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POTENTIAL OF REHABILITATION FOR ACCELERATION OF

FUNCTIONAL RECOVERY AND AMELIORATION OF THE


QUALITY OF LIFE OF PATIENTS IN THE CLINICAL
PRACTICE OF ORTHOPEDICS AND TRAUMATOLOGY

prof. Ivet Koleva, MD, PhD, DMedSc *


* Medical University of Sofia; BULGARIA

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


INTRODUCTION:

Orthopedic Traumatologic Rehabilitation


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

is an interdiscipline:
between Orthopedics & Traumatology (OT),

and Physical & Rehabilitation Medicine (PRM).


Sofia, 2010-2017
Traditions of Bg OT rehab school
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

MD with both specialties:


PRM & Rheumatology, OT:

Prof. Stefan BANKOV, MD. PhD, DMSc - PRM & Orthopedics & Traumatology

Prof. Yanka DAFINOVA, MD. PhD, DMSc - PRM & Rheumatology


Sofia, 2010-2017

Prof. Yavor VAJAROV, MD. PhD, DMSc - PRM & OT


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
OBLIGATORY
CONDITION
!!!
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

COMPETENCIES IN BOTH
THEMATIC FILDS:
PRM & OT
Sofia, 2010-2017
Necessary COMPETENCES
Sofia, 2010-2017

for working in
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

OT rehabilitation clinical practice:

Competences

Theoretical Practical Moral & Ethical


competences;
knowledge skills Capacity for Team work
Prof. Yvette Koleva, DM, PhD, DMSc
Georges Mialaret, 1973

WHAT ? FOR WHOM ?


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Content, programmes Psychological problems

HOW ?
Methods, techniques
Sofia, 2010-2017

RESULTS (Evaluation)
Prof. Yvette Koleva, DM, PhD, DMSc
Quality of Care
!!!
The problem:
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
The Quality of Life
!!!
The tragedy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
The OT Rehabilitations opinion
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

From the point of view of OT rehabilitation


the objective must be to assure the
quality of life and the dignity of these
patients.
The problem is to define the approach and
Sofia, 2010-2017

the care .
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Protocol for registration of patients data

Clinical data: somatic examination, OT & neurological exam (pyramidal signs,


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

paralysis / paresis, muscle tone, coordination, balance), kinesiological


assessment, manual muscle test, assessment of muscle tone & muscle dysbalance,
balance, grip & gait; functional exam /incl. functional muscle test/; algesic
diagnostics /Visual analogue scale VAS 0-20/; Performance Status Scales;
vibratory sensibility, thermo-sensibility, autonomy in ADL (activities of daily living);
ICF evaluation; neuro-psychological battery /tests of Zung for depression and
anxiety/;
Instumental data: excitomotory electrodiagnostics, electroneurography,
electromyography, neuro-imagery (X-ray graphy, CT, MRI); doppler sonometry,
PET, SPECT.

Oxford Textbook of Palliative Medicine, Oxford University Press. 1993;109.


Sofia, 2010-2017

.
ASSESSMENT & EVALUATION
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Functional Assessment Scales ,


different for every pathology
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OT exam + Kinesiological exam
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Sofia, 2010-2017
Anterior pelvic tilt

Prof. Yvette Koleva, DM, PhD, DMSc


*
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Flexion and extension


Abduction and adduction
Elevation and depression
Rotation

Sofia, 2010-2017
GONIOMETRY
active & passive

Prof. Yvette Koleva, DM, PhD, DMSc


External rotation
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

The LOTUS POSTURE of Yoga,


demonstrating external rotation of the leg
at the hip.

Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc
Internal rotation
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Circumduction

Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc
Special motion
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Plantar flexion

Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc
PALMAR FLEXION & DORSAL FLEXION OF THE HAND

Praying Hands by Albrecht Drer, demonstrating


dorsiflexion of the hands.
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Flexion and extension of the hand

Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Pronation and supination of the foot & arm

Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc
Inversion and eversion
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Eversion of the right foot

Sofia, 2010-2017
Inversion of the right foot
Prof. Yvette Koleva, DM, PhD, DMSc
Sofia, 2010-2017
Opposition
Prof. Yvette Koleva, DM, PhD, DMSc
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Scapulo-humeral rhythm
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Scapulo-humeral rhythm
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
FUNCTIONAL ANALYSIS OF ACTIVITIES
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Assessment of the stature
???
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Prof. Yvette Koleva, DM, PhD, DMSc


Sofia, 2010-2017

Assessment of ADL
Functional evaluation of the patient in PRM must be based on
INTERNATIONAL CLASSIFICATION OF
FUNCTIONNING, DISABILITY AND HEALTH
(ICF, WHO, 2001)
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

HEALTH CONDITION
(alteration / disease)

ICF
Body functions Activities Participation
(and structures) (limitations) (disability)

Environmental factors Personal factors


ICF Options
balancing expectations and risks in OT cases
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

A wide range of ICF options


with an increasing need for activities and participations

PERSONAL
BODY FACTORS ACTI
FUNCTIONS Technical Age, sex, VITIES
PAIN assistance Poly morbidity, Operating Management PARTICI
Health culture contact contact PATION
Range Verticalization
of Motion Family
ENVIRONMENT
MUSCLE
Home Mobility
FORCE/ Leisure
WEAKNESS Transport
Employment Locomotion Social life
COORDI
Health (rates
NATION (performance Political
Services based) Transport
BALANCE (time related) activities
based) Assurance
GAIT
Family Grasp
Sensibility ADL
Friends

and a need for adaptation to individual circumstances


FUNCTIONAL EVALUATION OF OT PATIENTS,
BASED ON ICF
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

The holistic approach to the patient must be obligatory the complex evaluation must
include:
COGNITIVE CAPACITIES (orientation, memory, attention, compliance during rehabilitation,
conscience of necessity of preventive measures due to the principal disease);
PAIN (localization, type, intensity /verbal or visual analogue scale/; activities increasing
pain);
RANGE OF MOTION (active and passive);
MUSCLE FORCE OR MUSCLE WEAKNESS, motor deficiency;
COORDINATION (neuro-muscular coordination; static, locomotor or dynamic ataxia);
MOBILITY (necessity of technical aids, gadgets; instruments, etc.);
ENDURANCE (capacity to support extreme changes, necessity of pauses during
investigations and functional activity);
INDEPENDENCE IN ACTIVITIES OF DAILY LIVING (bathing, dressing, eating, hygiene,
Sofia, 2010-2017

necessity of assistance in the self-care).


The final complex evaluation,
based on ICF, have to include :
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

BODY FUNCTIONS (pain, range of motion, motor weakness,


dyscoordination syndromes - ataxia);
ACTIVITIES (verticalization, mobility, standing up, walking,
transport, grasping, ADL);
PARTICIPATION (family life, leisure, social life, participation in
political activities);
ENVIRONMENTAL FACTORS (environment at home & at work,
family & friends, health insurance, health assurance, social
Sofia, 2010-2017

contacts);
PERSONAL FACTORS (health culture, polimorbidity, age, sex).
***

FUNCTIONAL EVALUATION of patients with neurological


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

conditions, with sensory, motor, autonomic dysfunctions


and deficiencies must be effectuated before and after every
rehabilitation course.

