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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 99-101

Orthopaedic and traumatological rehabilitation


Klinikum am Kurpark Baden for Orthopaedics and Rheumatology, Baden, Austria

Date of Submission17-Jun-2019
Date of Acceptance17-Jun-2019
Date of Web Publication23-Aug-2019

Correspondence Address:
Christian Wiederer
Klinikum am Kurpark Baden for Orthopaedics and Rheumatology, Renngasse 22500 Baden
Austria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_54_19

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  Abstract 


The target of orthopaedic or traumatological rehabiliation has changed over the last years. Scores of pain or flexibility of joints are not longer the final aims. Now just best functional improvement in everyday activities is the most important goal of a successful rehabilitation. There are many conservative therapeutic methods for rehabilitation settings, especially including training therapy, water therapy and occupational therapy. This article describes the extern and intern evidence based knowledge about many important forms of therapies.

Keywords: Osteoarthrosis, rehabilitation, therapy


How to cite this article:
Wiederer C. Orthopaedic and traumatological rehabilitation. Hamdan Med J 2019;12:99-101

How to cite this URL:
Wiederer C. Orthopaedic and traumatological rehabilitation. Hamdan Med J [serial online] 2019 [cited 2019 Nov 21];12:99-101. Available from: http://www.hamdanjournal.org/text.asp?2019/12/3/99/265253




  Introduction Top


Acute and chronic diseases of, as well as post-operative degenerative changes and changes caused by trauma in the, musculoskeletal system are one of the most common reasons for rehabilitation measures, whereby various therapies in different phases of recovery are summarised under the term rehabilitation.

In principle, the components and objectives of rehabilitation were defined in the Technical Report of the World Health Organization [1] as early as 1981 as follows:

“Rehabilitation includes all measures aimed at reducing the impact of disabling and handicapping conditions, and at enabling the disabled and handicapped to achieve social integration.”

“Rehabilitation aims not only at training disabled and handicapped persons to adapt to their environment but also at intervening in their immediate environment and society as a whole in order to facilitate their social integration.”

“The disabled and handicapped themselves, their families and the communities they live in should be involved in the planning and implementation of services related to rehabilitation.”

What is remarkable about this definition is the multimodal spectrum of measures, on the one hand, and the ground-breaking objective of self-initiative and the maximised independent participation in daily life, on the other hand.


  Fundamentals of Rehabilitation Top


The phase model of rehabilitation distinguishes among a multilevel structure with four sequenced phases. Phase one concerns the early mobilisation at acute-care hospitals, whereas phase two encompasses post-acute inpatient and outpatient care. In the third phase, outpatient rehabilitation measures are carried out to reinforce therapeutic success achieved in phases one and two. Finally, phase four is the long-term after treatment through home therapy and individual exercise.

Rehabilitation measures are indicated in many medical specialities, from neurology to oncology. However, the most common reasons for rehabilitation still lie within the indications of orthopaedics, traumatology and rheumatology. These mainly include not only degenerative musculoskeletal diseases such as osteoarthritis but also pathologies caused by intervertebral discs as well as congenital or acquired diseases, because of static disorders or deformities or dysfunction of the musculoskeletal organs or post-traumatic or post-operative resulting conditions after injuries of the musculoskeletal system. Inflammation- and metabolism-related clinical pictures lie within the domain of rheumatological rehabilitation, which usually has different objectives and therapeutic emphases in comparison to orthopaedic and traumatological rehabilitation.

This collectively inhomogeneous orthopaedic–therapeutic patient group naturally exhibits not only differing issues but also very individual therapy objectives, mostly improved mobility, functional improvement in everyday activities such as personal hygiene and clothing and unclothing, pain relief or the therapy of peripheral paralysis.

In general, medicine strives for restitutio ad integrum. Rehabilitation, however, aims for restitutio ad optimum. In consultation between patient, physician and therapist, the individual therapeutic objective is adjusted to realistically match the patient's initial situation, rehabilitation potential and wishes.

