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CHAPTER 3: PHYSICAL AND REHABILITATION MEDICINE (PRM) - CLINICAL SCOPE
3.2 Physical and Rehabilitation Medicine – Clinical Scope:
Specific Health Problems and Impairments
Sam S. H. Wu1,2,3, Chulhyun Ahn1
Department of Physical Medicine and Rehabilitation, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Geisinger Health System,
Danville, PA, USA, 2Department of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ, USA, 3Department of Physical Medicine
and Rehabilitation, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
1
IntroductIon
neurologIcal condItIons
The World Health Organization estimates that there will soon
be 1 billion persons with disabilities suffering from functional
deficits. The financial impact due to lost productivity
compounded by the substantial healthcare costs associated
with these disabilities will amount to staggering tens of
trillions of dollars. A solution to this global vicissitude is
to find pathways for the optimization of these individuals’
function to provide the best chance for them to return to
being productive members of society. Because physicians
specializing in physical and rehabilitation medicine (PRM – in
some countries, also known as physiatrists) are trained to be
restorers of function, they are indeed a major stakeholder in
this process.
Stroke
In keeping with the epithet “quality of life medical
specialty,” the physiatric clinical practice focuses on
enhancing an individual’s functional status and lessening
his/her disability through prevention, diagnosis, and
nonsurgical management of disorders commonly associated
with functional deficits: most notably, disorders affecting
neurological, musculoskeletal, and cardiopulmonary
systems. Commonly managed conditions in the physiatric
practice include stroke, spinal cord injury, brain injury,
multiple sclerosis, neuropathies, neuromuscular disorders,
orthopedic conditions, amputation, vascular problems,
trauma, work-related injuries, cardiac disorders, pulmonary
conditions, malignancy, and burns.
This subchapter will discuss the more common health problems
and impairments encountered by persons with disabilities. The
selection of these conditions is not meant to be all-inconclusive.
The tools used in diagnosing some of these conditions are
discussed in the subchapter on diagnostic tools. Moreover,
the treatments of some of these conditions are discussed in
the subchapter on interventions.
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A cerebrovascular accident, also known as stroke, entails
rapidly developing focal or global cerebral dysfunction due
to cerebrovascular insufficiency or intracranial hemorrhage.
The incidence of stroke is approximately 795,000 cases a year
in the US alone, of which about 610,000 are new strokes and
the remaining 185,000 are recurrent ones.[1] Approximately
85% of the strokes are ischemic and the rest are hemorrhagic.
Stroke is estimated to account for 13% of all causes of
death worldwide.[2] The resultant neurological deficits vary
depending on the cerebral territory affected. Common clinical
presentations include but are not limited to decreased muscle
strength, incoordination, spasticity, altered sensation, aphasia,
dysarthria, dysphagia, apraxia, neglect, seizure, impaired
bowel/bladder control, and ataxia. These impairments lead to
impaired functional mobility such as balance loss, ambulatory
dysfunction, and difficulty with transfers; deficits in daily
activities of living such as dressing, bathing, eating, grooming,
and toileting; and difficulty with speech, language, cognition,
and swallowing.
Nearly half of all strokes have thrombotic etiology with
perfusion failure distal to the site of vascular occlusion or
severe stenosis. Hypertension, hyperlipidemia, tobacco use,
a sedentary lifestyle, diabetes, and hypercoagulable states are
risk factors for vascular thrombosis. Transient ischemic attack
is a brief episode of neurological dysfunction without evidence
of infarction and it commonly precedes thrombotic strokes.
Address for correspondence: Sam S. H. Wu,
Department of Physical Medicine and Rehabilitation, Geisinger
Commonwealth School of Medicine, Geisinger Musculoskeletal Institute,
Geisinger Health System, 64 Rehab Lane, Danville, PA 17821, USA.
E-mail: samshwu@hotmail.com
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For reprints contact: reprints@medknow.com
How to cite this article: Wu SS, Ahn C. 3.2 Physical and rehabilitation
medicine – Clinical scope: Specific health problems and impairments. J Int
Soc Phys Rehabil Med 2019;2:S29-34.
