ALL ABOUT REHAB: PAIN &OTHERS

Rehabilitation Strategy Points of Management in Thoracic Malignancy

2009-10-27T19:03:00.000+07:00

Rehabilitation Strategy Points of Management in Thoracic Malignancy

Nury Nusdwinuringtyas

Pulmonary Rehabilitation Division, Department of Physical Medicine & Rehabilitation, Cipto Mangunkusumo Hospital, Jakarta

ABSTRACT

Rehabilitation has been described as the restoration of a patient to a person. The aim of rehabilitation with its holistic approach according to the World Health Organization is not only to train disabled and handicapped person to adopt environment and society as a whole, but also to facilitate the social integration where to live and they should be in the mainstream of community level.

Types of cancer rehabilitation, includes preventive, supportive, and palliative aspects. The goal of preventive rehabilitation therapy is to achieve maximal function considered to be cured or in remission. The goals of supportive rehabilitation therapy include providing adaptive self-care equipment in an attempt to offset what can be a steady decline in the patient’s functional skills. Palliative rehabilitation therapy goals are to improve or maintain comfort and function during the terminal stage of the disease. Palliative care rehabilitation at its best is the transformation of the dying into the living.

Patients with thoracic malignancies mostly suffer from respiratory symptoms (i.e. dyspnea) and pain. The World Health Organization estimates that 25% of all cancer patients die with unrelieved pain. Up to 60% of patients at all stages of the disease process experience significant pain. Most of this pain can be adequately relieved by analgesics. Cancer pain is managed by using opioid agonists and adjuvant drugs (i.e. antidepressants, anticonvulsants, benzodiazepines, neuroleptics, psychostimulants, antihistamines, corticosteroids, and calcitonin) which are chosen to supplement analgesics for their specific secondary effects or to treat side effects.

In addition to pain, the most common problems being dealt by patients with thoracic malignancies are dyspnea, excessive mucus secretion, and persistent cough. Weakness, lack of activity, and an inability to swallow saliva lead to chest infections, and these, aggravated by the inability to cough, and clear mucus, are distressing for patients and caregivers alike. To relief those symptoms, many approaches can be done including breathing exercise, postural drainage, inhalations, humidifiers, and nebulizers.

Dyspnea creates anxiety, and anxiety creates dyspnea. Breaking the cycle by a management strategy is necessary if any relief is to be provided. Patient can be taught to extend their activity range significantly if they follow a simple system involving breathing control, relaxation, organizing their activity into short periods with rest at regular intervals.

It is possible that oxygen supplementation could improve function in patients with cancer dyspnea, but such studies have not been conducted. The main objective of oxygen therapy in advanced cancer patients is symptomatic relief rather than prevention of long term complications; therefore, intermittent use can be acceptable and less psychologically burdensome in patients who present with intermittent exacerbation of dyspnea. Pulse oximetry is used to measure oxygen saturation, which will determine the effect of supplemental oxygen for patients with dyspnea.

Rupture tendon bicipitalis

2009-02-22T07:09:00.004+07:00

mr B.A 30 y.o, came to me a week ago, with chief complaint pain at his left arm . He noticed, pain began after he cought a ball 10 days before.

I found the bulk of his bicep not properly at the site. I asked him to use arm sling and send him to radiologist to do USG -soft tissue . The result: partial rupture tendon. The pain gone , after he use arm sling.

I found the diameter of his biceps, less 2,5 cm than the right one. The bulk of his left side look normal as his right side, but diameter less as about 2.5 cm.

I asked him to began exercise, first with isometric without anya bend at his elbow. The with slihgt bend, gradually after a week.

Dysphagia

2009-02-18T21:47:00.003+07:00

Knee pain

2008-11-09T21:50:00.008+07:00

Bow leg at the left one.

Knee pain bilateral with history stroke, and slight paretic at the left side.

19 y o , obesity girl

Please, cut your weight

65 y.o lady, bony enlargment, right side bigger than the laeft.

Tendinitis bicipitalis

2008-10-03T08:31:00.004+07:00

A lady, about 50 y o, midwife at a big hospital , came to me due to pain at her right shoulder. It was bicipitalis tendinitis. The regiment: ILIB plus scanner (20 minutes scan mode given as spot 40 minutes as moving light) . The pain gone after the 3rd visited.