The evaluation have to be based on the holistic approach to


the patient, including :

specialized OT examination, &


Sofia, 2010-2017

Functional examination.
In clinical practice we apply the
COMPLEX REHABILITATION PRINCIPLE
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Physiotherapy, electrotherapy,
massages, ergotherapy
In different groups of diseases
Or
Synergic combination of different
physical modalities and techniques:
Complex rehabilitation programme for
every health condition

Prof. Ivet Koleva, DM, PhD, DMSc


In OT Rehab we apply the
PHYSICAL-THERAPEUTIC AND
REHABILITATION PUZZLE
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

KINESI PREFORMED
(physio) MODALITIES
(electro/magneto/light/th)
therapy

ERGO
ES (occupational)
therapy

The found is always adapted diet and strict medication of the basic disease
Modalites physiques / PHYSICAL MODALITIES Lego style
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

ES MAGNETO-Therapy

KINESI-Th IONTOPHORESIS

ERGO-Th TENS
LASER DEEP
OSCILLATION
Sofia, 2010-2017
10-2017
OT REHABILITATION ALGORITHM :
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

TRAINING OF THE FUNCTION -

KINESIOTHERAPY (PHYSIOTHERAPY) & ERGOTHERAPY

PREFORMED MODALITIES

Electro-stimulation, pain relief, reduction of oedema, stimulation of


regeneration, stimulation of peripheral nerves and muscles, etc.

Prof. Yvette Koleva, DM, PhD, DMSc


KINESITHERAPY:

ANALYTIC
EXERCICES Sofia, 2010-2017
MS & MI
augmentation du
mouvement de base
Pour les muscles
paravertebraux
PIR
strech techniques
Massages

Prof. Yvette Koleva, DM, PhD, DMSc


MANUAL THERAPY

L5, S1 --- tractions & mobilisations

PNF

Sacro-iliac blockage MANIPULATIONS;

Patellar Mobilisations

Post-isometric relaxation for soleus muscle

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


Vue anterieure

Vue posterieure

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


Proprioceptive neuro-muscular facilitation
(PNF)
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Activities of daily living
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

(ADL)
Sitting in bed

Verticalization

Balance training

Gait education & training up-stairs and down-stairs


Sofia, 2010-2017
OCCUPATIONAL THERAPY:
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Mirror box
therapy

A diagram of a mirror box.


A patient inserts their hand into one hole,
Sofia, 2010-2017

and their "phantom" into the other.


When viewed from an angle, the brain is
tricked into seeing two complete hands
phantom limb / phantom pain
Mirror therapy for

in amputees
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Occupational therapy

Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Passive Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Passive Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Passive Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
PASSIVE ACTIVE MECHANO-Therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
PASSIVE ACTIVE MECHANO-Therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
PASSIVE ACTIVE MECHANO-Therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
PASSIVE ACTIVE MECHANO-Therapy

STRETCHING
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
MECHANO-THERAPY

ACCESSORIES
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
ctive Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
ctive Mechanotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Medical
(LPG device)
Hubert
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
xtension therapy
CERVICAL TRACTIONS

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


xtension therapy
CERVICAL TRACTIONS

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


xtension therapy
LUMBAR TRACTIONS

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


Extension vertebrotherapy
Lumbar tractions

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


PREFORMED PHYSICAL
MODALITIES
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

FUNCTIONAL
ELECTROSTIMULATIONS

PHYSICAL ANALGESIA
PREFORMED PHYSICAL FACTORS

- ELECTROSTIMULATIONS
(exponential form of pulses, ti=200 msec, tp=1000 msec, Fr=0,25-0,5 Hz,

3 min. for every muscle


15-20 procedures

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


(low and middle frequency)
Devices for electro-therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
ELECTRODES
for electrotherapy with
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

low frequency and middle frequency currents


Sofia, 2010-2017
DEVICES
portable
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
: .