© 2019 The Journal of the International Society of Physical and Rehabilitation Medicine | Published by Wolters Kluwer - Medknow
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Wu and Ahn: PRM clinical scope
Table 1: The Rancho Los Amigos Levels of Cognitive
Function Scale
Rancho Los Amigos Levels of Cognitive Function Scale Levels
Level
I
II
III
IV
V
VI
VII
VIII
Response
No response to visual, verbal, tactile, auditory, or noxious
stimuli
Generalized response
Localized response
Confused and agitated
Confused and inappropriate
Confused and appropriate
Automatic and appropriate
Purposeful and appropriate
The second most common type of cerebrovascular accident
is embolic stroke which represents about 26% of all
strokes. The emboli are typically of cardiac origin although
microemboli that dislodge from cerebrovascular thrombi
could occur. Impaired atrial motility in the setting of atrial
fibrillation is a significant risk factor for mural thrombi
formation. Cardiac emboli are also commonly produced in
the presence of rheumatic heart disease, bacterial/marantic
endocarditis, prosthetic heart valves, and vegetations at heart
valves. Usually, the neurological deficits are acute and can be
accompanied by seizure.
Lacunar strokes result from occlusion of small arteries and are
estimated to account for 13% of all strokes. Higher cortical
functions are typically not affected in lacunar strokes.
Hypertensive intracerebral hemorrhage often presents with
acute-onset headache, vomiting, and impaired consciousness
along with other focal neurological deficits. Putamen is the
most common location of hemorrhage. Hemiplegia results
from compression of adjacent internal capsule. Other common
locations of hemorrhage are thalamus, pons, cerebellum, and
cerebral hemisphere.
Subarachnoid hemorrhage typically stems from rupture
of saccular aneurysms and less commonly from ruptured
arteriovenous malformations. Severe headache, nuchal
rigidity, and altered level of consciousness are frequent clinical
manifestations of subarachnoid hemorrhage. There is increased
risk of recurrent bleeding
Brain injury
Brain injury results from external forces, hypoxia, or toxic
substances. Brain damage resulting from vascular occlusion
or rupture is called stroke and is not usually included in
the category of brain injury which is further classified as
traumatic and nontraumatic. Causes of traumatic brain injury
include motor vehicle accidents, violence, falls, and sports
injury. Each year, approximately 10 million traumatic brain
injuries are reported to occur worldwide.[3] The epidemiology
of traumatic brain injury appears to follow similar patterns
globally. Approximately 80% of traumatic brain injuries are
classified as mild while 10% are moderate and another 10%
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are severe. The pathophysiological findings in traumatic
brain injury include cortical contusion, diffuse axonal injury,
focal hemorrhage such as epidural or subdural hematoma and
subarachnoid hemorrhage as well as secondary cytotoxic and
vasogenic edema that follow the initial insult. Dependent on
the type, severity, and location of the injury, the patients present
with a variety of focal or global neurological deficits.
The Rancho Los Amigos Levels of Cognitive Function Scale
is an eight-level scale that focuses on cognitive and behavioral
recovery after traumatic brain injury [Table 1].[4] Levels I
through III represent coma, vegetative state, and minimally
conscious state, respectively. Once a patient emerges out
of posttraumatic amnesia, he/she is at level IV or above. As
the levels go up, the confusion and agitation subside and the
patient’s behavior becomes more purposeful.
Spinal cord injury
The incidence of spinal cord injury ranges from 12.1 to
57.8 cases per million people worldwide. [5] The risk of
spinal cord injury is higher in males and in 30–50 years old
individuals. Motor vehicle accidents are the leading cause of
spinal cord injury in developed countries while falls are the
most frequent cause in developing countries. Other causes
include violence, sports injuries, spinal tumors, infections,
ischemia due to vascular compromise, radiation exposure,
multiple sclerosis, and nutritional deficiencies.
