Emerging Interventions in Rehab Medicine
Any sufficiently advanced technology built to help our patients could be considered as God's gift to mankind. In the advent of newer interventions being introduced in the country, it's not to be taken with much surprise how rehab medicine is progressing.
The University of the Philippines-Philippine General Hospital Dept.of Rehab Medicine celebrates it's 40th anniversary with the theme: "Trailblazing at 40". As one of the doctors have said, it's looking back and looking forward to another forty years of making progress in the field. The organizing committee has brought several alumni of the department to somehow relive and celebrate the founding days, and share updates that they are currently practicing to improve patient status for the 11th Post-Graduate course in cooperation with Disability First Foundation.
Part I:
Stimulating the Brain and Neuroplasticity
Dr.Reynaldo Rey-Matias has shared an emerging technology on Transcranial Magnetic Stimulation (TMS) from his visit in South Korea. An interesting approach that promises a lot of potential, but definitely requires thorough training and mastery before application.
Neuroplasticity is the brain's ability to reorganize, produce adaptive changes in correlation with the environment and function. As we know, the formation of new synapses and unmasking of pathways account for neuroplasticity. The bottomline of which is to establish a new connection, the fastest possible way. In evidence, repetitive use of TMS are said to promote neuroplasticity. It is a non-invasive, painless technique applied to stimulate and inhibit the hemispheric activity, by using long term potentiation(high frequency), and long term depression (low frequency) currents, based on Faraday's theory of induction that magnetic currents can be transformed as electrical currents in the brain.
In simpler terms: While physical therapists use electrical stimulation directly on paralyzed and weak muscle groups brought about by any damage anywhere in the corticospinal tract; doctors can use TMS to:
1. To stimulate the affected hemisphere of the brain
2. To restrain movement in the normal hemisphere
Example: (R) MCA stroke c (L) hemiplegia
A sample application would be:
a. Apply Long Term Potentiation on (R) hemisphere
b. Apply Long Term Depression on (L) hemisphere
The electrode placement follows the homoncular representation in the brain. And as such, it would be mostly effective for Upper extremity application, since the lower extremity homonculus is found in the medial side of the brain. This technique can not isolate individual muscles for stimulation, and is applied in groups. The contraction is twitch-like, similar to that of peripheral electrical stimulation which are currently in use in the clinics.
It is also used to predict functional recovery for prognostication.The inability to elicit a motor evoked potential leads to poor functional recovery; while persistent contralateral MEP in acute stages could be favorable. Negative effects of this intervention are: possible increase in spasticity and reflexes, allodynia through selective activation of C-fbers, linked to dementia d/t failure to block synapses, and may lead to synkinesis. In children there is extensive brain reorganization and may produce cognitive problems. Equipment cost: PHP 6-8M.Treatment 15 mins/session x 5 days a week for 2 weeks. Effects evident up to 6mos.
Microneurography
Dr.Jerico dela Cruz shares a relatively new approach called Microneurography. This is the application of tungsten needles on the nerve fiber to stimulate muscle groups. The technology is somehow similar to that of EMG-NCV (being more of a diagnostic equipment), with focus on Autonomic fibers for sympathetic nerve activity. As Dr.Dela Cruz has mentioned, the localization of a nerve fiber takes so much time as it requires precision (not to mention expensive and relatively complex equipment), and is done under anesthesia. The laborious task of locating the nerve bundle itself takes more time than the actual treatment of amplifying nerve signals and facilitating muscle contraction.
A Case of Three Brothers: CTS in Hunter's Syndrome
Similar to that of the case presentation/SEM we are having at school, the resident doctor presented a case of Hunter's Syndrome (lysosomal storage disease :iduronate sulfate) with a study on occurence of CTS in this patient population. A case of twins and their brother with dysmorphic facial features, short stature and, other multi-organ/system findings admitted at PGH.
While most researches agree that the hand is the most affected region, it is not clear whether this is brought about by the disease process itself (inflammatory response of the flexor retinaculum, and deposition of inflammatory substances to the median nerve), or a separate entity. The argument whether CTS is brought about by the pathologic processes involving Hunter's syndrome; or CTS being a disease brought about by another mechanism excluding that of Hunter's, is not clearly defined. More so, the evaluation on other plexopathies was not carried out, to know whether they also exist.
