Physical Rehabilitation




(1)
Laboratory of Anatomy, Biomechanics and Organogenesis, Université Libre de Bruxelles, Brussels, Belgium

(2)
Department of Electronic and Informatics – ETRO, Vrije Universiteit Brussel, Brussels, Belgium imec, Leuven, Belgium

 



Start by doing what is necessary, then what is possible, and suddenly you are doing the impossible. – Saint Francis of Assisi



2.1 Definition and Principles


Before discussing of the use of serious games in rehabilitation, it seems appropriate to define and obtain some precise notions about rehabilitation.

Rehabilitation is a key health strategy to address disability (Meyer et al. 2011).

Rehabilitation is a branch of physical medicine. Rehabilitation, in the area of health, can be defined as the ability to rehabilitate patients in his environment: “the aim of rehabilitation is to restore or return a person to as state of optimal functioning in interaction with his/her environment” (Meyer et al. 2014). Another interesting definition of the rehabilitation is the one from the World Health Organisation “a set of measures that assist individuals who experience, or a likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments” (WHO 2011). Two key elements of the rehabilitation are included in this definition. The first one is the importance of trying to restore optimal functioning of the patient. Of course, unfortunately, in some cases it is not possible to restore “normal” mobility or activity; therefore, rehabilitation is mainly focusing on the function and autonomy during activity of daily living. The second important aspect is the interaction with the environment: interaction with the surrounding objects (move, eat, wash) in order to be as independent as possible but also to interact with people. Social aspect is one of the keys, and unfortunately often neglected, aspect of the rehabilitation and, more generally, of the overall management and integration of disabled people in the society.


2.1.1 A Multidisciplinary Teamwork


Due to the complexity of the pathologies, the rehabilitation is, generally, not performed by a single therapist. Depending on the underlying pathology, a team of specialists are working with the patient to fulfill the best as possible the need and requirement of this particular patient. This expertise from various medical and paramedical points of view is needed in order to have a holistic approach of a particular patient suffering from a specific pathology living in his own environment. It is important to note that two patients presenting the same pathology won’t systematically receive the same treatment because lots of parameters have to be taken into consideration (Albert et al. 2012). The International Classification of Functioning, Disability and Health (ICF) from the World Health Organization (WHO) has been created to underline the importance that personal and environmental could and should play in rehabilitation1.


2.1.1.1 Medical Doctors


The medical doctors involved in the rehabilitation field are, most of the time, doctors in physical medicine and rehabilitation (neurologists can also play the role of team leader). They are responsible of the diagnosis, assess the severity of the disease and the associated troubles and complications. Based on this evaluation, they built a specific rehabilitation program for this specific patient (e.g., Does this patient require occupational therapy? How many sessions of physiotherapy are required? Does this patient need surgery or pharmacological treatment?). During all the rehabilitation process, the doctors control the progress of the patients and, in collaboration with the other professionals in charge of the patient, modify the treatment if needed.


2.1.1.2 Physiotherapists


Physiotherapists are one of the cornerstones of the physical rehabilitation. Generally, it is with physiotherapist that the patients spend most of the rehabilitation time. There are plenty of different techniques, approaches, and philosophies in physiotherapy. Physiotherapists adapt their treatments and exercises depending on the nature of the diseases (neurological, orthopedics). One of the most popular approaches for neurological disease is the neurodevelopment treatment (NDT) (Bobath 1967). The aim of this method is to facilitate the movement by reducing muscle tone and inhibiting primitive and abnormal reflex. Another important aspect of the NDT approach is to allow the patients to have a greater independence and really focus on the movement. We won’t list here each technique (details will be provided in Chap. 4). From a scientific point of view, it is important to underline that no particular technique has a higher level of evidence than another one (Kollen et al. 2009). The other important point about physiotherapy and rehabilitation is that the more the patient is moving and performing the exercises the better and faster the progress will be (Langhorne et al. 2011).


