Thermal rehabilitation in aged people after osteoporotic vertebral fracture

7/28/2019 Thermal rehabilitation in aged people after osteoporotic vertebral fracture

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TRAUMATOLOGY AND ORTHOPEDIC II DIVISION - PISAUNIVERSITY

Chiefdirector : Prof. G. GuidoDEPARTMENT OF FUNCTIONAL ORTHOPEDICAL

REHABILITATIONResponsible: Prof.ssa G. Raffaet

Prof. G. Raffaet

in collaboration with Dr. F. Falossi, Dr. C. Genovesi

Techirghiol, 12 novembre 2012

Thermal rehabilitationin aged people after

osteoporotic vertebral

fracture


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ELDERLY PERSON

"Ageing is a privilege and a goal of society.Its also a challenge, that has an impact on all the aspects of

the XXI century societyOMS

In the worldin 2000 600 millions

in 2025 1,2 billionsin 2050 2 billions

DEMOGRAPHIC REVOLUTION OF OUR SOCIETYpeople > 60 years

In Europe1 in 5

In Italyin 2001 10.5 millionsin 2006 11.5 millionstoday > 20%

in 2051 1 in 3 data ISTAT


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the roleof Physical Medicine and Rehabilitationin the field ofgeriatricmust be understoodin its broadest sense

PHYSICAL AND REHABILITATIVE MEDICINE

PREVENTIVE THERAPEUTIC

. there is no true geriatrics withoutrehabilitationand there are no compelling recovery methods

that are not concernedat the same time

thephysicalandmentalaspects of the elderly

Antonini,1973


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but with aging

are gradually reduced the capacities of a prompt andreasonable "adjustment"to the environment

full and conscious use of all the opportunities for life that the

environment offers offers

Healthy Elderly

Physiologically

agedwith all the changes

quantitative andqualitative

of the various organsand systems

PathologicalElderly

The signs of old ageadd up to the results ofold diseases and chronicdevelopmental disorders

until the situations of

disabilityand loss of autonomy

Elderlyis not synonymous of disease


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The assessment of elderly patient

identify not only

what the patient is unable to do

negative

search in the subject the

psycho-biological residual potentialwith whichbuild day after day his recovery process

positive

GLOBAL ASSESSMENT :

1. Functional capacity : activities scales of daily livingindices of overall assessment (Barthel..)

2. Mental state : behavior, cognitive function ..3. Physical health : also as the absence of disease

or alteration of the welfare state

4. Social support : family, importance of the links, isolation of theelderly

5. Financial possibilities both personal that socialstructures involved


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In Italy almost 4,000,000 women with osteoporosis Prevalence more than 40% over 60 years

ESOPO study. Osteoporos Int 2003

OSTEOPOROSIS

Public health problem

continuously growing


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AGE-specific and SEX-specific incidence of osteoporotic fractures

OSTEOPOROTIC FRACTURES

vertebral fractures radiographically evident

hip fractures

wrist fractures


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There is a new osteoporotic vertebralfracture around the world

every 22

20-25% of Caucasian women and men over age 50 have avertebral fracture

VERTEBRAL FRACTURES

50% of women over age 80 have a vertebral fracture

M.L.Brandi, 2010


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UNDERSTIMATION OFVERTEBRAL FRACTURES

Fechtenbaum J et al. Reporting of vertebral frctures on spine x-rays

Osteoporos Int. 2005

Delma PD et al. Underdiagnosis of vertebral fractures is a world wide problem: theimpact study. J Bone Miner Res 2005

30 - 50 %

UNRECOGNIZED

studies conducted at European

and world level

oligo-symptomatic

The most of patientsNOT receive

correct diagnosis and appropriate therapy

Only 1/3 comes to medical attention


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50%MODERATE SEVERE - PAIN

SUBJECTS WITH 1 OR MORE

VERTEBRAL FRACTURES

CHRONIC

BACK PAINsleep disorders

difficult to wash and dress

uncertainty of gait

Ismail AA et al. 1999

40-89%10-15%

DISABILITY

Trevisan C., Mattavelli M. et AA, 2007

MORTALITY

Those who have a vertebral fracture has an increasedrisk of dying if compared to their peers withoutfractures