INTELLECT Chattanooga Intelect Legend XT 2 Channel


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Combo (stim and ultrasound) Unit Without Cart


by INTELLECT
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


Vectra Genesys Therapy System

Vectra Genisys is the first modular


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

therapy system that consolidates


up to six therapeutic modalities in
one system, at a fraction of what
these modalities would cost alone.
Unique modular design lets you
choose what fits best in your
clinical setting now or easily add to
later without the replacement of
products. - See more at:
http://www.djoglobal.com/products/
chattanooga/vectra-genisys-
therapy-
system#sthash.1qRPTm8V.dpuf
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


Different forms of
low & middle frequency
electric currents
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Rectangular, triangular, trapezius,


sinusoidal, semi-sinusoidal,
tiratronic,
exponential (positive or negative)
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


Low and middle frequency electric currents
BIPOLAR periodic sinusoidal and faradic;
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

- aperiodic.

MONOPOLAR currents.
Sofia, 2010-2017
Preformed physical modalities
for anti-pain effect
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

PHYSICAL
ANALGESIA
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


TENS

-TRANSCUTANEOUS ELECTRICAL NERVE


STIMULATION (TENS):
-BTL-06, programme 1617, 10-20 m, 10-20 min., XIV proc.

- Intelect 340 Combo Electrotherapy Unit (Intelect, Chattanooga group, 2004), programme
TENS ( , 40%,
20-400 msec., 1-250 Hz), 15-20 m,
15 - 20 min., XV e.

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


MAGNETIC FIELD
(CHAMP MAGNETIQUE)

LOW FREQUENCY PULSED MAGNETIC FIELD

- Low frequency low intensity magnetic field


-204 , 10-20 minutes, V procedures pro cursu

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


Devices
Low frequency pulsed magnetic field
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Light therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
LASER - acronym of

Light
Amplification
by

Stimulated
Emission Intense
highly directional
of
beam of light
Radiation
Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017
- LASER - He-Ne, 5-10 mW/cm2, D = 1,5 cm, 3 min. , 6 fields per die, XV procedures

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Devices
Physiolaser in any configuration between 635 to 904 nm:
from 50 mW/ 785 nm up to terrific 500 mW/810 nm or 90 W/904 nm.
New: 200 mW/685 nm (red).
Sofia, 2010-2017

DEEP
OSCILLATION
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

The influence of the method DEEP OSCILLATION is based on pulsed


electrostatic field, generated in a zone of the patients body.

BASIC INDICATIONS:
SN & SM conditions,
Pain relief;
TRAUMATOLOGY,
SURGERY.

FFECTS OF
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

DEEP OSCILLATION
Anti-inflammatory effect;
Stimulation of micro-circulation;
Oedema reduction;
Tissue regeneration;
Pain relief;
Contra fibrosis .
DEEP OSCILLATION
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

DEEP OSCILLATION

Evident
,
,







Sofia, 2010-2017


(
)
DEEP OSCILLATION



Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
DEEP OSCILLATION


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
DEEP OSCILLATION
( )
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Shock wave therapy
Shockwave is an acoustic wave which carries high energy to painful spots and
myoskeletal tissues with subacute, subchronic and chronic conditions.
The energy promotes regeneration and reparative processes of the
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

bones, tendons and other soft tissues.


Shockwaves are characterized by jump change in pressure, high
amplitude and non-periodicity.
The kinetic energy of the projectile, created by compressed air, is
transferred to the transmitter at the end of the applicator and further into
the tissue.