The American Spinal Injury Association (ASIA) Impairment
Scale is commonly used to assess the extent and severity of
spinal cord injuries. The overall neurological level of injury
as defined by ASIA Impairment Scale is the more rostral of
motor or sensory levels of injury. The clinical manifestation of
patients with the same neurological level of injury may differ
significantly depending on the degree and extent of the injury.
The ASIA scale captures the degree of neurological impairment
with a scale from A through E, with A being complete injury
and E complete recovery following spinal cord injury.
The functional impairment and medical complications due to
spinal cord injury include weakness, gait dysfunction, sensory
deficits, neurogenic bowel and bladder, pressure ulcers, muscle
spasticity, joint contractures, hygiene problems, osteoporosis,
degenerative joints, musculoskeletal and neuropathic pain,
autonomic dysfunction, respiratory insufficiency, and sexual
dysfunction. These complications can all contribute to
difficulties with functional mobility, and activities of daily
living, and to morbidity and mortality.
Musculoskeletal dIsorders
Neck problems
The incidence of neck pain, also known as cervicalgia, is
estimated to be from 10% to 20% of the general population.
The lifetime prevalence could be up to two-thirds of the
population.[6] The clinical manifestation of cervical pain often
reflects the underlying problem. An acute-onset cervicalgia
following a traumatic event without neurological deficits
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Wu and Ahn: PRM clinical scope
is most commonly due to neck muscle or tendon strain,
or ligament sprain. Subacute cervicalgia accompanied by
neurological changes radiating to the upper extremity raises
the concern for cervical radiculopathy compromising one
or more cervical nerve roots. Involvement of the cervical
intervertebral discs can lead to cervicalgia elicited by lifting
heavy objects, coughing, or sneezing. Progressive cervicalgia
with insidious onset accompanied by systemic manifestations
raises the possibility of a slowly growing tumor. Cervical
myelopathy due to congenital or acquired cervical stenosis
can cause gait dysfunction with or without leg weakness and
impaired coordination of the upper extremities.
Low back problems
Low back pain is the second most common complaint for
physician visit after upper respiratory infection. The incidence
and prevalence of low back pain in the general population
are reported to be 5% and 23%, respectively. The lifetime
prevalence of low back pain could be up to 85%.[7]
Low back pain is one of the most common conditions encountered
by PRM physicians. This condition is often generated by
degenerative disc changes, facet arthropathy, paraspinal muscle
and tendon strain, or vertebral ligament sprain. These entities are
associated with excessive physical activities that increase stress
and strain at the spine. Patients frequently report chronic pain
at low back that may radiate to gluteal regions. Impingement
of spinal nerve roots due to disc herniation, foraminal stenosis
or facet hypertrophy can produce radicular symptoms in the
lower extremities. In severe central lumbar spinal canal stenosis,
patients may develop neurogenic claudication.
Fractures
Fracture refers to compromise in the continuity of the bony
tissue. Fractures usually originate from high tensile or shear
stress due to a traumatic impact. However, in the presence
of underlying conditions such as bone tumor, osteoporosis,
or osteogenesis imperfecta that undermine bony strength or
resilience, pathologic fracture can occur on minor impact.
Fractures of femoral neck, vertebral bone, pelvis, facial bones,
and humerus are especially frequent in elderly people prone to
falls. Stress fractures are very small disruption of the cortical
surface produced by repeated submaximal stress over time. It
is common in weight-bearing bones such as tibia, navicular
bone, and metatarsal bones in athletes.
Arthritis
The hallmark of osteoarthritis, also known as degenerative
joint disease, is degeneration of articular cartilage. Secondary
bony changes ensue including generation of osteophytes,
subchondral eburnation, and cyst formation. Commonly
involved joints are the hip, knee, cervical/lumbar vertebra,
interphalangeal joints of the hand, and first carpometacarpal/
tarsometatarsal joints. Pain and joint stiffness are common
clinical presentations.
Rheumatoid arthritis is characterized by chronic inflammatory
changes primarily in the joints but sometimes in other organ
systems as well. Nonsuppurative proliferative synovitis and
pannus formation give rise to joint erosion and destruction.
Joint involvement is typically symmetric and polyarticular
and can be accompanied by systemic manifestations such as
low-grade fever, malaise, and weakness.
