Techirghiol, 12 novembre 2012

TRAUMATOLOGY AND ORTHOPEDIC II DIVISION - PISA UNIVERSITY Chiefdirector : Prof. G. Guido DEPARTMENT OF FUNCTIONAL ORTHOPEDICAL REHABILITATION Responsible: Prof.ssa G. Raffaet

Thermal rehabilitation in aged people after osteoporotic vertebral fracture

Prof. G. Raffaet
in collaboration with Dr. F. Falossi, Dr. C. Genovesi

ELDERLY PERSON
It s also a challenge, that has an impact on all the aspects of the XXI century society OMS DEMOGRAPHIC REVOLUTION OF OUR SOCIETY people > 60 years

"Ageing is a privilege and a goal of society.

In the world

in 2000 in 2025 in 2050

600 millions 1,2 billions 2 billions

In Europe

1 in 5

In Italy in 2001 in 2006 today in 2051

10.5 millions 11.5 millions > 20% 1 in 3 data ISTAT

PHYSICAL AND REHABILITATIVE MEDICINE

the role of Physical Medicine and Rehabilitation in the field of geriatric must be understood in its broadest sense

. there is no true geriatrics without rehabilitation and there are no compelling recovery methods PREVENTIVE THERAPEUTIC that are not concerned at the same time the physical and mental aspects of the elderly
Antonini,1973

Elderly

is not synonymous of

disease

but with aging are gradually reduced the capacities of a prompt and reasonable "adjustment" to the environment

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

Healthy Elderly
Physiologically aged with all the changes quantitative and qualitative of the various organs and systems

Pathological Elderly
The signs of old age add up to the results of old diseases and chronic developmental disorders until the situations of disability and loss of autonomy

The assessment of elderly patient

identify not only what the patient is unable to do
search in the subject the psycho-biological residual potential with which build day after day his recovery process

negative

positive

GLOBAL ASSESSMENT :
1. Functional capacity : 2. Mental state : 3. Physical health :
activities scales of daily living indices of overall assessment (Barthel..) behavior, cognitive function ..

also as the absence of disease or alteration of the welfare state 4. Social support : family, importance of the links, isolation of the elderly 5. Financial possibilities both personal that social structures involved

OSTEOPOROSIS
Public health problem continuously growing
In Italy almost 4,000,000 women with osteoporosis Prevalence more than 40% over 60 years
ESOPO study. Osteoporos Int 2003

OSTEOPOROTIC FRACTURES

vertebral fractures radiographically evident

hip fractures
wrist fractures

AGE-specific and SEX-specific incidence of osteoporotic fractures

VERTEBRAL FRACTURES

There is a new osteoporotic vertebral fracture around the world

every 22

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

50% of women over age 80 have a vertebral fracture

M.L.Brandi, 2010

UNDERSTIMATION OF VERTEBRAL FRACTURES studies conducted at European and world level

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

30 - 50 %

Osteoporos Int. 2005

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

Only 1/3 comes to medical attention

The most of patients NOT receive correct diagnosis and appropriate therapy

SUBJECTS WITH 1 OR MORE VERTEBRAL FRACTURES

CHRONIC BACK PAIN

DISABILITY
sleep disorders difficult to wash and dress uncertainty of gait

40-89%
MODERATE SEVERE - PAIN
Trevisan C., Mattavelli M. et AA, 2007

50%

10-15%
Ismail AA et al. 1999

MORTALITY
Those who have a vertebral fracture has an increased risk of dying if compared to their peers without fractures Riduction of 16% of the 5 year survival
M.L.Brandi, 2010

Domino effect

A VERTEBRAL FRACTURE INCREASES BY 5 TIMES THE RISK OF A NEW VERTEBRAL FRACTURE WITHIN ONE YEAR AFTER THE EVENT
Ross PD et al. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med, 1991.

Emphasis kyphotic curve Forward displacement axis gravitazional INCREASEED FLEXOR MOMENT

Vicious circles triggered by osteoporotic vertebral fractures .