Acoustic waves with high energy peak used in Shockwave therapy interact with
tissue causing overall medical effects of accelerated tissue repair and cell
growth, analgesia and mobility restoration. All the processes mentioned in this
section are typically employed simultaneously and are used to treat chronic,
sub-acute and acute (advanced users only) conditions.
New Blood Vessel Formation Reversal of Chronic Inflammation
Nutrient blood flow is necessary to start and maintain the repair processes Chronic inflammation occurs when the inflammatory response is not completely halted. It can
of damaged tissue structure. The application of acoustic waves creates damage healthy tissue and results in chronic pain. Mast cells are one of the key components of
capillary microruptures in tendon and bone. Due to microruptures the the inflammatory process. Their activity may be increased by using pervasive acoustic waves.
expression of growth factors such as eNOS, VEGF, PCNS and BMP is Mast cell activation is followed by the production of chemokines and cytokines. These pro-
significantly increased. inflammatory compounds first enhance the inflammatory process and in the next step help
As a result of these processes arterioles are remodeled, stimulated to grow restore normal healing and regenerative processes.
and new ones are formed. The new blood vessels improve blood supply
and oxygenation of the treated area and support faster healing of both the
tendon and the bone.
Scientific support Stimulation of Collagen Production
Biological Mechanism of Musculoskeletal Shockwaves The production of a sufficient amount of collagen is a necessary precondition for the
repair processes of the damaged myoskeletal and ligamentous structures. Shockwave
therapy accelerates procollagen synthesis. The therapy forces the newly created collagen
fibers into a longitudinal structure which makes the newly formed tendon fibers more
dense and stiff and creates a firmer structure.
Shock wave therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Dissolution of Calcified Fibroblasts


Calcium build-up is most often a result of micro-tears
or other trauma to a tendon. Acoustic waves
break up the existing calcifications. Shockwave
therapy starts the biochemical decalcification of
the calcium build-up of a toothpaste-like
consistency and treats the tendon. The granular
particles of calcium are then removed by the
lymphatic system.

Dispersion of Pain Mediator Substance P Release of Trigger Points


Substance P is a neurotransmitter that mediates pain Trigger points are the principal cause of pain in the back, neck, shoulder and
information through C-fibers. This neuropeptide is generally limbs. They are associated with palpable nodules in taut bands of muscle
associated with intense, persistent and chronic pain. It relays fibers and have extremely contracted sarcomeres. The dysfunctional
pain messages to the central nervous system. Lowering the sarcomeres contract so tightly that they begin to cut off their own blood
concentration of Substance P reduces the stimulation of supply. This causes the waste products to build up. Waste product build-
afferent nociceptive fibers and thus reduces the pain. up irritates the sensory nerve endings which then causes even more
Decreasing Substance P, histamines and other nociceptive contraction. This vicious cycle is referred to as metabolic crisis. The
metabolites also helps inhibit development of inflammatory assumed mechanism of action is that the delivered acoustic energy
oedema. Acoustic waves generated by Shockwave therapy unblocks the calcium pump and thus reverses the metabolic crisis in the
lower the Substance P concentration and trigger pain relief. myofilaments and releases the trigger points.
Shockwave Therapy in OT pathology
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Highly effective treatment of tendon-related pain

INDICATIONS in OT practice:
tennis elbow
shoulder tendonitis
heel, achilles and knee trauma
degenerative disorders

SOURCE: http://www.shockwave-therapy.co.uk
In some cases
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Drug therapy

Infiltration therapy

etc.
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Meso therapy
Infiltration therapy
Michel Pistor (19242003) performed clinical research and founded the
field of mesotherapy. Multi-national research in intradermal therapy culminated with Pistor's work from 1948 to
1952 in human mesotherapy treatments.
The French press coined the term Mesotherapy in 1958.
The French Acadmie Nationale de Mdecine recognized Mesotherapy as a Specialty of Medicine in 1987.
Popular throughout European countries and South America, mesotherapy is practiced by approximately 18,000

Sofia, 2010-2017
physicians worldwide
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

http://mi-medicalinnovation.com/img/cms/20_MIMedicalInnovation_schematechniquemesotherapieAng.jpg
Infiltration therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

mesotherapy
before the procedure (respective pre-formed modality )

in loco doloris, or segmental application

before the application of physical modalities (electrotherapy, magnetic field, vibration,etc.)