Musculoskeletal disorders of the limbs
Musculoskeletal disorders can present as joint pain, muscle
weakness, decreased range of motion, and altered muscle
tone in the extremities. Trauma is a causative factor of acute
injury, but more commonly, musculoskeletal problems in
the upper and lower limbs result from chronic degenerative
changes in the bony and soft tissues. Common bone problems
include fractures, arthritis, tumors, osteomyelitis, and genetic
disorders. Tendons can develop tendinopathy, tendinitis, partial
or complete rupture, impingement, and snapping. Ligaments
could undergo partial or complete rupture and sprain. Joint
cartilage and menisci could sustain traumatic as well as
degenerative changes. Muscle pathologies include muscle
strain, tear, impingement, ischemia, inflammation, infection,
and necrosis.
Musculoskeletal disorders of the upper limbs
Rotator cuff impingement is the most common cause of shoulder
pain. Impingement of the supraspinatus tendon under the
acromion and greater tuberosity is frequently observed in rotator
cuff impingement. It can progress to rotator cuff tendinopathy
and tear. Adhesive capsulitis restricts glenohumeral range of
motion and causes shoulder pain. Degenerative joint disease
of the shoulder joint involves destruction of the glenohumeral
joint resulting in pain and limited range of motion.
Common conditions in the elbow region include medial
epicondylitis which is caused by repetitive valgus stress to the
elbow and lateral epicondylitis which is caused by repetitive
wrist extension and forearm supination. Medial epicondylitis
is known as golfer’s elbow while lateral epicondylitis is known
as tennis elbow. Ulnar and radial collateral ligament sprain
produce pain localized to medial and lateral aspect of the
elbow, respectively, as well.
De Quervain’s tenosynovitis arises from tenosynovitis of
the tendons and sheaths of the first wrist compartment and
produces pain and tenderness on the radial side of the wrist.
Ganglion cysts which are synovial fluid-filled cystic masses
commonly found on the dorsal or volar aspect of the wrist
may generate pain on ranging the wrist or pressure. Stenosing
tenosynovitis, commonly known as trigger finger, causes finger
locking in a flexed position.
Musculoskeletal disorders of the lower limbs
Patients with greater trochanteric hip bursitis report lateral
hip pain and have difficulty lying on the affected side. This
condition is due to inflammation of the bursa over the greater
trochanter and is associated with conditions that produce
muscle imbalance and reduced flexibility.
Avascular necrosis of the femoral head is precipitated by
interruption of vascular supply to the femoral head and leads
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to hip pain of insidious onset that worsens with weight bearing
and hip range of motion. Use of steroid and alcohol increases
the risk of avascular necrosis.
Slipped capital femoral epiphysis is a hip condition where the
head of the femur slips off the neck of the femur. This condition
occurs during periods of rapid growth in adolescents who
present with hip pain, stiffness, and often instability.
Anterior cruciate ligament (ACL) sprain or tear is one of the
most frequent knee injuries. It often occurs during sports
activities that involve sudden deceleration and changes
in directions. Instability and effusion of the knee joint are
common after ACL injury.
Patellofemoral syndrome, also known as biker’s knee or
runner’s knee, is a broad term denoting anterior knee pain
around the patella. The pain is typically worse with negotiating
stairs or riding bicycles as the contact pressure between the
patella and femur increases.
Lateral ankle sprain is the most common ankle sprain and
usually takes place on inversion of a plantar-flexed foot.
Anterior talofibular ligament is the most frequently involved
ligament in lateral ankle sprain followed by calcaneofibular
ligament and posterior talofibular ligament.
Plantar fasciitis entails increased fascial tension and
inflammation of the plantar fascia and is a common cause of
plantar heel pain. Tight Achilles tendon, pes cavus and planus,
and bone spurs increase the risk of plantar fasciitis.