Upates on Osteoarthritis -the controversy on OA being an INFLAMMATORY condition as was supposed to be a non-inflammatory due to the old classification of seropositive and seronegative arthropathies and rheumatic conditions
Weekend Warriors and Sports Rehabilitation - discussed conditioning and prevention plus treatment for sports injury with focus on ACL injury (in a female athlete); Henning progam (Accelerated Rounded turns, bent knee landing, 3-step stop) said to decrease ACL injuries by 89%. Plyometric training plus biomechanical analysis (using videocamera of a phone), plus technique training appear to effectively reduce ACL injuries based on separate studies conducted by Mandelbaum, Myklebust, and Hewett.
Orthotics in Sports- The hype on distance running cause people to invest in expensive footwear with the mentality that this indeed improves perofmance and decreases risk of injury. While most footwear companies capitalize on their claim of improving athlete performance, the sparse amount of RCTs and meta-analysis to prove this claim, are not to be held reliable at the moment. While there are areas that may be built-up to improve support, shoes can also be built-down to decrease pressure, as the need may be. Prescription shoes and orthoses are available at this time.
Day 2
Patient Safety In Rehabilitation Medicine:
While "To Err is Human", professionals in the medical field are responsible to ensure that quality of care for our patients is never compromised. On statistics, 98,000 deaths/year happen because of sentinel events and malpractice. Dr.Bate could never be more practical on the following tips he has presented, so as to minimize the risks of error:
1. Pt Identification: use name tags, ask complete name, birthday,etc. Use at least 2 patient identifiers. Do not rely on room numbers, and surnames (which are commonly mistaken for another person)
2.Improve Communication- report tests and diagnostics in a timely basis, do a read back on verbal orders. This also included avoiding the use of abbreviations such as >< (greater/less than) which may be easily confused with L or 7. Misinterpretation of abbreviations are fairly common, especially those which have several counterparts per field (Do PT q am - do Physical Therapy or Prothrombin Time?); and he suggests that full words be written to avoid confusion.
Performance and Competency Assessment:
Dr.Mojica presented the paradigm shift in the curriculum. From passive learners to active-student directed participants, analysis of student performance must also be changed. Curiosity driven learning entails that educators must measure not only "what they know" but also "how and why they know". It seemed like listening to a masters class in education, as he presented assement tools, which have already been tested. To site a few:
Directly Observed Clinical Skill -a variant of Mini-CEX
Case-based Diagnosis
Mini-PAT (Peer assessment)
Multi-360 Source Feedback
Portfolio -systematic collection of records reflecting key eval
Emerging Interventions in Rehab Medicine: PT, OT, Speech
PT and OT:
The use of iPads and Wii for dexterity skills are being widely applied to improve patient performance. Specialty clinics providing occupational therapy for school readiness abound in the country, but the need for additional programs for those who are 'transitioning' from school-age to adolescence. As Ms.Anna has mentioned, parents are usually prepared to face that their children are finishing the school-readiness program, but they are not aware of what to do after graduation. While a lot of OT services focus on the pediatric population, it is not deniable that the geriatric population would also need "transitioning" training as they become reitrees.
Motor relearning has been one of the most discussed paradigm in rehabilitation of patients with neurologic conditions. The lecture focuses on task-specific training which is best applied in the home setting. Teaching a patient to do transfer techniques (bed-wheelchair-toilet) and enabling them to be independent as much as possible prove to be more important than any other interventions a PT can provide.
Speech Therapy:
The availability of cochlear implants create an audible change in early-diagnosed population (for sensorineural deafness) combined with Audioverbal therapy. Early diagnosis (as early as 6 mos) and implantation increases the likelihood that the hearing of the child may be improved. The surgery costs 1M/ear with no immediate effects, batteries replaced every 3 days, and the training must be carried out religiously with the parents.
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This seminar has taught me a good number of things, both as a clinician and educator. For one, I cannot be content with the status quo. Every so often, updates come in and one has to keep abreast with the times. That we, Physical Therapists must discover new approaches in improving patient status, and must not settle for the contemporary and given. This is being said under the premise that the foundation must also be solid, principles are well understood, before venturing into newer intervention.
As an educator, my eyes have been opened that we must be sensitive on assessment of student performance. That it is not only about what our students know, but more so, considering the affective parts of their learning experience. It is not enough that they know what to do given a patient with Parkinson's Disease, it is not sufficient that they know how to assess, treat, and document; but the quality of performance on how they do their clinical skills is more important.
If we want to improve the quality of life of our patients, we must first improve ourselves (rehab professionals) that we may deliver the best services we can for those who are entrusted to our care. As a PT, I always consider rehabilitation as a two-way process,a give and take, that as we make our patients better, we ourselves, get our own dose of treatment. May our practice bring healing to those who are in pain and disability, and learning to our scarred and swollen neurons. Today I have been 'rehabilitated', I look forward to my next treatment session.
Goodnight.