Riduction of 16% of the 5 year survival M.L.Brandi, 2010


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Domino effect

Emphasis kyphotic curve

Forward displacement axis gravitazional

INCREASEED FLEXOR MOMENT

A VERTEBRAL FRACTUREINCREASES BY 5 TIMES THE RISKOF A NEW VERTEBRAL FRACTURE

WITHIN ONE YEAR AFTER THE

EVENTRoss PD et al. Pre-existing fractures and bone mass predict vertebral

fracture incidence in women. Ann Intern Med, 1991.


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Vicious circles triggeredby osteoporotic vertebral fractures .

1) REFRACTURE

1 FRACTURE

PAIN,DISABILITY,

BALANCE DISORDERS

PSYCHOLOGICALPROBLEMS

REDUCTION INPHYSICAL ACTIVITY

INCREASEDRISK

OF FALL


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INCREASEDMORTALITY

OF 25%

2) INCREASED MORTALITY


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CONSERVATIVE SURGICAL

Reley 2001

Kyphoplasty

Herv Deramond 1987Vertebroplasty

TREATMENT of

VERTEBRAL FRACTURES

Whatever the type of treatment undertakenconservative or surgical

the rehabilitation plays an important rolebecause

Allows a mobility and functionality rahidearecovery as complete as possible


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Its essential that prevention, maintenance and recoveryprograms of the elderly find an appropriate locations

HOSPITAL EXTRA-HOSPITAL

REHABILITATION SITES

Day hospitalAmbulatory

(zona or district)

Home programs

Rehabilitation centres

Early and protecteddischarges without losing

the terapeutic programeffectivness


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SPAA very appropriate places to address the rehabilitation needsof these patients and that thanks to

natural water rich active ingrediens

climate

health facilities

Ideal location for the overall management of the

elderly both thephisicaland the psychic

in line with the concept of Health dictation OMS


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RECOVERY OF PATIENT WITH OSTEOPOROTICFRACTURE

TAKING CHARGE GLOBAL

of Subject

REHABILITATION PROJECT

CUSTOM MADE

FACTORS RELATED TOPATIENT

GENERAL CONDITIONS

teamwork

FACTORS RELATED TO

FRACTURE


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REST IN BED 2 weeks onaverage (min. 10 days, max.30days)

BRACE A LOAD WITH THREEPOINTS on average 60 days

GRADUAL WEANING FROMTHE BRACE on average 20 days

TP DRUG

CONSERVATIVETREATMENT

REHABILITATIONPROJECT


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WE CANNOT FIND CLINICAL STUDIES

BASED ON THE EVIDENCE OFCONSERVATIVE TREATMENT FOR

PATIENTS WITH SPINALOSTEOPOROTIC FRACTURES

In literature

1. PAIN CONTROL

2. PREVENTION AGGRAVATION DEFORMITY

3. EARLY FUNCTIONAL RECOVERY

OBJECTIVES OF TREATMENT



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2- CONTROL OF PAIN

1- PREVENTION OF IMMOBILITY COMPLICATIONSpressure ulcers, TVP, respiratory complications, etc..

correct positioning on the bed

anti-decubitus mattress, latex mattress, etc.

breathing exercises

manteining a regular alvo

drug therapy

physical therapy(Elettroterapia antalgica: tens, correnti diadinamiche,magnetoterapia,

etc..)