Amputation
Existing data suggest that 185,000 individuals are estimated
to undergo an amputation of upper or lower extremity in the
US each year. There were 1.6 million individuals with one or
more limb amputations in the US in 2005.[8] Upper extremity
amputees account for <30% of all individuals with amputations
in the US. Trauma represents 90% of the etiology for all upper
limb amputations. In the United Kingdom, there were 42,294
major lower limb (22,645 above knee and 19,658 below knee)
and 52,525 minor lower extremity amputations between
2003 and 2013.[9] In Norway, the population prevalence of
adult-acquired major upper limb amputation was estimated
at 11.6/100,000 adults. The patients were predominantly men
with traumatic, unilateral, and distal amputations acquired at
a young age.[10]
Amputations due to vascular conditions represent the greatest
portion (82%) of lower extremity amputations followed by
amputations secondary to trauma (16%), malignancy (0.9%),
and congenital deformity (0.8%). Diabetes is a major risk
factor of lower limb amputation along with hypertension and
smoking.
Congenital limb deficiencies are slightly more common
in the upper extremities (58%) with left short transradial
amputation being the most common. Teratogenic agents such
as thalidomide and amniotic band syndrome are associated
with congenital limb deficiency.
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According to the level of amputation, the types of upper
extremity amputations include finger amputation, wrist
disarticulation, transradial amputation, elbow disarticulation,
transhumeral amputation, shoulder disarticulation, and
forequarter amputation. Finger amputation is the most frequent
upper extremity amputation (78%) followed by transradial
and transhumeral amputations. The levels of lower limb
amputations include toes, midfoot, ankle, transtibial, knee,
transfemoral, hip, and hemipelvectomy. Toe amputation
accounts for 31.5% of lower limb amputations closely followed
by transtibial (27.6%) and transfemoral amputations (25.8%).
neuroMuscular dIsorders
Neuromuscular disorders encompass a diverse group of
disorders primarily affecting peripheral nervous system and
skeletal muscles. Neuropathic disorders include motor neuron
diseases, various entrapment neuropathy of peripheral nerves,
polyneuropathy, and neuromuscular junction disorders. The
etiology of neuropathy is diverse and includes inherited or
sporadic genetic derangements, metabolic disorders, toxins,
infection, autoimmunity, and mechanical stress. Neuropathic
disorders present with variable extent of muscle weakness,
sensory changes, and spasticity.
Neuromuscular junction disorders stem from inefficient
transmission of electrochemical signals across the synapse
between motor neuron and the skeletal muscle, either due
to decreased release of neurotransmitters from presynaptic
terminal (e.g., Lambert-Eaton myasthenic syndrome and
botulism) or impaired action of neurotransmitter at the
postsynaptic membrane (e.g., myasthenia gravis). The result
is variable weakness in trunk, extremities, respiratory muscles,
and bulbar muscles.
Myopathic disorders have equally diverse origin and can be
classified as dystrophic, myotonic, congenital, or myopathic.
The Duchenne and Becker’s myopathies are representative
of dystrophic myopathy and result from absence or low-level
presence of dystrophin gene, respectively. The dystrophic
myopathies manifest as skeletal muscle weakness of variable
onset, progression, severity, and extent resulting in impaired
mobility and activities of daily living. The cardinal symptom
of myotonic myopathies is delayed relaxation of skeletal
muscles after contraction. The myopathies are exemplified by
polymyositis, dermatomyositis, and inclusion body myositis.
Polymyositis and dermatomyositis result in proximal muscle
weakness with myalgia and can have autoimmune, infectious,
or malignant causes. Dermatomyositis has additional cutaneous
manifestations. Patients with inclusion body myositis usually
develop painless weakness in the distal as well as proximal
muscles.
cardIac dIsorders, pulMonary dIsorders
Debility, impaired endurance, and decreased strength associated
with cardiac disorders and pulmonary disorders are the targets
of cardiac and pulmonary rehabilitation, respectively.
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Wu and Ahn: PRM clinical scope
Candidates for pulmonary rehabilitation programs include
individuals with obstructed airway disease and restrictive lung
disease. Examples of obstructive airway disease are chronic
obstructive pulmonary disease, asthma, and cystic fibrosis.