2.1.1.3 Occupational Therapists


Occupational therapists and physiotherapists are working closely together. Physiotherapists are mainly working on the muscles (e.g., to avoid spasticity) and joints (e.g., to avoid retraction and restoring/preserving enough range of motion); occupational therapists focus their work on (fine) motor function. To summarize roughly, the physiotherapists try to restore enough mobility, and the occupational therapists try to make patients (re)learn some (basic) and functional motion in order to increase their independences (Arbesman et al. 2013). To increase patients’ independence, two different, but often complementary, approaches are possible: improving directly the function (in collaboration with physiotherapists) or modifying the environment to allow patient performing these activities, e.g., modify and adopt home environment in order to prevent falls in older people (Pighills et al. 2011), modify the classroom for student with autism (Kinnealey et al. 2012), etc.


2.1.1.4 (Neuro)Psychologists


Depression and anxiety are highly prevalent in patients with chronic diseases, but remain too often undertreated despite significant negative consequences on patient health. Multiple consequences of a chronic disease diagnosis can contribute to depression or anxiety: the loss of a sense of self-worth, anxiety, and uncertainty about the future, loss of relationships and social isolation, and feelings of guilt (Dejean et al. 2013). In the perspective of a more holistic approach of the patient, a psychological and eventually spiritual support must be provided to patient in the early start of the disease (Schulz-Stübner 2007). It is important to note that this psychological support is not only provided by the medical team, the role of the family and relatives is also preponderant (Glass et al. 2004).


2.1.1.5 Speech Therapists


Lesions in the brain (e.g., stroke, cerebral palsy) do not only induce motor problem. Depending on the localization of the primary lesions, some other troubles can be induced. The location of the brain responsible for speech production (Broca’s area) and speech comprehension (Wernicke’s area) are often affected during stroke. Rehabilitation of the speech, or other communication ways, is thus an important part of the process for some pathology, especially in the light of the definition of the health by the WHO (e.g., optimal interaction with the environment).


2.1.1.6 Prosthetists


The use of prosthesis or medical devices, as temporary or permanent help, aims to give a greater autonomy to patients during activities of daily living and/or rehabilitation session. Depending on the severity of the disability medical devices varied from full support electric wheelchairs in case of severe paraplegia to ankle’s brace support to avoid spasticity of the triceps surae during gait in case of light form of spasticity.

For the lower limbs, most orthoses focus on controlling ankle position and kinematic motion during the gait (McNee et al. 2007).

For the upper limbs, the objective is to improve function by increasing the range of motion, limit deformation, and increase functions (Autti-Rämö et al. 2006).

The settings and the optimal functioning of the materials is a team effort including not only the prosthetists but also physiotherapists and occupational therapists. Casting can be an alternative to orthoses in order to increase the efficacy of treatment (e.g., intensive rehabilitation, surgery, botulinum toxin injection) (Hayek et al. 2010).


2.1.1.7 Sports Coach


The definition of the rehabilitation includes “to achieve and maintain optimal functioning in interaction with their environments” (WHO 2011). It is therefore obvious that sport should be considered as a complement to the conventional rehabilitation treatment not only for the physical benefits but also for the important and positive effects of the social interaction. Sports for disabled people have been popularized by the huge development and the media coverage of the Paralympic Games. New specialties are emerging in the faculty of physiotherapy or sport sciences in physical activities adapted for people with disabilities.

Important efforts are also done in the development of affordable material (prosthesis, wheelchairs, etc.) to allow disabled people to train and enjoy sport’s activities.

Finally, we can also note here the importance that the animals can play during rehabilitation and in particular horses during hippotherapy session.


2.1.1.8 Social Workers


Although only a few people would spontaneously think about social workers in the rehabilitation team, these ones play an important role. Social workers try to solve some obstacles related to rehabilitation (e.g., access to care, financial issues). They also have an important role in the dialogue with the family. They do not only provide material support (access to institution, materials, etc.), they can also be a part on the treatment (e.g., social workers can visit the family to help and support parents with disabled children (Weindling et al. 2007)). This example underlines the fact that the disease affects not only the patient but also his family. It is therefore sometimes interesting to work with family to decrease stress and anxiety level by allowing the patient to evolve in a more favorable environment.