1) REFRACTURE
PAIN, DISABILITY, BALANCE DISORDERS PSYCHOLOGICAL PROBLEMS

1 FRACTURE

INCREASED RISK OF FALL

REDUCTION IN PHYSICAL ACTIVITY

2) INCREASED MORTALITY

INCREASED MORTALITY OF 25%

TREATMENT of VERTEBRAL FRACTURES

CONSERVATIVE SURGICAL

Kyphoplasty

Whatever the type of treatment undertaken conservative or surgical the rehabilitation plays an important role because Allows a mobility and functionality rahidea recovery as complete as possible
Herv Deramond 1987

Reley 2001

Vertebroplasty

REHABILITATION SITES
Its essential that prevention, maintenance and recovery programs of the elderly find an appropriate locations

HOSPITAL

EXTRA-HOSPITAL

Early and protected discharges without losing the terapeutic program effectivness

Day hospital Ambulatory

(zona or district)

Home programs Rehabilitation centres

SPA
A very appropriate places to address the rehabilitation needs of these patients and that thanks to

natural water rich active ingrediens

climate health facilities

Ideal location for the overall management of the elderly both the

phisical

and the

psychic

in line with the concept of Health dictation OMS

RECOVERY OF PATIENT WITH OSTEOPOROTIC FRACTURE

TAKING CHARGE GLOBAL of Subject

teamwork
REHABILITATION PROJECT CUSTOM MADE

FACTORS RELATED TO FRACTURE

FACTORS RELATED TO PATIENT

GENERAL CONDITIONS

CONSERVATIVE TREATMENT
REST IN BED 2 weeks on average (min. 10 days, max.30
days)

BRACE A LOAD WITH THREE POINTS on average 60 days GRADUAL WEANING FROM THE BRACE on average 20 days TP DRUG

REHABILITATION PROJECT

In literature
WE CANNOT FIND CLINICAL STUDIES BASED ON THE EVIDENCE OF CONSERVATIVE TREATMENT FOR PATIENTS WITH SPINAL OSTEOPOROTIC FRACTURES

OBJECTIVES OF TREATMENT

1. PAIN CONTROL
2. PREVENTION AGGRAVATION DEFORMITY 3. EARLY FUNCTIONAL RECOVERY

REHABILITATION PROJECT

BEDDIG PHASE

1- PREVENTION OF IMMOBILITY COMPLICATIONS

pressure ulcers, TVP, respiratory complications, etc..
correct positioning on the bed
anti-decubitus mattress, latex mattress, etc.
breathing exercises manteining a regular alvo

2- CONTROL OF PAIN
drug therapy
physical therapy (Elettroterapia antalgica: tens, correnti etc..) diadinamiche,magnetoterapia,

REHABILITATION PROJECT

BEDDIG PHASE

3- MAINTENANCE RANGE OF MOTION AND MUSCLE TONE-TROPISM

oculomotricit

Arch support

Rotations

Lifting

Ex. mobilization passive, assisted and attive

REHABILITATION PROJECT

BEDDIG PHASE

4- STATIC STRETCHES
isometric muscle girdle

Become aware of the active muscle control of the trunk

REHABILITATION PROJECT

PHASE LOAD WITH BRACE

1-ISOMETRIC AND ISOTONIC EXERCISES MM SPINAL

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

2- EXERCISES OF BALANCE AND COORDINATION

When the vertical station is without pain Maximum mechanical stress induced muscolar contractions

Vertical load

sitting position

3- TRAINING OF STEP AND WALKING

REHABILITATION PROJECT

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

REHABILITATION PROJECT

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

REHABILITATION PROJECT

Subjects with osteoporotic fractures yet

EXERCISE

The GRADUAL international avoid excessive review loads of the and Literature stress fractures seems to show the best possible stimulus is the VARIABLE dynamic mechanical stimulation to the bone to
obtain an effect ofMUSCLE type osteoblastic STRENGTH OF TRANSMITTED BY TENDONS TO

BONE TISSUE DURING CONTRACTION ADAPTED to the individual subject

CONSTANT time

isometric, isotonic exercise with no load or light weights, gradually progressive resistance

The rehabilitation IN THE GYM can be integrated and completed

THE EXERCISE IN WATER that amplifies possibilities and spatialities operational

HYDROKINESIOTHERAPY
THERE IS NO EVIDENCE OF EFFICACY ON THE BONE MASS

USEFUL IN PATIENTS WITH STRONG PAIN AND WITH RECENT FRACTURE

BETTER - AEROBIC CAPACITY -FLEXIBILITY -EXTENSION OF MOVEMENT

REDUCE THE PAIN

ANTICIPATE THE LOAD

PHYSICAL INACTIVITY in elderly fractured patience

HYPOXIA with the stagnation of circulating fluids RECRUITMENT and OVERRIDE OSTEOCLASTS