Came again a week ago, after night duty. I asked her to take Ultrasound diagnostic for her right shoulder and I'm going to combine low laser with taping.

I'll report the results and upload the documentations.

Yusuf- evaluation

2008-09-22T08:48:00.003+07:00

15 September 2008

Ramsay Hunt Syndrom

2008-08-22T08:24:00.010+07:00

July, 4 - 2008

July, 12 - 2008

August, 13 - 2008. Big smile !

THE HIPPOCRATIC OATH (Fourth Century B.C.)

2008-08-05T05:55:00.002+07:00

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make suggeastion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free of slaves.

What I may see or hear in the course of the treatment or outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Yusuf- chronic wound

2008-06-30T20:33:00.007+07:00

Yusuf, 12 y.o. Recovered from ALL

The first picture, May 24, 2008. Bad odor, dirty> the Regiment ILIB and Scanner mode no 7 for 1 hour (both)

A week after, more clean no odor

Mei, 29, 2008
ILIB and scanner mode 0

June 29, 2009
ILIB and Scanner mode 1
just for the skin

Scoliosis

2008-06-04T22:29:00.003+07:00

Wound - granulation

2008-06-04T22:24:00.005+07:00

June 4, 2008

Saturday , June 7 th 2008

Monday, June 23,2008

nasopharynx cancer- post radiation

2008-05-31T23:05:00.003+07:00

Will be the next

wound

2008-05-25T19:14:00.009+07:00

A boy, 12 y o, wound at his back. The treatment still in progress

Saturday, May, 24- 2008
ILIB mode 7

Sunday, may, 25- 2008
ILIB mode 7

Monday, May 26- 2008
ILIB mode 0

Tuesday, May, 27 - 2008
ILIB mode 0

Wednesday
ILIB mode 0

Friday, May, 30- 2008

ILIB mode1

Saturday, May 31, 2008
using ILIB mode 1

June, 29, 2008

Mr Djoko- hearing loss

2008-05-16T11:40:00.012+07:00

Mr Djoko, one of my patient, came to me 2 weeks ago. He suddenly loss his hearing at the left side. Laser given by ILIB and ear probe . After the first treatment, he felt “better”, no “full” sensation again on his lefl ear. Everyday laser for four times, and ones a week after the 4^th , :

The audiogram after treatment : found normal

(left side : before; right side: after)

Regiment for Mr Djoko:

day 1: ILIB 30 mint; ear probe 30 min

day 2 : ILIB 40 min; ear probe 30 min

day 3 ILIB 50 min; ear probe 30 min

day 4 ILIB 60 min; ear probe 30 min

a week after: ILIB 60 min, ear probe 30 min

He already got stroke few years ago, his hearing loss could cause by ischemic. Lee and Baloh found that ten percent of patients with vertebrobasilar stroke had unilateral hearing loss, almost always with vertigo. Treatment with steroids has class I evidence for being a beneficial treatment--even if the cause turns out to be vascular. Usually tapering oral steroids are given, sometimes with pentoxifylline, and occassionally acyclovir or valacyclovir.

For Ms Djoko, the Laser combine with neurotopic agent

From jurnal:

The low level laser therapy of inner ear dysfunction has been made use of in Germany since the end of the eighties (for example by Dr. Uwe Witt, Hamburg and Dr. Lutz Wilden in Bad Fuessing) and is also to be found in quite a few other countries (Italy, France, Scandinavia, Switzerland, Hungary, Japan, Russia etc.). .

As the observation of healing processes has shown in the course of the years, even serious impairments such as the most excruciating cases of tinnitus, hearing loss, vertigo and Meniere's Disease can be considerably alleviated and even healed with the aid of modern Low Level Laser Therapy (LLLT).

How does LLLT work?

For a detailed discussion, see Dr. Lutz Wilden' article: Import of Radiation Phenomena of Electrons and Therapeutic Low-Level Laser in Regard to the Mitochondrial Energy Transfer, Journal of Clinical Laser Medicine & Surgery, Volume 16, Number 3, 1998, Mary Ann Liebert, Inc., Pp.159-165

Each cell contains a number of power plants, called mitochondria. The function of these power plants is to produce ATP, the form of energy which can be used by the cell to function properly.