2.1.2 The Neuromusculoskeletal System


The general aim of rehabilitation is to restore or return a person to a state of optimal functioning. For achieving this goal, different objectives are targeted such as posture, balance, strength, coordination, endurance, and dexterity.

For a healthy subject, a lot of daily activities are done automatically, without even thinking about it, despite this “automation” even a relatively simple motion such as taking a glass and drinking it required optimal functioning and the synchronization of a lot of systems. It is interesting to have an overview of this complex system in order to understand the pathologies, and therefore the different strategies of rehabilitation. Here is a (non-exhaustive and simplified) list of the principle component of the nervous and musculoskeletal system involved in voluntary contraction.

We try to schematize all these information in Fig. 2.1 with the main function of each component and few examples of pathologies that can affect each level.



  • Central nervous system (CNS)



    • The motor cortex: Located in the frontal lobe, it is involved in the programming (mainly in the premotor cortex that is located in front of the motor cortex), the execution and the control of voluntary movement. Lesions (e.g., stroke, traumatic brain injury, tumors) in the motor cortex induce paralysis. The motor cortex is composed by different components: the primary motor cortex, the premotor cortex, the supplementary motor cortex, and the posterior parietal cortex.


    • The cerebellum: Involved in the coordination, precision, and accurate timing of the motion. The cerebellum is important in the acquisition and learning of new skills and motricity. It allows supervised learning of a new task by transmitting the error between the expected motion and the performed one to the motor cortex: it’s a feedforward learning. Therefore, a lesion in the cerebellum induces posture and balance disorders, difficulties with motor learning and fine movement controls (dexterity). The cerebellum has also an important cognitive function mainly for the language and the attention.


    • The basal ganglia: Acts like an inhibitor for motor systems, when this inhibition is released the motor system is activated. The basal ganglia also play a role in the acquisition of new skills: it’s involved in the reinforcement learning. Lesions in the basal ganglia induce trouble in motor control, mainly hyperkinetic disorders (e.g., difficulty to initiate movement in Parkinson’s disease, difficulty to prevent unintentional movement in Huntington’s disease).


    • The spinal cord: Makes the link between the CNS and the peripheral nerves. Relays information from brain to muscles through the efferent or descending pathways (pyramidal and extrapyramidal tracts) and from peripheral (muscles, joints, glands, organs) to brain through the afferent or ascending pathways (dorsal column medial lemniscus system, spinocerebellar tracts, anterolateral system). Patients with spinal cord injuries could present various symptomatologies depending on the severity and localization of the lesions: from muscle weakness and loss of sensitivity within limited regions (i.e., herniated disc) to full body paralysis (i.e., laceration of the spinal cord in the cervical spine due to trauma).


  • Peripheral nervous system



    • The nerves: Relays between the spinal cord and the muscles, joints, ligaments, bones, etc. Nerves can be stretched, compressed, cut inducing muscles’ weakness or paralysis (efferent), loss of sensitivity, and proprioception (afferent).


  • Musculoskeletal system



    • The muscles: Muscles’ contraction is a complex mechanism involving neuromuscular junction (release of neurotransmitter [mainly acetylcholine]) and the slide of myo-filaments (actin and myosin) to produce changes in muscles’ lengths and finally producing motion. The muscle spindles also provide information to the CNS relative to the length and the stretch of the muscle; those information are called proprioception. In rehabilitation, it is important to restore or preserve the proprioception to maintain optimal functioning of the musculoskeletal system (fine motor function and balance). The muscles are attached to bones by tendons (also containing proprioceptive fibers).


    • The joints: Movement can be defined as the change of position of one bone related to another one. Bones are linked together through joints; these joints are reinforced by ligaments. Ligaments provide lots of proprioceptive information (avoiding luxation of the joint).


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Fig. 2.1
From brain to muscles: a simplified view of the different component involved in voluntary contraction. Blue color is for central nervous system, green color is for the peripheral nervous system, and red color is for the musculoskeletal system. Left column summarized main functions of each component, right one lists major pathologies concerning each levels

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Apr 17, 2018 | Posted by in NURSING | Comments Off on Physical Rehabilitation

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