MOVEMENT Early in water

bone resorption
microporotic cavity formation loss of vertical trabeculae in the vertebral bodies

HYDRATION cartilage covering TURNOVER of synovial fluid

SETTING

A NEW FRACTURE
IN THE VERTEBRAL BODIES

improvement TRADE METABOLIC joint environment

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

CINE BALNEOTERAPY

in thermal water is an important tool in the treatment of patients after osteoporotic vertebral fracture

Especially

the therapeutic effects linked to the physical characteristics of water

specific effects of thermal water

EXCLUSION CRITERIA
ABSOLUTE
Heart failure RELATED Arrhythmias high risk Ischemic heart disease Epilepsy Uncontrolled hypertension Urinary incontinence Phlebitis Swallowing disorders Active infections Fecal incontinence Fever Neoplasms in place Previous interventions for cancer Immunodeficiency Insufficiency renal

TEMPORARY
Skin lesions Dermatopatia Conjunctivitis Timpani open Infectious Diseases Shame Fear of water

The contraindications to thermal rehabilitation are scarce and frequently relative

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

TREATMENT PROGRAM IN SPAS

THERAPEUTIC EXERCISE IN THERMAL POOL
- Daily sessions - Duration of sessions: 40 ' - Sulphate-calcium-magnesium, carbon - Salinity '2949 mg / l - Temperature: 35 -36 c

DURATION OF PROGRAM: 2 WEEKS

DAILY EXERCISES IN THE GYM

PHYSICAL THERAPY
always considering any contraindications for each case

MUD
action anti-inflammatory analgesic muscle relaxant eutrophic stimulating action on metabolic processes effects on general kinaesthesia

Tens, Magnetoterapy, Laserterapy

MECHANISMS OF ACTION THERMAL THERAPY THERMAL STRESS

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 4. Increased power of immune defenses

5. Riduction of infiammatory process

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

THERMAL STRESS
Neuro-endocrine reactions GH: STIMULUS TO CHONDROGENESIS and OSTEOGENESIS

REHABILITATION PROTOCOL IN WATER

Relaxation exercises Stretching exercises Exercises of global mobility

1- RELAXATION EXERCISES
"slow" passive and active mobilization
progressively greater amplitude respecting pain threshold
FLOATING IN VERTICAL

FLOATING IN SUPINO

IN FLOATING IN PRONE

2- STRETCHING EXERCISES
To remedy any tensions and correct the posture of the spine compromised by muscular retractions

3- EXERCISES OF GLOBAL MOBILITY To recovery the normal joint range

upper limbs

lower limbs

CRENOBALNEOTHERAPY
Reduction of loads and support action (buoyant force) Muscle relaxant effect to decreased muscle tone (heat) Analgesic effect to increase the pain threshold (PI and viscosity) -> stimulation of baroreceptors joint (g.c.s.) Increase stimuli esterocettori (PI and viscosity) -> amplification of motor patterns and better perception position of the body segments

Increased proprioceptive stimulation (resistance and motions of turbulence) -> Continuous postural control and intense muscle work

1. ALLOWS ACTIVE AND PASSIVE MOBILIZATION EXERCISES IN MAXIMUM SECURITY 2. PREPARE THE PATIENCE TO "DRY REHABILITATION

REHABILITATION IN THE GYM

The criteria for the CHOICE of exercises
strengthening of the extensor muscles of the spine ipercifosi correction and overall posture exercises for balance and proprioception motor coordination (truncated upper limbs, trunk, lower limbs) respiratory coordination natural load exercises

The EXCLUSION criteria exercises

prevent flexion of the trunk exercises involving posture monopodaliche, kneeling or quadrupediche use of weights or other loads that are not natural exercising in place unsafe and too expensive in terms of energy

CONCLUSIONS
The rehabilitation therapy in thermal water is an important resource for the care and delicate process recovery of ADL of elderly patients

In VERTEBRAL OSTEOPOROTIC FRACTURES the hydrokinesiotherapy allowing you to anticipate the load has proved a valuable tool in the early recovery
- MOVEMENT

- FEATURES AND JOINT - MUSCLE TROPHISM

IN THE ABSENCE OF PAIN

CONCLUSIONS
Stay in a spa can become an opportunity to develop useful strategies education and awareness
Explain to the patient

what is osteoporosis

Recommend rules adequate lifestyle

etc.

PATIENT

First actor of its recovery

Thanks