The inner mitochondrial membrane is a large collector surface folded onto a small total volume. All nutritive molecules (fats, proteins and glucose) are oxidized within the cell to the last molecular nutritive component, that is, pyruvate. The pyruvate is then imported into the cellular power plant, where it disintegrates into carbon dioxide and water in the immediate proximity of the collector surface of the mitochondrion. The molecular bond energy thus released, which corresponds with visible, ultraviolet and infrared light as far as its wavelength and frequency is concerned, is utilized by the mitochondrion to produce the cellular fuel ATP.

The collector surface of our cellular power plant is enlarged by the mushroom-shaped protrusions of the inner mitochondrial membrane. The molecular bond energy of the pyruvate is released in the form of light energy. The antennae pigments are capable of absorbing this light energy and transmit it to our cellular power plant, which can now produce the cellular fuel ATP. The natural solar radiation also stimulates the antennae pigments of the mitochondrion to produce ATP.

Low level laser light is compressed light from the red and infrared spectrum of the electromagnetic radiation. It reaches the cellular power plants of low-lying cells as well and is absorbed by their collector surfaces as an additional source of energy. The cellular power plants can thus produce more ATP. The cellular energy is the fuel the inner ear cells strives after and needs. A sufficiently high supply of cellular energy enables our inner ear cell to work under optimum conditions and is the essential prerequisite to ensure a successful self-healing process.

Low level laser light increases the energy output in our cellular power plant.

diagram

2008-04-21T19:37:00.001+07:00

plexus lumbosacral

2008-03-29T21:39:00.003+07:00

The lumbar plexus is a nervous plexus in the lumbar region of the body. It is formed by the loops of communication between the anterior divisions of the first three and the greater part of the fourth lumbar nerves; the first lumbar often receives a branch from the last thoracic nerve.

It is situated in the posterior part of the Psoas major, in front of the transverse processes of the lumbar vertebræ.

Branches

The lumbar plexus differs from the brachial plexus in not forming an intricate interlacement, but the several nerves of distribution arise from one or more of the spinal nerves, in the following manner: the first lumbar nerve, frequently supplemented by a twig from the last thoracic, splits into an upper and lower branch; the upper and larger branch divides into the iliohypogastric and ilioinguinal nerves; the lower and smaller branch unites with a branch of the second lumbar to form the genitofemoral nerve.

The remainder of the second lumbar nerve, and the third and fourth lumbar nerves, divide into ventral and dorsal divisions.

The ventral division of the second lumbar nerve unites with the ventral divisions of the third and fourth lumbar nerves to form the obturator nerve.

The dorsal divisions of the second and third nerves divide

Division	Name	Source	Target
Main	Iliohypogastric nerve	1 L.	Skin over the lateral gluteal region and above the pubis ^[1]
Main	Ilioinguinal nerve	1 L.	Skin over the root of the penis and upper part of the scrotum (male), skin covering the mons pubis and labium majus (female)
Main	Genitofemoral nerve	1, 2 L.	Genital Branch: Cremaster muscle, skin of scrotum/labia majora Femoral Branch: Skin on anterior thigh
Dorsal	Lateral femoral cutaneous	2, 3 L.	Skin on the lateral part of the thigh
Ventral	Obturator nerve (and Accessory obturator nerve, when present)	2, 3, 4 L.	Medial compartment of thigh
Dorsal	Femoral nerve	2, 3, 4 L.	Anterior compartment of thigh
Ventral	Lumbosacral trunk	4, 5L., 1, 2, 3, 4 S.	Sacral plexus

into two branches, a smaller branch from each uniting to form the lateral femoral cutaneous nerve, and a larger branch from each joining with the dorsal division of the fourth nerve to form the femoral nerve.

The accessory obturator, when it exists, is formed by the union of two small branches given off from the third and fourth nerves.

low level laser for plantar fasciitis

2008-03-22T20:45:00.004+07:00

Usually the is 30 Joule/ treatment, using Diode
But 5 years ago, for one patient, 60 years old lady, near 90 Joule needed . Used simultaneusly with calcaneal pad,the pain gone till this days.

Plantar Fasciitis

2008-03-22T20:41:00.003+07:00

Introduction

Plantar fasciitis causes stabbing or burning pain that's usually worse in the morning because the fascia tightens (contracts) overnight. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing or after getting up from a seated position.

