Criteria for Fibromyalgia
Widespread pain with a minimum duration of 3 months
Both right and left sides
Both above and below the waist
Axial skeletal pain
Wolfe F, et al.Arthritis Rheum 1990, 33:60-72.

Enhanced central processing of painful stimuli is manifested by:
Hyperalgesia (increased response to painful stimuli) and
Allodynia (sensitivity to normally non-painful stimuli)
A pathognomonic finding in fibromyalgia.

Eleven or more
tender points
at 18 specific
anatomical sites

The Etiology of fibromyalgia remains unclear, Current hypotheses:
Aberrant CNS processing of pain
Dysfunction of the hypothalamic-pituitary-adrenal axis

Triggers of Fibromyalgia
Physical trauma (car accidents)
Infections such as hepatitis C, Epstein-Barr virus, parvovirus, or Lyme disease
Emotional stress
The "Gulf War illnesses"

Aggravating factors were:
Emotional distress
Weather changes
Exertion

Healthy individuals with normal sleep and exercise patterns when deprived from Sleep and exercise Suffered from
Increased Pain
Fatigue
Mood disturbance
Cognitive disturbance
Sleep deprivation causing greater impact

Why should we know it better?
It is the second most common diagnosis made in rheumatology clinics
and the most common cause of generalized, musculoskeletal pain in middle aged women

Why should we know it better?
It is associated with substantial morbidity and disability
It may masquerade the initial stages of SLE or RA

Why should we know it better?
Co-existing fibromyalgia may be confused with a flare of SLE and RA
Patients with FM were found to have significantly higher (HAQ) scores than RA patients.

It has to be differentiated from other serious causes of myalgia
Polymylgia rheumatica
Statins therapy
Hypothyroidism
Polymyositis.

Optimal treatment of FMS mandates a multidisciplinary approach, including
.Pharmacologic and
Non- Pharmacologic interventions

Treatments should be specifically tailored to Patient reports of :
Pain intensity Function
Associated features such as
Depression
Fatigue
Sleep disturbance.

Pharmacologic treatment:
Strong evidence for
Antidepressants:
Dual re-uptake inhibitors
TCA (amitryptiline, cyclobenzaprine)
SNRIs ( milnacipram, duloxetine)
Anticonvulsants Gabapentin
Pregabalin

Non-Pharmacological therapies
Strong evidence
Education
Aerobic exercises
Cognitive behavioral therapies

Educational Points
The patient must be reassured that fibromyalgia is a real illness, and not imagined .
The benign nature of the disorder should also be emphasized.
It is not a deforming condition, and that it is neither life-threatening nor a cosmetic problem.

Aerobic Exercises
General guidelines:
Begin 2–3 months after start of drug therapy
Begin with low impact exercises

Take away message
Patient Education
Aerobic exercises
Heated pool treatment
Cognitive behavioral therapies
Complement drug therapy.