A large number of indications require the rehabilitation of the musculoskeletal system. For reasons of scope and clarity, this article primarily concentrates on rehabilitative options for arthrosis of the knee and hip joints. However, also, the efficacy of inpatient orthopaedic rehabilitation following the implantation of hip and knee endoprostheses has been illustrated by Kladny, 2007[2] in a controlled trial.


  Forms of Therapy Top


Not only do numerous different indications exist but also depend on the stage and individual progression of the disease as well as comorbidity, so do a multitude of treatment methods.

The most significant conservative therapeutic methods in inpatient and outpatient rehabilitation include movement therapy, hydrotherapy, exercise therapy, support through occupational therapy, manual-medical methods, electrical therapy with an emphasis on low and medium frequency, ultrasound and thermotherapy. Not only diverse massage techniques, from post-operative decongesting manual lymph drainage to complex decongestive therapy for oedemas, but also relaxation techniques, biofeedback and acupuncture are utilised in different combinations and within various parts of the multimodal range of therapies in alignment with the patient's symptomatology.

Furthermore, newer, innovative procedures such as focused and radial shockwave therapy and the local application of autologous plasma with an increased proportion of growth factors are more and more frequently found among the array of treatments within rehabilitative medicine.

In terms of physical medicine, multimodality means that, corresponding to symptomatology and clinical examination results, an attending physician specifies a multifaceted therapeutic concept in consultation with the patient, which is modified depending on progress during the course of therapy. Finally, to guarantee sustainable therapeutic success, an exercise therapist develops an attainable home exercise programme together with the patient.

The composition of multimodal therapy follows the considerations of evidence-based medicine, whereby rehabilitative medicine and more generally physical medicine pay attention not only to external but also to internal evidence as well as patient expectations. Thereby, the therapy programme prescribed conforms to the underlying concept of evidence-based medicine according to Sackett et al.,[3] which propagates the optimal intersection between external and internal evidence as well as patient needs.

In the following, rehabilitation measures for osteoarthritis and at this point of the article, for gonarthrosis and coxarthrosis, will be addressed specifically. In particular, forms of therapy for which effectiveness has been determined according to external evidence will be explained.

Paul et al.[4] demonstrated the benefits of combined motion exercises within the kinetic chain on pain relief and mobility improvement in comparison to isolated motion exercises for the knee.

In 2015, Lu et al.[5] showed that motion exercises in water are effective for gonarthrosis patients and thereby verified Silva et al.,[6] 2008 propagation that exercises performed in a therapy pool are more effective than “dry” exercises carried out in therapy rooms.

A Cochrane systematic review by Fransen et al.[7] showed in 2015 that motion exercises reduce knee joint pain for osteoarthritis patients and lead to improvements both in function and quality of life.

Similar results are conveyed by another Cochrane systematic review by Bartels et al.[8] that covers motion exercises in water for arthroses in the knee and hip joints. Furthermore, pain relief, improved function and increased quality of life after hydrotherapeutic measures were recorded in this case.

Not only motion therapy and therapeutic exercise can lead to the strengthening of muscles but also electrostimulation, mostly applied at low-frequency impulses, can lead to the strengthening of atrophic musculature. Already in 2003, Talbot et al.[9] showed that the targeted stimulation of a weakened quadriceps in patients with gonarthrose leads to an increase of 9.1% in muscular strength, whereas the non-stimulation control group showed a 7% decrease in strength.

Rutjes et al.,[10] on the other hand, conjecture weak evidence for the benefit of therapeutic ultrasound on pain reduction and functional improvement in their review.

This coincides with a report in a review article by Zhang et al.[11] in 2016, which gave an account of the positive effects of ultrasound therapy on gonarthritic joints with regard to analgesia and functionality.

In 2016, Branco et al.[12] verified the effect of sulphur and thermal baths without specific compounds on gonarthrosis and determined that both pain occurrence according to the visual analogue scale as well as function scores of arthrosis patients showed improved results as opposed to the untreated arthrotic control group. Furthermore, analgesic consumption was lower in the therapy group.