REDUCTION OF PAIN
Padua L, I Aprile, F Cecchi, et al.
Pain in postsurgical Orthopedic Rehabilitation: A multicenter study.
Pain Medicine, 13, 2012, 769-776.
Mesotherapy & Pain

Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD,


DMSc
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Infiltration therapy

Sofia, 2010-2017
Meso therapy
Prolo therapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Nerve blocks
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Occupational therapy
Environment adaptations
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

HOME ADAPTATION
Sofia, 2010-2017
OCCUPATIONAL THERAPY
Adapting the environment for ADL
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
ADL
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
ADL
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Occupational therapy

TECHNICAL AIDS
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Brace
Walker boot
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Shoulder brace
Arm sling
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DM

Universal arm sling


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Shoulder wrap - Cryotherapy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


Lumbar spine - Volare
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Modular system

Prof. Yvette Koleva, DM, PhD, DMSc


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM


Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


REHABILITATION OF THE
GRASP & GAIT
-
CONTEMPORANEOUS METHODS

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


Typical locations of the surface stimulation electrodes that
are used to retrain reaching and grasping functions
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Controlled active
flexor splint
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Synergistic splint
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Differential tendon-
gliding splints
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Controlled passive extensor splint
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Immediate controlled active motion splint
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Buddy splint and proximal Phalangeal fracture resting splint


Sofia, 2010-2017
A REFLEX MODEL OF MOTOR CONTROL
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

STIMULUS BLACK BOX RESPONSE

CNS
SENSORY INPUT

MOTOR OUTPUT
Sofia, 2010-2017

Prof. Yvette Koleva, DM, PhD, DMSc


Centre of gravity
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM Sofia, 2010-2017
Using the gravity
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

wheelchair with tilting possibility

oxygen transport
Sofia, 2010-2017
"Light Operated Mouse And Keyboard
LOMAK
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
SPECIAL KEYBOARDS
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

You can think about a lot of things, that one can do with
computers.

Nearly everything, that works with electricity, can be done


with a kind of roboticals, doors, curtains, television,
computers...
Sofia, 2010-2017
PROSTHESIS
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Pre-history

Ancient Egypt
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Otto-bock
C-leg
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
PARALYMPICS
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
MYO-ELECTRIC ROBOTIZED PROSTHESIS
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Fig. 3. Rolled dielectric elastomer acting as a bicep on a full-size human skeletal
muscle. Field-activated polymers operate at high voltage and low current. Further
development of lightweight and efficient voltage conversion and driving circuitry is
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

required for operation off of batteries. High voltage must be isolated from the user.
However, the potential danger of high voltage can be greatly reduced by limiting the
available current. For example, operation of 100 W actuators at 5000 V (a typical
maximum for dielectric elastomers) would require just 20 mA a nonlethal amount.
Sofia, 2010-2017
prosthetic hand
yo electric
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Michelangelo Hands of God (Creation)
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Otto-bock
MICHELANGELO HAND Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Michelangelo hand
the grip types
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

MICHELANGELO NEW PROSTHETIC HAND


BY OTTO BOCK
http://www.youtube.com/watch?v=pOgfuDrtZyc
Sofia, 2010-2017
for gait rehabilitation
EMG Biofeedback
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Exoskeleton
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
Modern exoskeletons

Prof. Yvette Koleva, DM, PhD, DMSc


Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
010-2017
Exoskeletons in industry
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

FORTIS exoskeleton
http://www.lockheedmartin.com/us/pr
oducts/exoskeleton/fortis.html

Prof. Yvette Koleva, DM, PhD, DMSc


010-2017
US Navy
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

U.S. Navy to Test and Evaluate Lockheed Martin Industrial Exoskeletons

http://aerospace.firetrench.com/2014/08/u-s-navy-to-test-and-evaluate-lockheed-martin-industrial-exoskeletons/

Prof. Yvette Koleva, DM, PhD, DMSc


010-2017
Exoskeletons in Rehab
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Prof. Yvette Koleva, DM, PhD, DMSc


010-2017
http://designyoutrust.com/2011/10/robotic-exoskeletons-help-the-paralyzed-walk-again/
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Prof. Yvette Koleva, DM, PhD, DMSc