BEDDIG PHASE


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BEDDIG PHASE

3- MAINTENANCE RANGE OF MOTION AND MUSCLETONE-TROPISM

Ex. mobilization passive, assisted and attive

oculomotricit Arch support

RotationsLifting


O O C


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4- STATIC STRETCHES

isometric muscle girdle

Become aware of the active muscle control of the trunk

BEDDIG PHASEREHABILITATION PROJECT


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1-ISOMETRIC AND ISOTONIC EXERCISES MM SPINAL

Active axial stretching of the muscles of the trunk and of the back

Vertical load sitting position

When the verticalstation is without pain

Maximum mechanical

stress induced muscolarcontractions

3- TRAINING OF STEP AND WALKING

2- EXERCISES OF BALANCE AND COORDINATION

PHASE LOAD WITH BRACEREHABILITATION PROJECT



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PHASE OF WEANING THE BRACE

1- ACTIVE EXERCISES for the MOBILIZATION OF THE COLUMN

in the gym or/and in the water

Isometric and isotonic exercises of the mm. ANTICIFOTIZZANT

(mm. spinal extensors)

Only Isometric exercises of the mm. ABDOMINAL



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PHASE OF WEANING of THE BRACE

2- CORRECTION OF POSTURAL ALTERATIONS exercises for balance control

of motor coordination

of responsiveness

ATTITUDE CIFO-LORDOTIC

increased risk of falls



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GRADUAL avoid excessive loads and stress fractures VARIABLE dynamic mechanical stimulation to the bone toobtain an effect of type osteoblastic

ADAPTED to the individual subject

CONSTANT time

The international review of the Literature seemsto show the best possible stimulus is the

STRENGTH OF MUSCLE TRANSMITTED BY TENDONS TOBONE TISSUE DURING CONTRACTION

isometric, isotonic exercise with no load or lightweights, gradually progressive resistance


Subjects with osteoporotic fractures yet

EXERCISE


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The rehabilitationIN THE GYM

can be integrated

and completed

THE EXERCISE IN WATERthat amplifies possibilitiesand

spatialities operational


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THERE IS NO EVIDENCE OF EFFICACY

ON THE BONE MASS

USEFUL IN PATIENTS WITH STRONG PAINAND WITH RECENT FRACTURE

BETTER - AEROBIC CAPACITY

-FLEXIBILITY

-EXTENSION OF MOVEMENT

REDUCE THE PAIN

ANTICIPATE THE LOAD

HYDROKINESIOTHERAPY


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HYDRATION cartilage covering

TURNOVER of synovial fluid

improvement TRADE METABOLICjoint environment

HYPOXIA with the stagnation of

circulating fluidsRECRUITMENT and OVERRIDE

OSTEOCLASTS

bone resorption

microporotic cavity formation

loss of vertical trabeculae

in the vertebral bodies

MOVEMENT

Early in water

Prof.ssa G.L.MauroOrtopedia News suppl Anno XVI N 1-3 2010

SETTING

A NEW FRACTURE

IN THE VERTEBRAL

BODIES

PHYSICAL INACTIVITYin elderly fractured patience


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CINE BALNEOTERAPY

Especially

in thermal wateris an important tool in the treatment of patients

after osteoporotic vertebral fracture

the therapeutic effectslinked to the physical

characteristicsof water

specific effectsof thermal water


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EXCLUSION CRITERIA

The contraindications to thermal rehabilitation arescarce and frequently relative

M. De Fabritis, S.Masiero, S. Mariotti, G. Gigante, EUR MED PHYS 2009; 45 (SUPPL. 1 TO NO.3)

ABSOLUTE

Heart failureArrhythmias high riskIschemic heart diseaseUncontrolled hypertensionPhlebitisActive infectionsFecal incontinenceFeverNeoplasms in placePrevious interventions for cancerImmunodeficiencyInsufficiency renal

RELATED

EpilepsyUrinary incontinenceSwallowing disorders

TEMPORARY

Skin lesionsDermatopatia

ConjunctivitisTimpani openInfectious DiseasesShameFear of water

TREATMENT PROGRAM


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THERAPEUTIC EXERCISE

IN THERMAL POOL

- Daily sessions

- Duration of sessions: 40 '