Causes of restrictive pulmonary disease include intrinsic lung
disease with increased lung tissue stiffness, extrinsic lung
disease involving increased chest wall stiffness, neuromuscular
disease, and cervical spinal cord injury that result in respiratory
muscle weakness and thoracic spine deformities that limit
chest wall expansion.
The objective of cardiac rehabilitation is to promote
patient’s overall fitness by improving cardiovascular
fitness. Cardiovascular conditions that could benefit from
cardiac rehabilitation include coronary artery disease,
angina, myocardial infarction, congestive heart failure,
cardiomyopathy, postcoronary artery bypass graft, postheart
transplantation, and peripheral vascular disease.
cancer
Patients who are in the midst of battling cancer are often
debilitated and are predisposed to develop muscle atrophy, joint
contractures, deconditioning, debilitating pain, neuropathies,
and orthostatic hypotension. Furthermore, individuals who
survive cancer frequently manifest residual symptoms as a
result of local and systemic effect of cancer burden itself,
or interventions for cancer such as surgery, radiation, or
chemotherapy. Conditions amenable to PRM intervention are
tumor-related lymphedema, peripheral neuropathy resulting
from the use of chemotherapeutic agents, and decreased range
of motion stemming from radiation-induced fibrosis.
pedIatrIc condItIons
Cerebral palsy (CP) is the most common cause of childhood
disability. The prevalence of CP can range from 1.5 to more than
4 per 1000 children worldwide.[11] CP is a static encephalopathy
meaning that although a patient’s functions may change over
time, the underlying brain lesion is nonprogressive. CP is
primarily a neuromotor deficit with associated cognitive
and sensory problems. CP is currently classified into spastic
CP, dyskinetic CP, and mixed Type CP. Spastic CP accounts
for 75% of CP. Subgroups of spastic CP consists of spastic
monoplegia, spastic diplegia, spastic triplegia, spastic
tetraplegia, and spastic hemiplegia. Dyskinetic CP is associated
with athetosis, chorea, choreoathetosis, dystonia, and ataxia.
Independent sitting by the age of 2 years is a good prognostic
indicator for ambulation.
Spina bifida is the second most common cause of childhood
disability. Spina bifida is a neural tube defect. Neural tube
defect is categorized into anencephaly, encephalocele, and
spina bifida. The incidence of neural tube defects varies
greatly around the world from 0.6–3 to 4/1,000 live births.[12]
Spinal bifida is classified into spina bifida occulta (no cystic
sac formation; no neurologic deficit) and spina bifida cystica.
Subgroups of spina bifida cystica are meningocele (cystic sac
containing spinal fluid and meninges; neurologic signs can be
normal) and myelomeningocele (cystic sac containing spinal
fluid, meninges, and spinal cord; neurological deficit includes
motor paralysis, sensory deficits, neurogenic bowel, and
bladder with associated Arnold–Chiari Tye II malformation,
hydrocephalus, and tethered spinal cord). Lower levels of
spinal lesions in spina bifida patients are associated with higher
levels of motor functions.
Scoliosis is classified into functional scoliosis and structural
scoliosis which consist of subgroups of congenital, idiopathic,
acquired, and secondary. Functional scoliosis is reversible
whereas structural scoliosis is not. The majority of scoliosis
is idiopathic scoliosis. Secondary scoliosis can be caused
by neuromuscular disease or connective tissue disease.
Cobb’s angle is used to determine the angle of the spinal
curve. Vital capacity is the most common abnormality on
pulmonary function test as the spinal curve progresses past
50°. In idiopathic scoliosis, observation is indicated when the
spinal curve is 1°–20°, bracing when 21°–40°, and surgery
when >40°. For scoliosis due to neuromuscular diseases,
observation is indicated when the spinal curve is 1°–20°,
and surgery when >20°. However, bracing or surgery may be
considered sooner if there is an accelerated progression in the
spinal curve.