Signs and symptoms

Plantar fasciitis usually develops gradually, but it can come on suddenly and be severe. And although it can affect both feet, it more often occurs in only one foot at a time. Watch for:

Sharp pain in the inside part of the bottom of the heel, which may feel like a knife sticking in the bottom of foot
Heel pain that tends to be worse with the first few steps after awakening, when climbing stairs or when standing on tiptoe
Heel pain after long periods of standing or after getting up from a seated position
Heel pain after, but not usually during, exercise
Mild swelling in heel

Causes

Under normal circumstances, plantar fascia acts like a shock-absorbing bowstring, supporting the arch in the foot. But, if tension on that bowstring becomes too great, it can create small tears in the fascia. Repetitive stretching and tearing can cause the fascia to become irritated or inflamed. The causes of plantar fasciitis can be:

Physical activity overload. Plantar fasciitis is common in long-distance runners. Jogging, walking or stair climbing also can place too much stress on your heel bone and the soft tissue attached to it, especially as part of an aggressive new training regimen. Even household exertion, such as moving furniture or large appliances, can trigger the pain.
Arthritis. Some types of arthritis can cause inflammation in the tendons in the bottom of your foot, which may lead to plantar fasciitis.
Diabetes. Although doctors don't know why, plantar fasciitis occurs more often in people with diabetes.
Faulty foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can adversely affect the way weight is distributed when you're on your feet, putting added stress on the plantar fascia.
Improper shoes. Shoes that are thin-soled, loose, or lack arch support or the ability to absorb shock don't protect your feet. If you regularly wear shoes with high heels, your Achilles tendon â€” which is attached to your heel â€” can contract and shorten, causing strain on the tissue around your heel.

Risk factors

Your risk of developing plantar fasciitis increases if you are:

Active in sports. Activities that place a lot of stress on your heel bone and attached tissue are most likely to cause plantar fasciitis. This includes running, ballet dancing and aerobics.
Flat-footed or have high arches. People with flatfeet may have poor shock absorption, which increases the stretch and strain on the plantar fascia. People with highly arched feet have tighter plantar tissue, which also leads to poor shock absorption.
Middle-aged or older. Heel pain tends to be more common with aging as the arch of your foot begins to sag, putting stress on the plantar fascia.
Overweight. Carrying around extra pounds can break down the fatty tissue under the heel bone and cause heel pain.
Pregnant. The weight gain and swelling that accompany pregnancy can cause ligaments in your body â€” including your feet â€” to relax. This can lead to mechanical problems and inflammatory conditions.
Being on your feet. People with occupations that require a lot of walking or standing on hard surfaces, including factory workers, teachers and waitresses, can damage their plantar fascia.
Wearing shoes with poor arch support or stiff soles. A closet of poorly designed pumps, loafers and boots can mean plantar problems.

Complications

Ignoring plantar fasciitis may result in a chronic condition that hinders your regular activities. You may also develop foot, knee, hip or back problems because of the way plantar fasciitis changes your walking motion.

Treatment

If self-care techniques don't help, your doctor might suggest other treatments to heal your heel.

Conservative treatment
For most people, the condition improves within a year of beginning conservative treatment. Nonsurgical treatments that may promote healing include:

Night splints. Your doctor may recommend wearing a splint fitted to your calf and foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight so that they can be stretched more effectively.
Orthotics. Your doctor may prescribe off-the-shelf or custom-fitted arch supports (orthotics) to help distribute pressure to your feet more evenly.
Physical therapy. A physical therapist can instruct you in a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilize your ankle and heel. A therapist may also teach you to apply athletic taping to support the bottom of your foot.

Medications and procedures
If conservative treatment doesn't provide relief, you might consider:

Corticosteroids. When other treatments don't work, your doctor may suggest one or two injections of corticosteroid medication into the region of the plantar fascia attachment at the heel for temporary relief. Multiple injections aren't recommended because they can weaken your plantar fascia and possibly cause it to rupture, as well as shrink the fat pad covering your heel bone. Another method for delivering corticosteroid medication is a technique known as iontophoresis (i-on-to-fuh-RE-sis), which uses gentle electric current to draw the medicine into the area of discomfort.
Surgery. Only a small percentage of people need surgery to detach the plantar fascia from the heel bone (plantar fasciotomy). It's generally an option only when the pain is severe and all else fails. Side effects include a weakening of the arch in your foot.