- Sulphate-calcium-magnesium, carbon

- Salinity '2949 mg / l

- Temperature: 35 -36 c

DAILY EXERCISES

IN THE GYM

DURATION OF PROGRAM:

2 WEEKSTREATMENT PROGRAM

IN SPAS

PHYSICAL THERAPYalways considering

any contraindicationsfor each case

MUD

action anti-inflammatory

analgesic

muscle relaxant

eutrophic

stimulating action on

metabolic processes

effects on general

kinaesthesia

Tens, Magnetoterapy, Laserterapy
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4. Increased power of immune defenses

1. Intense hyperemia of the skin and deep tissues periarticular

2. Riducing muscle hypertonicity

3. Remodeling connective fundamental component

- vascular neoformation- neosynthesis glycosaminoglycans- cellularisation, etc

5. Riduction of infiammatory process

6. Neuro-endocrine reactions (stimulates productions of ACTH, FSH, LH)

MECHANISMS OF ACTION THERMAL THERAPY

THERMAL STRESS


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THERMAL STRESSNeuro-endocrine reactions

GH: STIMULUS TO CHONDROGENESIS and

OSTEOGENESIS


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Relaxation exercisesStretching exercisesExercises of global mobility

REHABILITATION PROTOCOLIN WATER

1- RELAXATION EXERCISES


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IN FLOATING IN PRONE

FLOATING IN SUPINO

FLOATING IN

VERTICAL

1 RELAXATION EXERCISES

"slow" passive and active mobilization

progressively greater amplitude

respecting pain threshold

2- STRETCHING EXERCISES


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2- STRETCHING EXERCISES

To remedy any tensions and correct the posture of the

spine compromised by muscular retractions

3- EXERCISES OF GLOBAL MOBILITY


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3- EXERCISES OF GLOBAL MOBILITY

upper limbslower limbs

To recovery the normal joint range


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Reduction of loads and support action (buoyant force)

Muscle relaxant effectto decreased muscle tone (heat)

Analgesic effectto increase the pain threshold (PI and viscosity)-> stimulation of baroreceptors joint (g.c.s.)

Increase stimuli esterocettori (PI and viscosity) -> amplification ofmotor patterns and better perception position of the body segments

Increased proprioceptive stimulation (resistance and motions ofturbulence)

-> Continuous postural control and intense muscle work

CRENOBALNEOTHERAPY

1. ALLOWS ACTIVE AND PASSIVE MOBILIZATIONEXERCISES IN MAXIMUM SECURITY

2. PREPARE THE PATIENCE TO "DRY REHABILITATION


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strengthening of the extensor muscles of the spineipercifosi correction and overall postureexercises for balance and proprioceptionmotor coordination (truncated upper limbs, trunk, lower limbs)respiratory coordinationnatural load exercises

The criteria for the CHOICE of exercises

The EXCLUSION criteria exercisesprevent flexion of the trunkexercises involving posture monopodaliche, kneeling or quadrupedicheuse of weights or other loads that are not naturalexercising in place unsafe and too expensive in terms of energy

REHABILITATION IN THE GYM
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CONCLUSIONS

The rehabilitation therapy in thermal water

is an important resourcefor the care and delicate process

recovery ofADL of elderly patients

In VERTEBRAL OSTEOPOROTIC FRACTURESthe hydrokinesiotherapy

allowing you to anticipate the loadhas proved a valuable tool

in the early recovery

- MOVEMENT- FEATURES AND JOINT- MUSCLE TROPHISM

IN THE ABSENCE OF PAIN

CONCLUSIONS


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CONCLUSIONS

PATIENT

First actor ofits recovery

Explain to the patient what is osteoporosisRecommend rules adequate lifestyle etc.

Stay in a spa can become an opportunity to develop

useful strategies education and awareness


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Thanks

Documents

Thermal rehabilitation in aged people after osteoporotic vertebral fracture