Juvenile rheumatoid arthritis (JRA) is the most common
connective tissue disease in children with variable prevalence
worldwide from 0.038 to 3.7/1000 population.[13,14] JRA has
an onset of <16 years with arthritic symptoms lasting at least
6 weeks. JRA is categorized into polyarticular rheumatoid
factor negative, polyarticular rheumatoid factor positive,
pauciarticular type I, pauciarticular type II, and systemic
onset. Sacroiliitis is associated with pauciarticular type II
while iridocyclitis is associated with both pauciarticular
type I and type II. Antinuclear antibodies are associated
with polyarticular rheumatoid factor negative, polyarticular
rheumatoid factor positive, and pauciarticular type I. Severe
arthritis is associated with polyarticular rheumatoid factor
negative, polyarticular rheumatoid factor positive, and
systemic onset.
Leukemia is the most common childhood cancer followed
by brain cancer.[15] The most common childhood posterior
fossa cancer is cerebellar astrocytoma followed by
medulloblastoma.[15] MRI with contrast is the gold standard
diagnostic tool for brain cancer.[15] Headache and weakness
are common symptoms, and seizure is a frequent presenting
sign for brain cancer.[15] Rehabilitation focus for brain cancer
is on deficits in cognition, speech, language, swallow, mobility,
ambulation, ADLs, safety, and community reintegration.
Specific location of the brain cancer often determines the
deficits.[15]
Osteosarcoma is the most common childhood primary bone
tumor.[15] Amputation or limb salvage is often the treatment.[15]
Rehabilitation focus is on amputation, prosthetic and pain
management, and community reintegration.
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gerIatrIc condItIons
Geriatric rehabilitation focuses on changes in body systems
as part of normal and abnormal aging. It is not always clear
whether a certain change, for example, development of
muscle weakness, is a natural aging process or due to disuse
or other comorbidities. Aging with a disability is a related
but separate consideration that concerns the decline in the
ability to manage and compensate for functional deficits with
advancing age.
Physiologic changes associated with aging involve multiple
body systems. Muscle strength – force produced by single
muscle fibers, force per unit cross-sectional area, and the ability
to generate force rapidly – declines with age.[16] The elderly
experience decreases in exercise-induced adaptations, such
as increased heart rate, stroke volume, and cardiac output.[17]
Postural hypotension is more common in the aged, leading
to increased risk of falls. Thoracic wall mobility and vital
capacity decrease and the effort needed to overcome wall
stiffness increases in older adults.[16] Loss of bone density is
more common in the elderly. Skin frailty prevails consequent
to reduced tissue elasticity, decreased blood perfusion, and
loss of sensory sensitivity. Visual and auditory acuity also
decline with age.
Diseases and disorders that are more common in the elderly
and negatively impact the function of an aging individual
include cerebrovascular accident, cardiovascular disease,
diabetes, degenerative joint and spine disease, osteoporosis,
motor neuron disease, Parkinson’s disease, malignancy, and
dementia. Disuse and immobilization brought on by disability
have a greater significance in older than younger adults as
evidenced by more pronounced immobilization-induced loss
of lean body mass in older persons.[18]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest
references
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
suMMary
The clinical practice of the medical specialty of PRM includes
patients with a wide variety of health conditions that have
significant effects on function and quality of life. Although
there are exceptions, most health conditions in a PRM setting
affect the nervous, musculoskeletal, and/or cardiopulmonary
systems, sometimes independently but also in combination.
More specifically, patients with brain disorders (stroke and
traumatic brain injury) and spinal cord injuries can significantly
benefit from PRM interventions. Disorders of single or
multiple joints (including the limbs and spine) represent a
large percentage of the patient population in a PRM practice;
this has been particularly true in the last 10–20 years. In some
centers, patients with cardiac dysfunction, pulmonary disease,
and cancer are targets of rehabilitation programs. Age is not a
criteria for the selection of patients for PRM services, and both
children and elderly have conditions amenable and responsive
to PRM interventions.
S34
13.
14.
15.
16.
17.
18.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB,
et al. Heart disease and stroke statistics–2013 update: A report from the
American Heart Association. Circulation 2013;127:e6-245.
Ropper AH, Samuels MA, Klein JP, editors. Cerebrovascular diseases.