TELE-REHABILITATION
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
EFFECTS OF OT REHABILITATION
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Pain relief;
Increase of range of motion;
Prevention of complications;
Increase of muscle force;
Decrease of muscle weakness;
Training of neuro-muscular coordination;
Restoration of scapulo-humeral and pelvi-femoral rhythm;
Balance and gait training;
Psycho-emotional effects;
Amelioration of autonomy of patients in every day activities;
Sofia, 2010-2017

Resocialization of patients;
Amelioration of quality of life of patients.
OT Rehabilitation
PROs & CONTRAs
PROs
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Natural treatment (We must respect the experience of God)


No contra-indications
Without side-effects
Cheap treatment (No expensive drugs)

CONTRAs
Lack of sufficient evidence (we are in the era of EB medicine & EB rehabilitation);
Necessity of interdisciplinary team (OT surgeon, radiologist, PRM specialist, etc).
Sofia, 2010-2017
GROUPS OF REFLECTORY CONNECTIONS
PROPRIO-VISCERAL
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

(zones of Mackenzie)
CUTANEOUS-
VISCERAL
(zones of Head) MOTOR-VISCERAL
(zones of Mackenzie)

PERIOSTAL-VISCERAL
(zones of Vogler-Krauss)

REFLECTORY
CONNECTIONS
SUBCUTANEOUS-
CONNECTIVE TISSUE-
VISCERAL
(zones of Leube-Dicke)
Sofia, 2010-2017
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Conclusions

Prof. Yvette Koleva,


DM, PhD, DMSc
Prof. Ivet Koleva, DM, PhD, DMSc
Algorithm of OT Rehab management
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

The rehabilitation have evolved from


Diagnose and Adios to a comprehensive care of
the patients problems.
We consider that the emphasis on early diagnosis
and management is obligatory.
Actually PRM in Bulgaria is not yet viewed with skepticism.
Rehabilitation procedures are well accepted like a first line therapy
Sofia, 2010-2017

with proven safety and benefit profile.


Our proposal
for
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

COMPLEX ALGORITHM OF
OT MANAGEMENT

The complex algorithm must include:


systematic drugs,
OT care;
PRM complex,
Sofia, 2010-2017

patient education.
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Physical modalities:
one or two pre-formed modalities;
one cryo- agent.;
one or two kinesitherapeutic procedures
/incl. passive & active exercises, mechano-therapy, stretching
techniques, post isometric relaxation, analytic exercises.
Sofia, 2010-2017
Rehabilitation a la carte
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM
Sofia, 2010-2017
The Rationale:
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

We could recommend our

rehabilitation strategy

for complex treatment of OT conditions.


Sofia, 2010-2017
Home message
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

OT rehabilitation is obligatory
in these cases.
Sofia, 2010-2017

La reeducation fonctionnelle est obligatoire pour les patients


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

In clinical rehabilitation practice -


CHOLISTIC APPROACH
to the OT patient
REHABILITATION TEAM
for OT patients

General practitioner
Specialists in OT, Radiology; PRM

Ergotherapist
Phisiotherapist
Kinesitherapist
Nutricioniste
Psychologist,
Sociologist
Nurse.

Prof. Yvette Koleva, DM, PhD, DMSc Sofia, 2010-2017


In clinical practice -
PATIENT CENTERED APPROACH
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

PRM doctor

PATIENT

Physiotherapist
Ergo therapist

Prof. Ivet Koleva, DM, PhD, DMSc


QUALITY OF
Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

OT REHABILITATION
in OT cases

FUNCTIONAL EVALUATION & NEW ASSESSMENT METHODS

ICF

MODERN THERAPEUTIC METHODS

MODERN DEVICES

QUALIFICATION OF THE STAFF


Prof. Yvette Koleva, DM, PhD, DMSc, FEBPRM

Quality of OT rehab
Quality of life of OT patients