Prevention

You can take some simple steps now to prevent painful steps later:

Maintain a healthy weight. This minimizes the stress on your plantar fascia.
Choose supportive shoes. Give stilettos the boot. Also avoid shoes with excessively low heels. Buy shoes with a low to moderate heel, good arch support and shock absorbency. Don't go barefoot, especially on hard surfaces.
Don't wear worn-out athletic shoes. Replace your old athletic shoes before they stop supporting and cushioning your feet. If you're a runner, buy new shoes after about 400 miles of use.
Start sports activities slowly. Warm up before starting any athletic activity or sport, and start a new exercise program slowly.
Wake up with a stretch. Before you get out of bed in the morning, stretch your calf muscles, arch and Achilles tendon by reaching for your toes and gently flexing your foot. This helps reverse the tightening of the plantar fascia that occurs overnight.

Self-care

By following these self-care tips, you may be able to eliminate heel pain without further treatment:

Apply ice. Hold a cloth-covered ice pack over the area of pain for 15 to 20 minutes three or four times a day or after activity. Or try ice massage. Freeze a water-filled paper cup and roll it over the site of discomfort for about five to seven minutes. Regular ice massage can help reduce pain and inflammation.
Put your feet up. Stay off your feet for several days when the pain is severe.
Decrease your miles. You probably won't have to permanently retire your running or walking shoes, but it's a good idea to cover shorter distances until pain subsides.
Take up a no- or low-impact exercise. Swap swimming or bicycling for walking or jogging. You'll likely be able to return to your regular activities as heel pain gradually improves or disappears. However, some people find that the only way to avoid a recurring problem is to permanently modify their aerobic activities.
Add arch supports to your shoes. Inexpensive over-the-counter arch supports take the tension off the plantar fascia and help absorb shock.
Try acupressure techniques. Apply pressure to your heel by rolling a golf ball or tennis ball with the arch of your foot while you are standing and stabilized. This can help reduce pain and increase blood flow.
Use over-the-counter pain medications. Acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others), naproxen (Aleve) and others may ease pain and inflammation, although they won't treat the underlying problem. Use as directed, tapering off as your pain decreases.
Stretch your arches. Simple exercises using household objects can stretch or strengthen your plantar fascia, Achilles tendon and calf muscles.

streching forPlantar Fasciitis Prevention

2008-03-22T20:38:00.001+07:00

Hold each stretch for at least 30 seconds — don't bounce — and do one or two repetitions two to three times a day. Clockwise from upper left: 1. To strengthen arch muscles, place a towel on the floor, grab the towel with your toes and pull it toward you. 2. While sitting, grasp your toes and gently pull them toward you until you feel a stretch in the arch of your foot. Stretch one foot at a time. 3. Stand as shown, with your back leg straight and heel down. Move your hips forward until you feel a stretch in your calf. Switch legs and repeat. 4. Stand on a step near the bottom of your stairs, put your weight on the ball of one foot and slowly lower that heel until you feel your calf muscle stretching. Repeat on the other side.

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revitalitation- after radiation

2008-03-07T00:20:00.004+07:00

Skin lesion, after 30 times adiation due to papliloma larynx

A week after low level laser

Functional Evaluation After Prothesis Above The Knee

2008-02-26T15:42:00.003+07:00

chronic wound- the newest

2008-02-23T16:32:00.008+07:00

Remember about our chronic wounds ?

After given the right antibiotic, (guided by her sensitivity test), and low level laser (ILIB and scanner), and twice appear thread (10 cm , and 5 cm), the wound finally got better. No pain & able to walk properly.

rehabilitation after achilles tendon repair

2008-02-23T15:53:00.007+07:00

Mr A , 51 years old, executive .

Had his tendon repaired 3 months ago due to rupture of Achilles tendon, Mr Agus’ right foot was swollen. His right knee had “contraction” , because he always bend his knee, spam quadriceps. The laser (ILIB and scanner) was given for the relief of swelling and spasm, The major regiment : begin partial weight bearing for right foot, standing balance, walk “properly” with bilateral crutches. The 2^nd day : reduced swelling, the 5^th day : better standing balance , minimized spasm and he could manage his right knee. He went back to Badak - Bontang – Kalimantan on the 6th day.

February 13, 2008

February 14 , 2008

February 15 , 2008 : began to be given 10 kg weight for the right foot

February 17, 2008

Walk easily

chronic wound- after tendon repair

2007-12-29T19:49:00.000+07:00

diabetic limb - laser

2007-12-29T19:46:00.000+07:00