Last but not least, Smith,[13] among others, and also in 2016, assessed the intra-articular infiltration of autologous-conditioned plasma in joints with verified gonarthrosis of Grades II and III in comparison to sodium chloride infiltration. The verum group showed a WOMAC score decline of 78%, whilst the control group's score decreased by only 7% such that it can be concluded that the application of intra-articular autologous-conditioned plasma constitutes a good therapeutic option for gonarthrosis of Grades II and III.


  Conclusion Top


The rehabilitation of diseases of and changes in the musculoskeletal system are essential to enable affected persons to reach their individual rehabilitation goal and ultimately achieve optimal reintegration into daily life. The central therapeutic measures are movement therapy “ashore” and in the water, medical training therapy as well as electrical therapy, the use of ultrasound, balneotherapy and innovative therapies such as autologous-conditioned plasma infiltration. However, it must be noted that not all therapeutic measures are equally suited for every patient so that contraindications for single therapeutic modalities due to accompanying or underlying illnesses may exist and must receive consideration. Therefore, the securing of the optimal application of therapeutic modalities in the rehabilitative process through expertise in the field of physical medicine is imperative for rehabilitative medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Technical Report 668/1981 of the World Health Organization. World Health Organization; 1981.  Back to cited text no. 1
    
2.
Kladny B. Rehabilitation of younger patients with implanted endoprothesis. Orthop 2007;36:360-4.  Back to cited text no. 2
    
3.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn't. BMJ 1996;312:71-2.  Back to cited text no. 3
    
4.
Paul AK, Anwer S, Rau SS, Alghadir A. Comparison of the Combined Effects of Hip and Knee Muscle Strengthening vs. Knee Muscle Strengthening Alone on Pain, Function and Gait Parameters in Knee Osteoarthritis. PhysMed Rehab Kurort 2016;26:118-23.  Back to cited text no. 4
    
5.
Lu M, Su Y, Zhang Y, Zhang Z, Wang W, He Z, et al. Effectiveness of aquatic exercise for treatment of knee osteoarthritis: Systematic review and meta-analysis. Z Rheumatol 2015;74:543-52.  Back to cited text no. 5
    
6.
Silva LE, Valim V, Pessanha AP, Oliveira LM, Myamoto S, Jones A, et al. Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: A randomized clinical trial. Phys Ther 2008;88:12-21.  Back to cited text no. 6
    
7.
Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2015;1:CD004376.  Back to cited text no. 7
    
8.
Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev 2016;3:CD005523.  Back to cited text no. 8
    
9.
Talbot LA, Gaines JM, Ling SM, Metter EJ. A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee. J Rheumatol 2003;30:1571-8.  Back to cited text no. 9
    
10.
Rutjes AW, Nüesch E, Sterchi R, Jüni P. Therapeutic ultrasound for osteoarthritis of the knee or hip. Cochrane Database Syst Rev 2010;1:CD003132. doi: 10.1002/14651858.CD003132.pub2.  Back to cited text no. 10
    
11.
Changjie Z, Jie S, Chunjiao Z, Tian X, Zhongjie Yi, Ying K. Effect of ultrasound therapy for knee osteoarthritis: A meta-analysis of randomized, double-blind, placebo-controlled clinical trials. Int J Clin Exp Med 2016;9:30552-20561.  Back to cited text no. 11
    
12.
Branco M, Rêgo NN, Silva PH, Archanjo IE, Ribeiro MC, Trevisani VF, et al. Bath thermal waters in the treatment of knee osteoarthritis: A randomized controlled clinical trial. Eur J Phys Rehabil Med 2016;52:422-30.  Back to cited text no. 12
    
13.
Smith PA. Intra-articular autologous conditioned plasma injections provide safe and efficacious treatment for knee osteoarthritis: An FDA-sanctioned, randomized, double-blind, placebo-controlled clinical trial. Am J Sports Med 2016;44:884-91.  Back to cited text no. 13
    




 

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Introduction
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