In: Adams and Victor’s Principles of Neurology. 10th ed. New York:
McGraw-Hill Education; 2014. p. 778-884.
Ahmed S, Venigalla H, Mekala HM, Dar S, Hassan M, Ayub S, et al.
Traumatic brain injury and neuropsychiatric complications. Indian J
Psychol Med 2017;39:114-21.
Wagner AK, Arenth PM, Kwasnica C, Rogers EH. Traumatic Brain
Injury. In: Braddom RL, Chan L, Harrast MA, Kowalske KJ, Matthews
DJ, Ragnarsson KT, Stolp KA, editors. Physical Medicine and
Rehabiliation. 4th ed. Philadelphia: Elsevier Saunders; 2011. p. 1133-75.
Rahimi-Movaghar V, Sayyah MK, Akbari H, Khorramirouz R,
Rasouli MR, Moradi-Lakeh M, et al. Epidemiology of traumatic
spinal cord injury in developing countries: A systematic review.
Neuroepidemiology 2013;41:65-85.
Stanton TR, Leake HB, Chalmers KJ, Moseley GL. Evidence of
impaired proprioception in chronic, idiopathic neck pain: Systematic
review and meta-analysis. Phys Ther 2016;96:876-87.
Trompeter K, Fett D, Platen P. Prevalence of back pain in sports:
A systematic review of the literature. Sports Med 2017;47:1183-207.
Varma P, Stineman MG, Dillingham TR. Epidemiology of limb loss.
Phys Med Rehabil Clin N Am 2014;25:1-8.
Ahmad N, Thomas GN, Gill P, Torella F. The prevalence of major lower
limb amputation in the diabetic and non-diabetic population of England
2003-2013. Diab Vasc Dis Res 2016;13:348-53.
Østlie K, Skjeldal OH, Garfelt B, Magnus P. Adult acquired major
upper limb amputation in norway: Prevalence, demographic features
and amputation specific features. A population-based survey. Disabil
Rehabil 2011;33:1636-49.
Data & Statistics for Cerebral Palsy; 2016. Available from: https://www.
cdc.gov/ncbddd/cp/data.html. [Last accessed on 2017 Dec 10].
Wu SS, Cohen JM, Bodeau VS, Stiens SA. Neural tube defects:
Anatomy, associated deficits, and rehabilitation. In: O’Young BJ,
Young MA, Stiens SA, editors. Physical Medicine and Rehabilitation
Secrets. 3rd ed. Philadelphia: Mosby Elsevier; 2008.
Huang JL, Yao TC, See LC. Prevalence of pediatric systemic lupus
erythematosus and juvenile chronic arthritis in a Chinese population:
A nation-wide prospective population-based study in Taiwan. Clin Exp
Rheumatol 2004;22:776-80.
Manners PJ, Diepeveen DA. Prevalence of juvenile chronic arthritis
in a population of 12-year-old children in Urban Australia. Pediatrics
1996;98:84-90.
Gonzalez P, Luciano L, Schuman RM. Cancer rehabilitation.
In: Cuccurullo SJ, editor. Physical Medicine and Rehabilitation
Board Review. 3rd ed. New York: Demos Medical; 2015. p. 708-27.
Hughes VA, Frontera WR, Wood M, Evans WJ, Dallal GE, Roubenoff R,
et al. Longitudinal muscle strength changes in older adults: Influence of
muscle mass, physical activity, and health. J Gerontol A Biol Sci Med
Sci 2001;56:B209-17.
Bloch RM. Geriatric rehabilitation. In: Braddom RL, Chan L,
Harrast MA, Kowalske KJ, Matthews DJ, Ragnarsson KT, Stolp KA,
editors. Physical Medicine and Rehabiliation. 4th ed. Philadelphia:
Elsevier Saunders; 2011. p. 1419-37.
Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of
10 days of bed rest on skeletal muscle in healthy older adults. JAMA
2007;297:1772-4.
The Journal of the International Society of Physical and Rehabilitation Medicine ¦ Volume 2 ¦ Supplement 1 ¦ June 2019